VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Primeplus at M.E. Cox , Operated by Primeplus Senior Centers
644 North Lynnhaven Road
Virginia beach, VA 23452
(757) 625-5857

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: July 27, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-61 GENERAL PROVISIONS 22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 SUPERVISION 22VAC40-61 ADMISSION, RETENTION AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUND 22VAC40-61 EMERGENCY PREPAREDNESS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/27/2022 from 10:45 am to 1:20 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of participants present at the facility at the beginning of the inspection: 7 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 4 Number of staff records reviewed: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-61-50-E
Description:	Based on record review, the center failed to review the rights and responsibilities of participants annually with each participant, or, if a participant is unable to fully understand and exercise his rights and responsibilities, the annual review shall include his family member or his legal representative. Evidence of this review shall include the date of the review and the signature of the participant, family member, or legal representative and shall be included in the participant's file. Evidence: 1. The last review of rights and responsibilities of participants for Participant #4 is 10/07/2020.
Plan of Correction:	Staff #1 has informed and instructed the Administrative Assistant, Staff #3, to conduct an annual review of the participant's Rights and Responsibilities. All caregivers and participants will sign and date their annual review that will be administered starting Monday, August 8, 2022. These reviews will be in each of the participants file and will be conducted annually. Participant #4 and his caregiver received their annual review or Rights and Responsibilities and have signed the document. It has been placed in participant #4s file.
Standard #:	22VAC40-61-260-B
Description:	Based on record review, the center failed to obtain an evaluation by a qualified licensed practitioner that completes an assessment for tuberculosis (TB) in a communicable form no earlier than 30 days before admission. Evidence: 1. The documentation of a tuberculosis risk assessment for Participant #2 (dated 11/8/21) does not indicate whether or not Participant #2 is free from TB in a communicable form.
Plan of Correction:	Participant #2's Physician's Statement was faxed to their Dr.'s office on Wednesday, August 3, 2022 with the instructions to update the TB portion of the Physician's Statement.
Standard #:	22VAC40-61-520-D
Description:	Based on interview, the center failed to review the emergency preparedness and response plan annually or more often as needed, document the review by signing and dating the plan, and make necessary revisions. Evidence: 1. Staff #1 acknowledged the center does not have documentation that a review of the emergency preparedness and response plan has occurred annually.
Plan of Correction:	The Emergency Action Plan was reviewed and signed on Wednesday, August 3, 2022. It will be reviewed annually in the month of August going forward from this plan of correction.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. As of 7/27/22, Staff #5 was hired on 4/18/22 and does not have a completed criminal history record report in their record.
Plan of Correction:	Staff #1 mailed the Criminal History Record to Virginia State Police on 7/11/22 but it has not been returned to the Center. Staff #1 called the VA State Police Office on 8/3/22 to make sure it was received and it was. The clerk said it had cleared and was in the mail. Until the document is received, Staff #5 will not be alone with the participants and will always be with partnered another staff member.