VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sentara PACE - Churchland
5788 Churchland Boulevard
Portsmouth, VA 23703
(757) 392-2650

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

Inspection Date:

Complaint Related: No

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. Participant #4 did not have evidence of an annual review of rights and responsibilities of participants in their participant file.
Plan of Correction:	As previously noted, all participants will have their rights and responsibilities reviewed with a signature by September 30. The teams have been working aggressively on this commitment and do not foresee any barriers to meeting this deadline.
Standard #:	22VAC40-61-150-A
Description:	Based on record review and interview, the facility failed to ensure direct care staff attend at least 12 hours of training annually. Evidence: 1. Staff #4 (hire date 03-19-2020) had a total of 4.15 hours of annual training in 2021.
Plan of Correction:	Due to a glitch that occurred when the health system migrated to a new internal document management program, the team member?s training hours were not available prior to the end of the onsite inspection. The training hours were provided to the inspector via email. The time listed is not the total time the training qualifies for, but the time it took the team member to complete or 0.0 if the credit was entered by hand due to the training being in person session.
Standard #:	22VAC40-61-250-B
Description:	Based on record review, the center failed to ensure the participant record include a current photograph or narrative physical description of the participant, which shall be updated annually. 1. The record for Participant #2 and Participant #6 did not include a current photograph or narrative physical description of the participant.
Plan of Correction:	Participant #2 has had her photo added to her electronic medical record. Participant #6 was not able to participate in having her photo taken prior to POC submission. Participant #6 will have her photo taken as soon as possible.
Standard #:	22VAC40-61-360-B
Description:	Based on observation, the center failed to ensure menus for meals and snacks for the current week are dated and posted in an area conspicuous to participants. Evidence: 1. On 08-16-2022, while conducting the inspection at the center, the menu for meals and snacks does not include the items for ?Chef?s Entree of Choice? or ?Continental Breakfast? on the posted menu.
Plan of Correction:	For the breakfast, the center has posted a paper document listing the items served for ?Breakfast? each day. The Chef?s Entree of Choice line item will be removed the menu. Instead, a listing of the meal alternates is now posted daily.
Standard #:	22VAC40-61-410-A
Description:	Based on observation and interview, the center failed to ensure the interior and exterior of all buildings be maintained in good repair, kept clean and free of rubbish, and free from safety hazards. Evidence: 1. On 08-16-2022, while conducting the inspection at the center, the fence in the outdoor courtyard to the touch was not secure. 2. Staff #1 stated the door must remain unlocked as it is a fire exit and acknowledged the concern regarding the stability of the outdoor fence.
Plan of Correction:	Due to product shortages from the COVID pandemic, materials to repair/replace the fence have not been available. On 8/30, the third company has alerted the Site Director that the materials are available for order. Final pricing was also on hold due to the unavailability of products. The Site Director is anticipating a final quote and approval to occur within the next 5 business days.
Standard #:	22VAC40-61-510-A
Description:	Based on record review, the center failed to comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: 1. The last inspection by the appropriate fire official was completed on 04-06-2021.
Plan of Correction:	Despite multiple attempts to reach the Fire Marshall?s office, the Site Director was unsuccessful until 8/16. The representative from the Portsmouth Fire Marshal?s office informed the Site Director that he had been furloughed for the past few months and provided new contact information at that time. Up until this day, he had not responded to numerous voicemails, emails and an attempt to contact through a third party vendor. The Annual Fire Marshall inspection was completed on August 23, 2022 with no findings noted.