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: Aug. 16, 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: 08/16/2022 from 9:10 am to 3:07 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: 0 ? Census by end of day - 43 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 7 Number of staff records reviewed: 4 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. 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.