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: Jan. 26, 2023

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

Technical Assistance:

Part V. Admission, Retention and Discharge

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/26/2023 from 9:22 am to 11:50 am. 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: 3 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 #:	22VAC40-61-130-A
Description:	Based on discussion, the center failed to ensure the director is present at least 51% of the center's weekly hours of operation. Evidence: 1. During the onsite inspection, the center was unable to provide documentation that indicates the director is present at least 51% of the center?s weekly hours of operation.
Plan of Correction:	The Executive Director of Primeplus Senior Centers is aware of the violation and has posted a job opening for an Assistant Director/Nurse on Indeed as well as several other websites. When the Assistant Director is hired, they will be working at Primeplus Adult Day Services at M.E. Cox, Virginia Beach.
Standard #:	22VAC40-61-130-C
Description:	Based on discussion, the center failed to ensure the director complete 24 hours of continuing education training annually to maintain and develop skills. Evidence: 1. During the onsite inspection, the center was unable to provide annual training records for the director.
Plan of Correction:	The director has completed her CEU?s, but the binder that keeps those records was not onsite at the time of the inspection. The director will send the record of the C.E.U. classes that were completed in 2022.
Standard #:	22VAC40-61-160-A-1
Description:	Based on record review, the center failed ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff #5 works as direct care staff and does not have documentation of a current certification in first aid in their record.
Plan of Correction:	Staff # 5 is currently up to date on her certification in first aid from the American Red Cross. The certificate was not in her file at the time of the inspection. The certificate will be sent with the plan of correction on 1/15/2023.
Standard #:	22VAC40-61-190-A
Description:	Based on observation and interview, the center failed to have one staff person on the premises in charge of the administration of the center. Evidence: 1. In the absence of the Director, there was no staff person appointed by the licensee or designated by the Director to be in charge of the administration of the center.
Plan of Correction:	The Executive Director has appointed a staff member at each location who will act as the supervisor until the Director returns on 2/21/2023.
Standard #:	22VAC40-61-220-A
Description:	Based on record review and interview, the center failed to ensure a written assessment of a participant shall be secured or conducted prior to or on the date of admission by the director, a staff person who meets the qualifications of the director, or a licensed health care professional employed by the center. Evidence: 1. Participant #4 readmitted to the center on 11/17/2022 after discharging on 06/07/2022. The last assessment for Participant #4 in their record was completed on 03/28/2022.
Plan of Correction:	The UAI assessment of Participant #4 has been updated and each of the active participant?s UAI?s have been updated as well. Going forward, the assessments will be reevaluated and updated every 6 months going forward.
Standard #:	22VAC40-61-220-E
Description:	Based on record review and interview, the center failed to ensure the assessment be reviewed and updated at least every six months. Evidence: 1. The following assessments completed for each participant is the most current in their participant record: Participant #1 dated 03/09/2022 and Participant #3 dated 07/08/2022.
Plan of Correction:	The assessment tool needing review is the client?s UAI. Since the inspection on 1/26/2023, all the participant?s UAI?s have been update and moving forward they will be updated every six months.
Standard #:	22VAC40-61-300-E-7-a
Description:	Based on record review, the center failed to ensure each staff person who administers medication be authorized by ? 54.1-3408 of the Code of Virginia. Evidence: 1. The MAR indicates Staff #4 has administered 4 medications on 4 separate occasions in January 2023. 2. The center was unable to provide documentation of Staff #4?s certificate and or training program to administer medications.
Plan of Correction:	Staff #4 has a current medication aide certificate which was not in the file at the time of inspection. The certification was put in her file after the inspection and a copy of it will be sent to the inspector.