VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Helping Hands for Heroes
3315 High Street
Portsmouth, VA 23707
(757) 538-7900

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

Inspection Date: March 20, 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:

22VAC40-61-140 22VAC40-61-250 22VAC40-61-530 Background Checks

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: 03/20/2023 from 12:20 pm to 2:45 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: 4 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 Observations by licensing inspector: Lunch and an activity were observed. 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 #:	22VAC40-61-110-A
Description:	Based on record review and observation, the center failed to ensure prior to working directly with participants that all staff receive training in the items identified in the standard. Evidence: 1. The following staff did not have documentation of initial staff orientation and training in their record: Staff #2, Staff #3, and Staff #4. 2. Staff #2, Staff #3, and Staff #4 were present and observed working directly with participants during the onsite inspection on 03/20/2023.
Plan of Correction:	The staff training documentation was uploaded in Rippling, but now has been downloaded and placed in the employee?s file.
Standard #:	22VAC40-61-220-A
Description:	Based on record review, the center failed to ensure a written assessment of a participant 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. The following participants admitted on 3/13/2023 and did not have an assessment in their record: Participant #1, Participant #2, Participant #3, and Participant #4.
Plan of Correction:	The written assessments for the participants were conducted by the Director and licensed clinician.
Standard #:	22VAC40-61-230-A
Description:	Based on record review, the center failed to ensure prior to or on the date of admission, a preliminary multidisciplinary plan of care based upon the assessment be developed for each participant. The plan shall be reviewed and updated, if necessary, within 30 days of admission. Evidence: 1. The following participants admitted on 3/13/2023 and did not have a plan of care in their record: Participant #1, Participant #2, Participant #3, and Participant #4.
Plan of Correction:	The Plan of Care for the participants were conducted and completed.
Standard #:	22VAC40-61-240-A
Description:	Based on record review, the center failed to ensure at or prior to the time of admission, there be a written agreement between the participant and the center. The agreement shall be signed and dated by the participant or legal representative and the center representative. Evidence: 1. The following participants admitted on 3/13/2023 and did not have a written agreement between the participant and the center in their record: Participant #1, Participant #2, Participant #3, and Participant #4.
Plan of Correction:	The participants agreement was signed and completed.
Standard #:	22VAC40-61-260-B
Description:	Based on record review, the center failed to ensure the report of the required physical examination include the items listed in the standard. Evidence: 1. Participant #1?s physical examination did not include an assessment for tuberculosis consistent with the TB risk assessment as published by the Virginia Department of Health. 2. Participant #2?s physical examination indicated ?see attached chart? pertaining to all diagnoses and significant medical problems and medications of the participant; however, the physical examination did not contain the attached chart referenced on the document.
Plan of Correction:	The TB risk assessment was completed and placed in participants file. Participants completed medical documentation was placed in the participants file.
Standard #:	22VAC40-90-30-B
Description:	Based on record review, the facility failed to ensure a sworn statement or affirmation be completed for all applicants for employment. Evidence: 1. Staff #2 did not have a completed sworn disclosure statement in their file.
Plan of Correction:	All documents are in Rippling and has been downloaded and placed in employee?s file.