VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Riverside Adult Day Services Center-Denbigh
1010 Old Denbigh Blvd.
Newport news, VA 23602
(757) 875-2033

Current Inspector: Darunda Flint (757) 807-9731

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES

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: 3/20/2023 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: 21 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 6 Number of staff records reviewed: 4 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 Alyshia E. Walker, Licensing Inspector at (757) 670-0504 or by email at Alyshia.Walker@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 documented review of participants rights for Participant #3 was 1/23/2022 and the last documented review of participant rights for Participant #6 was 1/24/2020. 2. Staff #1 acknowledged the aforementioned documents were the most recent signed participant rights for Participants #3 and #6.
Plan of Correction:	1) Both Participant # 3 and Participant #6 Annual Rights forms were signed by participant and/or family on 3/20/23. 2) A 100% audit will be completed by the Director of Adult Day Services to ensure all participants have an annual rights document signed by April 20, 2023. 3) Director of Adult Day Services will send out Annual Rights one month prior to due date to participants to improve compliance. 4) Director will review spreadsheet of due dates two times each month to monitor compliance with regulation concerning annual rights. (Beginning 4/17/2023)
Standard #:	22VAC40-61-230-F
Description:	Based on a review of participant records, the center failed to ensure that the preliminary plan of care and any updated plans are signed by the participant, family member, or legal representative. Evidence: The last participant or legal representative signed review for Participant #3?s plan of care was 7/5/2022 and the last participant or legal representative signed review of Participant #6?s plan of care was 10/28/2020.
Plan of Correction:	1) Participant #3 signed Plan of Care on 3/29/23 and Participant #6 signed Plan of Care on 4/12/2023. 2) A 100% audit will be completed by the Director of Adult Day Services to ensure all participants have a current care plan signed by April 30, 2023. 3) Director will send out completed care plans immediately upon completion for review and signature. (ongoing) 4) Director will review spreadsheet of due dates two times each month to monitor compliance with regulation concerning care plan signature. (Beginning 4/17/2023)
Standard #:	22VAC40-61-240-D
Description:	Based on record review and discussion, the facility failed to ensure the participant agreement was reviewed and updated whenever there are any changes in the services or the financial arrangements. The updated agreement shall be signed and dated by the participant or his legal representative and the center representative. Evidence: 1. Records for Participants #2, #3, and #6 did not contain updated 2023 signed agreements. 2. Staff #1 acknowledged the aforementioned records did not contain updated 2023 agreements.
Plan of Correction:	1) Participant # 3 signed the 2023 Admission Agreement on 3/20/23; participant #6 family signed the 2023 Admission agreement on 3/21/2023 and participant # 2 remains unsigned. The agreement was sent to participant #2 family for signature on several occasions and again on April 5, 2023. Participant is currently out and will not be allowed to return to the center without a signed admission agreement. 2) A 100% audit will be completed by the Director of Adult Day Services to ensure all participants have a current Admission Agreement signed by April 30, 2023. 3) Director will send out Admission Agreement in early December for the upcoming year and upon admission (ongoing) 4) Director will review spreadsheet of due dates two times each month to monitor compliance with regulation concerning admission agreements. (Beginning 4/17/2023)
Standard #:	22VAC40-61-260-C
Description:	Based on resident record review and interview, the facility failed to obtain an annual physical exam for a participant. Evidence: 1. The record for Participant #1 did not contain an updated annual physical examination. 2. Staff #1 acknowledged record for Participant #1 did not contain an updated annual physical examination.
Plan of Correction:	1) Participant # 1 only attends the center a few weeks throughout the year. A physical exam form was sent for completion and was not done in its entirety upon return to the center. Director reached out to the family and proceeded with discharge indicating she may re-enroll with new forms when needed. 2) A 100% audit will be completed by the Director of Adult Day Services to check all annual physical exam dates by April 30, 2023 3) Director will send out annual exam notifications and forms two months prior to participants exam due date to ensure compliance with annual physical exam regulation. 4) Director will review spreadsheet of due dates two times each month to monitor compliance with regulation concerning physical exams. (Beginning 4/17/2023)
Standard #:	22VAC40-61-410-E
Description:	Based on observations made during the tour of the building, the center failed to keep all cleaning products and harmful materials stored in a locked place when not in use. Evidence: During the on-site inspection of the facility, the Licensing Inspector observed cleaning supplies (Windex, Disinfecting Wipes, and disinfecting sprays) on a small table in the common area accessible to participants.
Plan of Correction:	1) Windex, disinfecting wipes and sprays were immediately placed in locked closets. (3/20/2023) A locked cabinet replaced the table and will be used to store Windex, disinfecting wipes and sprays. (Corrected 4/11/2023) 2) 100% audit of facility was conducted on March 20, 2023, to ensure that chemicals are maintained in a locked cabinet when not in use. 3) Team members will be educated by the Director on importance of ensuring all above items will remain locked in a cabinet unless in use. The key to the above cabinet will be on the kitchen key holder for use. (Educated during staff meeting April 11, 2023) 4) Director will complete regular walk- throughs twice weekly to ensure all chemicals are stored and locked properly. (Beginning April 18, 2023)