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: June 8, 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:

22VAC40-61-240

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: 06/08/2023 from 12:35 pm to 2:40 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: 2 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 #:	22VAC40-61-140-B
Description:	Based on record review, the center failed to ensure direct care staff meet one of the requirements in this subsection. If the staff does not meet the requirement at the time of employment, they shall successfully meet one of the requirements in this subsection within two months of employment. Licensed health care professionals practicing within the scope of their profession are not required to complete the training in this subsection. Evidence: 1. Staff #3 was hired on 03/13/2023 as direct care staff. Staff #3 has a certification of completion for a nurse assistant training; however, it does not indicate the training is a Virginia Board of Nursing-approved nurse aide education program, program approved by the department, or at least 40 hours of training as taught by a licensed health care professional or, if online training is accessed, accredited by a national association.
Plan of Correction:	Staff #3 will enroll in a CNA program at TCC to start 7/7/23. However, the current certification on file from AHCA is accepted in the state of Virginia per the accredited program. Staff #4 is credentialed as a medical assistant in the state of Virginia and can function as direct care staff per your approval? all of their credentials are located in their staff file.
Standard #:	22VAC40-61-220-G
Description:	Based on record review, the center failed to ensure the initial assessment and any reassessments be in writing and completed, signed, and dated by the staff person identified in subsection A of this section. The assessment or reassessment shall also indicate any other individuals who contributed to the development of the plan with a notation of the date of the contribution. Evidence: 1. The assessment for Participant #2 is not dated nor signed by the staff person who completed the assessment. 2. The assessments for Participant #1 and Participant #4 are not dated.
Plan of Correction:	The assessment for participant #2 has been dated by the participant and signed by the staff. The assessment for participants 1 and 4 has been dated.
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. Participant #3 admitted to the center on 04/13/2023 and did not have a completed plan of care in their record.
Plan of Correction:	The initial screening was completed on 4/13/23 for participant #3. However, the plan of care was completed on 6/9/23 for participant #3.
Standard #:	22VAC40-61-230-F
Description:	Based on record review, the center failed to ensure the preliminary plan of care and any updated plans be in writing and completed, signed, and dated by the staff person identified in subsection B of this section. The participant, family member, or legal representative shall also sign the plan of care. The plan shall indicate any other individual who contributed to the development of the plan, with a notation of the date of contribution. Evidence: 1. The plan of care for Participant #1 and Participant #4 are not dated nor signed by the staff person who completed the plan. 2. The plan of care for Participant #2 is not dated nor signed by the participant or the staff person who completed the plan.
Plan of Correction:	The plan of care for participants #1 and #4 was dated and signed by the staff person who completed the plan of care. The plan of care for participant #2 was dated and signed by the participant and staff who completed the plan of care.
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 #3?s physical examination indicated the participant tested TB positive on 03/09/2023. The exam indicates the participant is free of communicable diseases; however, the exam indicates the participant was referred to pulmonary and prescribed Rifampin to treat. There was no additional documentation on the date a chest x-ray was completed (if performed). Participant #3 was noted to be an active participant at the center and present on the day of inspection.
Plan of Correction:	Participant #3 tested positive for TB on 3/9/23. A chest x-ray was completed on 3/10/23. Impression was negative. Documentation is noted in participant #3 record.
Standard #:	22VAC40-61-330-G-3
Description:	Based on observation, the center failed to ensure the current month's schedule of activities includes the name, type, date, and hour of the activity. Evidence: 1. During an inspection of the center, the June 2023 activity calendar did not include the type or hour of the activities.
Plan of Correction:	The activity schedule has been updated and includes the date, hours, and type of activities.
Standard #:	22VAC40-61-460-H
Description:	Based on observation, the center failed to ensure hot water at taps available to participants are maintained within a temperature range of 105?F to 120?F. Evidence: 1. During an inspection of the center, the hot water temperature in one of the two bathrooms to be utilized by participants read 75.6?F.
Plan of Correction:	The hot water temperature has been corrected by HVAC professionals.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. Staff #3 was hired on 03/13/2023; however, their background check was not completed until 05/08/2023.
Plan of Correction:	The background check was delayed by Virginia State Police as a company account was being set up at the same time as the background check was completed. Backgrounds were returned and requested to be placed on a different form. The delay was not within our control. The communications from VSP are available upon request.