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: July 25, 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:

22VAC40-61-50-D

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: 07/25/2023. 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: 11 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: 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 #:	22VAC40-61-50-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: 1. Participant #3 did not have evidence of an annual review of rights and responsibilities of participants in their participant file within the past year.
Plan of Correction:	The caregiver of participant #3 was emailed on 7/26/2023 letting them know that their statement of rights and responsibilities was due for review and a signature. The caregiver responded that they would come to the center next week for the review and to sign the document.
Standard #:	22VAC40-61-150-A-3
Description:	Based on record review, the center failed to ensure when adults with mental impairments participate at the center, at least four of the hours of annual training for direct care staff focus on topics related to participants' mental impairments. Evidence: 1. Staff #2 did not have at least four hours of training focused on topics related to participants' mental impairments in 2022.
Plan of Correction:	Staff #2 was made aware on 7/26/2023 that they need to complete 4 hours of training focused on the topic of Dementia. They will complete 4 hours of Dementia training before the end of August 31, 2023.
Standard #:	22VAC40-61-520-C
Description:	Based on discussion, the center failed to develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, participants, and volunteers with emphasis placed on an individual's respective responsibilities, except that for participants, the orientation and review may be limited to only subdivisions 1 and 2 of this subsection. The review shall be documented by signing and dating. Evidence: 1. Staff #1 did not have documentation of staff?s semi-annual review on the emergency preparedness and response plan.
Plan of Correction:	Staff #1 or the Assistant Director will conduct a review of the emergency preparedness and response plan on Wednesday, August 2, 2023 and again on December 2, 2023.