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: Oct. 24, 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:

22VAC40-61-150 22VAC40-61-160 22VAC40-61-220

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: 10/24/2023. 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: 6 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 3 Number of staff records reviewed: 3 Additional Comments/Discussion: There were no medications administered in the center during the onsite inspection. The following were reviewed: participant and staff records, fire drills, and the first aid kit. 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 #:	22VAC40-61-180-E-1
Description:	Based on record review, the center failed to ensure each staff person and volunteer identified in this subsection obtain an evaluation by a qualified licensed practitioner that completes an assessment for tuberculosis in a communicable form no earlier than 30 days before or no later than seven days after employment or contact with participants. Evidence: 1. Staff #5 was hired on 10/2/2023; however, the assessment for tuberculosis was completed on 7/10/2023.
Plan of Correction:	Staff #5 was hired 10/2/23. However their initial TB was completed on 7/10/23. An additional TB screening was completed on 10/30/23 to meet state requirement.
Standard #:	22VAC40-61-230-D
Description:	Based on record review, the center failed to ensure the plan of care include description of the identified needs and the date identified, the expected outcome or goal to be achieved in meeting those needs, the activities and services that will be provided to meet those outcomes or goals, who will provide them, and when they will be provided, if appropriate, the time by which the outcome or goals should be achieved, and date outcome or goal achieved. Evidence: 1. The plan of care for Participant #1, Participant #2, and Participant #3 does not provide or include a description of the identified needs and the date identified, the expected outcome or goal to be achieved in meeting those needs, the activities and services that will be provided to meet those outcomes or goals, who will provide them, and when they will be provided, if appropriate, the time by which the outcome or goals should be achieved, and date outcome or goal achieved.
Plan of Correction:	Plan of care and ISP's completed.
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, Participant #2, and Participant #3 are not dated nor signed by the participant, family member, or legal representative
Plan of Correction:	The Plan of Care for Participants 1, 2, and 3 were updated, and completed with the participant's/legal representative's signature.
Standard #:	22VAC40-61-260-A
Description:	Based on record review, the center failed to ensure within the 30 days preceding admission, a participant shall have a physical examination by a licensed physician. Evidence: 1. Participant #1 and Participant #3 did not have a completed physical examination in their record.
Plan of Correction:	According to discharge summary date 10/12/23 for participant #1, a physical exam was completed upon discharge. Also for Participant #3, a physical was completed 8/9/23. However, both participants are scheduled for new physicals 12/3/23.
Standard #:	22VAC40-61-330-G-2
Description:	Based on observation, the center failed to ensure the current month's schedule be posted in a readily accessible location in the center. Evidence: 1. A daily activity schedule was observed while at the center. There was not a monthly schedule of activities posted.
Plan of Correction:	Monthly schedule of activities was completed on 10/25/23.
Standard #:	22VAC40-61-340-B
Description:	Based on record review, the center failed to ensure when any portion of an adult day care center is subject to inspection by the Virginia Department of Health, the center be in compliance with those regulations, as evidenced by an initial and subsequent annual report from the Virginia Department of Health. 1. The last health inspection completed at the center was 06/10/2022.
Plan of Correction:	The Health Department would not allow us to schedule our inspection in June. Their rule is we must be open serving clients for at least 2 months to renew. Our first client was not received until Mid July. We have reached out to the Health Department as of last week in September and have not been scheduled for our reinspection. Our inspector has been reassigned and is no longer our inspector.
Standard #:	22VAC40-61-360-B
Description:	Based on observation, the center failed to ensure menus for meals and snacks for the current week are dated and posted in an area conspicuous to participants. Evidence: 1. The menu for meals for 10/16/23-10/20/23 was posted in the center on 10/24/23.
Plan of Correction:	The menu for meals was updated and posted on 10-24-23.
Standard #:	22VAC40-61-530-B
Description:	Based on observation, the center failed to ensure a fire and emergency evacuation drawing showing primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes, and fire extinguishers shall be posted in a conspicuous place. Evidence: 1. The posted fire and emergency evacuation drawings did not include areas of refuge, assembly areas, telephones, or fire alarm boxes.
Plan of Correction:	The posted fire and evacuation drawing were updated and completed including areas of refuge, assembly areas, and telephones.
Standard #:	22VAC40-61-540-E
Description:	Based on record review, the center failed to ensure the record of the required fire and emergency evacuation drills include all the items as identified in the standard. Evidence: 1. The record of the fire and emergency evacuation drills completed from May 2023-October 2023 did not document the identity of the person conducting the drill, the method used for notification of the drill, any special conditions simulated, the time it took to complete the drill, and the weather conditions.
Plan of Correction:	The record of the fire and emergency evacuation drills was completed and updated with method used for notification of the drill, special conditions simulated, the time it took to complete the drill, and the weather conditions.
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 #6 was hired on 08/14/2023; however, their background check was not completed until 09/26/2023.
Plan of Correction:	Staff #6 background check was completed 8-31-23 and received on 10-25-23.