VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sentara PACE - Churchland
5788 Churchland Boulevard
Portsmouth, VA 23703
(757) 392-2650

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

Inspection Date: Jan. 25, 2024

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

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: 01/25/2024 from 9:38 am to 2:25 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: 8 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 5 Number of staff records reviewed: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 2 participants. The following were reviewed: participant and staff records, fire drills, medication cart, 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 #:	22VAC40-61-150-A
Description:	Based on record review, the center failed to ensure staff who provide direct care to participants attend at least 12 hours of training annually. Evidence: 1. Staff #4 was unable to provide documentation of at least 12 hours of training annually in 2023 for Staff #3.
Plan of Correction:	Ensure at least 12 hours of annual training is completed and documented for each staff member.
Standard #:	22VAC40-61-160-A-1
Description:	Based on record review, the center failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff #4 was unable to provide documentation of a current certification in first aid for Staff #2 and Staff #3.
Plan of Correction:	Ensure all staff members have proof of first aid in their personnel file.
Standard #:	22VAC40-61-180-E-2
Description:	Based on record review, the center failed to ensure all staff and volunteers have an annual tuberculosis risk assessment completed. Evidence: 1. Staff #4 could not provide documentation of a current annual evaluation for tuberculosis (TB) consistent with the TB risk assessment as published by the Virginia Department of Health for Staff #3.
Plan of Correction:	Ensure all staff and volunteers have proof of annual tuberculosis risk assessment completed.
Standard #:	22VAC40-61-230-D
Description:	Based on record review, the center failed to ensure the plan of care be developed to maximize the participant's level of functional ability and to support the principles of individuality, personal dignity, and freedom of choice. Evidence: 1. Participant #5?s care plan dated 11/10/2023 indicates the participant?s code status as full code; however, the participant?s record reflected the participant as a DNR with a POST order dated 5/21/2023.
Plan of Correction:	Discrepancy was corrected on the date of the inspection.
Standard #:	22VAC40-61-250-B
Description:	Based on record review, the center failed to ensure the participant record include a current photograph or narrative physical description of the participant, which shall be updated annually. 1. The record for Participant #1 and Participant #2 did not include a current photograph or narrative physical description of the participant.
Plan of Correction:	Staff will ensure all participants have a photo in the medical record.