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: Feb. 14, 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

Technical Assistance:

22VAC40-61-220 22VAC40-61-540

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: 02/14/2024 from 10:15 am to 12:50 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: 4 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 #:	22VAC40-61-220-A
Description:	Based on record review, the center failed to ensure a written assessment of a participant be secured or conducted prior to or on the date of admission by the director, a staff person who meets the qualifications of the director, or a licensed health care professional employed by the center. Evidence: 1. Participant #3 admitted to the center on 08/28/2023; however, the assessment in Participant #3?s record was dated 10/09/2023.
Plan of Correction:	Participant #3 was admitted to the center on 08/28/2023. All intake information was completed that day. While reviewing the chart on 10/09/2023 we notice that the date wasn't recorded. The day it was notice is the day we recorded, and we used that date, all forms will be dated and sign on the day assessment is done.
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:	The Plan of Care for all three participants were updated to include identified needs, date identified, the expected outcome, goals, activities, and services that will be provided to meet those outcomes and goals and who will provide them and when they will be provided.
Standard #:	22VAC40-61-230-F
Description:	Based on record review, the center failed to ensure the participant, family member, or legal representative sign the plan of care. Evidence: 1. The plan of care for 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 #2 and #3 were dated and signed with the participants' legal representative 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 #3 admitted to the center on 08/28/2023; however, the physical examination in Participant #3?s record was dated 12/05/2023.
Plan of Correction:	Jen care completed physical within the 30 days but never provided us with a copy, after several request with proof of those request we decided to find another doctor to get the physical. Moving forward we will have physical before client has been in program for thirty days.
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 #1?s physical examination (dated 01/11/2024) did not include a statement that specifies whether the individual is considered to be ambulatory or nonambulatory or a statement that specifies whether the individual is or is not capable of self-administering medication. 2. Participant #3?s physical examination (dated 12/05/2023) did not include a completed assessment for tuberculosis.
Plan of Correction:	Participant #1 physical examinations was updated to specify if ambulatory or non-ambulatory and if capable of self-administering medication. Participant #3 physical examination was updated and completed assessment for Tuberculosis.
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 bathrooms to be utilized by participants read 94.5?F and the sink in the main activity space read 100?F.
Plan of Correction:	On 2/19/2024 our contractor came and service and adjusted the hot water to maintain temperature range of 105 to 120.
Standard #:	22VAC40-61-480-E
Description:	Based on observation, the center failed to ensure additional pillows be available as necessary for recliners. Evidence: 1. There were not additional pillows available as necessary for recliners to accommodate rest periods if needed.
Plan of Correction:	On 2/20/2024 the director went to Walmart and purchase additional pillows, blankets, and items to ensure all items accommodate rest periods if needed.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the center 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 01/10/2024; however, their background check was not completed during the onsite inspection on 02/14/2024.
Plan of Correction:	Staff #3 background check was mailed on 1/9/24, she was hired on 1/10/24 and not allowed to work with clients until 1/15/24. Background review was stamped 2/7/24 however we received it on 2/15/24 the day after you came. Moving forward, we will mail background checks a week before they are hired hoping the results are back in time.