VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: Aug. 12, 2024 and Aug. 20, 2024

Complaint Related: No

Areas Reviewed:

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

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/12/24 9:44am to 12:45 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: 98 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 Number of interviews conducted with participants:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: There were 98 participants in care at the time of the inspection. A tour of the interior and exterior area of the center was conducted. Water temperatures were sampled and the first aid kit was reviewed. Additional Comments/Discussion: Availability of records. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the initial inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The applicant has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to maintain future compliance with applicable standard(s) or law. If the applicant 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 should the facility be issued a license to operate. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov

Violations:

Standard #:	22VAC40-61-60-B-3
Description:	Based on record review, it was determined that the center did not ensure to keep such records and make such reports as required by this chapter for licensed adult day centers. Such records and reports may be inspected by the department's representative at any reasonable time in order to determine compliance with this chapter. Evidence: 1. Staff list and records were requested on 8/12/24 at 10:15am during initial onsite renewal inspection. The list of staff was provided after the conclusion of the visit by email on 8/12/24 at 3:07pm. 2. The Licensing Inspector had to return on 8/20/24 to review staff records.
Plan of Correction:	Employee files will be available for request for representative in a reasonable time to determine compliance. The Managers will audit employee files for records Bi-Monthly.
Standard #:	22VAC40-61-160-A-1
Description:	Based on record review, it was determined that the center did not 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 #3?s record did not contain documentation of a current certification in first aid 2. Staff #4 confirms the First Aid certification were not present in the records for staff #1, staff #2 and staff #3.
Plan of Correction:	Ensure that all staff members have proof of First Aid in their personnel files.
Standard #:	22VAC40-61-230-F
Description:	Based on record review, it was determined that the center did not ensure the participant, family member, or legal representative sign the plan of care. Evidence: 1. The plan of care for Participant #2 dated 7/20/24 is not dated nor signed by the participant, family member, or legal representative. 2. The plan of care for Participant #4 dated 6/17/24 is not dated nor signed by the participant, family member, or legal representative. 3. The plan of care for Participant #5 dated 4/12/24 is not dated nor signed by the participant, family member, or legal representative. 4. Staff #4 confirms the plans of care were not signed.
Plan of Correction:	Family/participant participates via phone. However, moving forward will mail care plans requesting signatures.
Standard #:	22VAC40-61-300-A
Description:	Based on observation and interview, it was determined the center did not ensure the center shall have, keep current, and implement a plan for medication management. The center's medication management plan shall address procedures for administering medication and shall include procedures for proper disposal of medication Evidence: 1. During the onsite inspection, there was an expired medication (Brimonidine Tartate 0.2% solution) on the cart for participant #7. 2. Staff #2 confirms the medication was expired.
Plan of Correction:	The medication cart will be checked monthly by Clinical Manager and Quarterly by the Director of Nursing.