VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Clean Hands Pure Hearts Adult Day Center LLC
1421 Kempsville Road
Suite D
Chesapeake, VA 23320
(757) 819-6774

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Dec. 12, 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 22VAC40-80 THE LICENSE 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

Activity Calendar

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: An unannounced monitoring inspection took place on 12/12/24 at 9:33 am to 12:33 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: 5 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 2 Number of staff records reviewed: 3 Number of interviews conducted with participants: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation of lunch and an activity was completed. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-61-180-E
Description:	Based on the record review and staff interview the center failed to ensure each staff person and volunteer identified in this subsection shall obtain an evaluation provided by a qualified licensed practitioner that completes an assessment for tuberculosis (TB) in a communicable form no earlier than 30 days before or no later than seven days after employment or contact with participants. Evidence: 1. The record for staff # 1, hire date of 7/01/24, did not contain an assessment for TB. 3. Staff #1 confirmed the record for staff #1 did not contain an assessment for TB.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-220-A
Description:	Based on the record review the center failed to ensure a written assessment of a participant shall 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?s #2 written assessment dated 11/25/24 is signed and dated as being completed by staff #2. 2. The record for staff #2 does not contain documentation of staff #2 meeting the requirements of the director or a licensed health care professional. 3. Staff #1 was not able to provide documentation of staff #2 meeting the qualifications of the director or a licensed healthcare professional.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-220-G
Description:	Based on the record review the center failed to ensure the initial assessment and any reassessments shall be in writing and completed, signed, and dated by the staff person identified in subsection A of this section. Evidence: 1. Participant?s #1 initial assessment was not signed and dated by the director or a staff person who meets the qualifications of the director.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-230-B
Description:	Based on the record review the center failed to ensure the participant plan of care shall be developed 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?s #1 plan of care dated 9/16/24 is signed and dated as being completed by staff #2. 2. Participant?s #2 plan of care dated 11/25/24 is signed and dated as being completed by staff #2. 3.The record for staff #2 does not contain documentation of staff #2 meeting the requirements of the director or a licensed health care professional. 4. Staff #1 was not able to provide documentation of staff #2 meeting the qualifications of the director or a licensed healthcare professional.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-260-A
Description:	Based on the record review and staff interview the center failed to ensure within the 30 days preceding admission, a participant shall have a physical examination completed by a licensed physician. Evidence: 1. The record for participant #1, admission date of 9/17/24, contains a physical examination dated as completed on 9/25/24, which is after the resident?s admission date. 2. The record for participant #2, admission date of 11/25/24, contains a physical examination dated as completed on 9/23/24, which is more than 30 days preceding the resident?s admission.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-260-B
Description:	Based on the record review the center failed to ensure the report of the required physical examination shall be on file at the center and shall include: an evaluation by a qualified licensed practitioner that completes an assessment for tuberculosis (TB) in a communicable form no earlier than 30 days before admission, and a statement that specifies whether the individual is considered to be ambulatory or nonambulatory. Evidence: 1. The record for participant #1, admission date of 9/17/24, contains an evaluation for TB completed on 9/27/24, which is after the resident?s admission date. 2. Participant?s #1 physical examination dated 9/25/24 does not contain a statement that specifies whether the individual is considered to be ambulatory or nonambulatory. 3. Participant?s #2 physical examination dated 9/23/24 does not contain a statement that specifies whether the individual is considered to be ambulatory or nonambulatory.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-330-D
Description:	Based on observation and staff interview the center failed to ensure there shall be a designated staff person who is routinely present in the center and who shall be responsible for managing or coordinating the structured activities program. This staff person shall maintain personal interaction with the participants and familiarity with their needs and interests and shall meet at least one of the qualifications as listed in the section (22VAC40-61-330). Evidence: 1. The facility staff list did not include identification of a designated staff person who meets the qualifications to manage or coordinate a structured activities program. 2. Staff #1 was not able to provide documentation of a designated staff person who meets the qualifications to manage or coordinate a structured activities program
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-540-E
Description:	Based on the fire drills review the center failed to ensure a record of the required fire and emergency evacuation drills shall be kept in the center for two years. Such record shall include all items as listed in this section (22VAC40-61-540-E) Evidence: 1. The facility?s fire drill records dated 11/12/24 and 12/02/24 did not include the following: Identity of the person conducting the drill; The time of the drill; Method used for notification of the drill; Number of staff and participants participating; Any special conditions stimulated; The time it took to complete the drill; and weather conditions.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-90-40-B
Description:	Based on the onsite record review, the center failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each staff person. Evidence: 1. The record for staff #2, hire date 9/23/24, contains a criminal history record report dated 11/25/24.
Plan of Correction:	Not available online. Contact Inspector for more information.