VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Helping Hands for Heroes
3315 High Street
Portsmouth, VA 23707
(757) 538-7900

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: Feb. 11, 2025

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 63.2 GENERAL PROVISIONS 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

22VAC40-90-40

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: 02/11/2025 from 09:07 am to 12:55 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: 19 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: 2 Additional Comments/Discussion: There were no medications administered in the center during the onsite inspection. The following were reviewed: participant records, staff records, criminal record checks, water temperature, observation of activity 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. 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov

Violations:

Standard #:	22VAC40-61-140-B
Description:	Based on observation and interview, it was determined the center did not ensure that the direct care staff meet one of the requirements in this subsection. Evidence: 1. Staff #3 works at the center as direct care staff; however, their record did not include Direct Care qualifications.
Plan of Correction:	Staff 3 completed a 40 hour personal care skills checklist but the proper paperwork wasn?t presented until now. Upon hire staff 3 had been a medical assistant.
Standard #:	22VAC40-61-180-E
Description:	Based on observation and interview, the center did not ensure that all staff had been screened annually for tuberculosis. Evidence: 1. Staff #4?s record did not contain an annual TB assessment. Last assessment was completed 1/8/2024.
Plan of Correction:	Staff 4 Annual TB Screening has been completed. All staff moving forward will have a annual TB assessment.
Standard #:	22VAC40-61-230-D
Description:	Based on record review, the center did not 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, 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:	Participant 1 plan of care was updated 2/24/25 to include full description of addition l needs and dates and expected outcomes or goals to be achieved.
Standard #:	22VAC40-61-260-A
Description:	Based on record review, the center did not ensure within the 30 days preceding admission, a participant shall have a physical examination by a licensed physician. Evidence: 1. Participant #2 start date was 11/1/24, the physical in the record was dated 9/19/24.
Plan of Correction:	Moving forward if physical is not completed within 30 days we will have the doctor will have to provide us a statement of no changes since the last visit.
Standard #:	22VAC40-61-260-B
Description:	Based on participant record review and staff interview, the facility did not ensure that the report of the required physical examination included a statement that specifies whether the individual is or is not capable of self-administering medication, or a statement that specifies whether the individual is considered to be ambulatory or non ambulatory. Evidence: 1. During the record review for Participant #1, it was noted that the facility?s Registered Nurse documented on the physical form that the participant could not self-administer medications and that the participant was not ambulatory. It was not completed by the physician who completed the initial physical.
Plan of Correction:	The physician only noted that participant 1 has worsening dementia while our RN gave a much more detailed evaluation. Moving forward we will ensure that the physician and the RN notes are the same.
Standard #:	22VAC40-61-520-D
Description:	Based on observation and interview, it was determined that the center did not ensure that the center shall review the emergency preparedness and response plan annually or more often as needed, document the review by signing and dating the plan, and make necessary revisions. Such revisions shall be communicated to staff, participants, and volunteers and incorporated into the orientation and semi-annual review. Evidence: 1. During renewal inspection on 2/13/25, there was no documentation that the emergency preparedness and response plan was reviewed annually.
Plan of Correction:	Emergency preparedness and response has been updated and created.