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MADONNA HOME INC.
814 W. 37th Street
Norfolk, VA 23508
(757) 623-6662

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: July 14, 2023

Complaint Related: No

Areas Reviewed:
22VAC40-73 GENERAL PROVISIONS
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
22VAC40-73 PERSONNEL
22VAC40-73 STAFFING AND SUPERVISION
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
22VAC40-73 BUILDINGS AND GROUND
22VAC40-73 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: Renewal
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/14/2023.
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.

Number of residents present at the facility at the beginning of the inspection: 13
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 6
Number of staff records reviewed: 3

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 #: 22VAC40-73-120-A
Description: Based on record review, the facility failed to ensure the orientation and training required in subsections B and C of this section occur within the first seven working days of employment.

Evidence:

1. The staff records of Staff #1 (hired 05/22/2023) and Staff #2 (hired 06/13/2023) do not include documentation of their staff orientation and initial training.

Plan of Correction: Staff orientation and initial training will be completed when the initial employment application is reviewed by the Administrator.

Standard #: 22VAC40-73-250-C
Description: Based on record review, the facility failed to ensure personal and social data be maintained on staff and included in the staff record.

Evidence:

1. Staff #2?s record does not include verification that the staff person has received a copy of their current job description.

Plan of Correction: Job descriptions will be placed in all potential employment applications.

Standard #: 22VAC40-73-260-A
Description: Based on record review, the facility 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 #3 works as direct care staff and does not have documentation of a current certification in first aid in their staff record.

Plan of Correction: The Assistant Administrator will check all CPR and first aid certifications on January fourth of every year.

Standard #: 22VAC40-73-330-A
Description: Based on record review, the facility failed to ensure a mental health screening be conducted prior to admission if behaviors or patterns of behavior occurred within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual.

Evidence:

1. Resident #2 admitted to the facility on 05/04/2023 and did not have a mental health screen completed in their resident record. The admitting UAI indicates Resident #2 had behavior within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-73-550-G
Description: Based on record review, the facility failed to annually review the rights and responsibilities of residents with each resident, or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person.

Evidence:

1. The records of Resident #1, Resident #3, Resident #4, and Resident #5 did not include a current written acknowledgement of having been so informed of the review of the rights and responsibilities of residents within the last year.

2. The records of Staff #1, Staff #2, and Staff #3 did not include a current written acknowledgement of having been so informed of the review of the rights and responsibilities of residents within the last year.

Plan of Correction: 1. All residents rights and responsibilities forms will be reviewed with the resident on the date of admission by the Assistant Administrator.

2. All written acknowledgments of rights and responsibilities will be reviewed yearly with the resident.

Standard #: 22VAC40-73-680-C
Description: Based on record review, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.

Evidence:

1. The July 2023 MAR for Resident #2 indicates the resident?s Nicotine 21 mg 24hr patch has not been administered 7/1/23-7/14/23 as it has not been available.

Plan of Correction: The LPN will be responsible for renewal of prescriptions and upon admission. The LPN will communicate with pharmacy to assure medications are placed on MARs correctly.

Standard #: 22VAC40-73-680-D
Description: Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.

Evidence:

1. Resident #2 admitted to the facility on 05/04/2023. Resident #2?s admitting medication list included an order for Sertraline 100mg tablet to be administered one time daily and Lamotrigine 100mg tablet to be administered one time daily; however, these two medications were never placed on Resident #2?s MAR or administered.

Plan of Correction: The LPN will be responsible for renewal of prescriptions and upon admission. The LPN will communicate with pharmacy to assure medications are placed on MARs correctly.

Standard #: 22VAC40-73-980-C
Description: Based on record review, the facility failed to ensure first aid kits be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date.

Evidence:

1. The first aid kit was last checked on 04/13/2023.

Plan of Correction: New first aid kit forms was designed to include sign off dates.

Standard #: 22VAC40-90-30-B
Description: Based on record review, the facility failed to ensure a sworn statement or affirmation be completed for all applicants for employment.

Evidence:

1. There is no sworn disclosure in Staff #2?s record.

Plan of Correction: All sworn statement is part of the employment application. The application will be checked by the charged nurse. The violation was corrected on 7/15/23.

Standard #: 22VAC40-90-40-B
Description: Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee.

Evidence:

1. There was not a completed criminal history record report for Staff #1 (hired 05/22/2023) and Staff #2 (hired 06/13/2023) in their record.

Plan of Correction: Have contacted the VA State Police. Date of contact 7/14/23.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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