VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lake Prince Woods
100 Anna Goode Way
Suffolk, VA 23434
(757) 923-5500

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Sept. 9, 2020 and Sept. 10, 2020

Complaint Related: No

Areas Reviewed:

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 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 09-09-2020 and concluded on 09-10-2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 27. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, criminal background checks and sworn disclosures of newly hired staff, staff schedules, fire drills, fire and health inspection reports, dietary oversight, and healthcare oversights submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-210-A
Description:	Based on staff records reviewed and interview, the facility failed to ensure each direct care staff attended at least 12 hours of training annually in a facility licensed for both residential and assisted living care. Evidence: 1. Staff #4 was hired on 10-11-2016 as a Registered Medication Aide (RMA) and Certified Nurse Aide (CNA). Staff #1 provided documentation staff #4?s training record which documented 7.5 out of the required 12 hours of training were completed from 10-11-2018 to 10-11-2019. 2. Staff #1 could not provide additional documentation of 4.5 hours of annual training for staff #4. 3. When asked if staff #4 had any additional annual training hours from 10-11-2018 to 10-11-2019 staff #1 stated staff #4 ?does not have additional hours.?
Plan of Correction:	Staff #4 was counseled on obligation to complete the required 12 hours of training and is current at present. The Associate Executive Director and the Staff Development Manager reviewed current direct care staff's education files for compliance with training hours. The AL Director will be notified of any direct care staff member who has not met their training obligations. The AL Director will ensure all annual trainings are completed as assigned. If non-compliance is identified, the direct care staff member will receive a corrective action and potential removal from the schedule until required training obligations are completed. This overall compliance measure will be monitored and reported quarterly to the QAPI Committee by the Associate Executive Director.
Standard #:	22VAC40-73-260-A
Description:	Based on staff records reviewed and interview, the facility failed to ensure each direct care staff member maintained current certification in first aid. Each direct care staff member who does not have current certification in first aid should receive certification in first aid within 60 days of employment. Evidence: 1. Staff #3 was hired as a Registered Medication Aide on 10-01-2019. Staff #1 could not provide documentation of staff #3?s current certification in first aid. Staff #3 did not receive certification in first aid within 60 days of employment. 2. Staff #1 acknowledged staff #3 did not have or receive certification in first aid within 60 days of employment.
Plan of Correction:	The last day employee #3 worked was 5/15/2020. According to the facility attendance policy, this employee will be terminated from the system. The AL Director and HR/Payroll Manager conducted an audit on 9/10/2020 of all direct care staff members to determine if all first aid certifications were current. No discrepancies were identified. Quarterly, the HR/Payroll manager will audit all direct care staff HR files monthly and update AL Director regarding noncompliance. During orientation, the HR/Payroll manager will notify the AL Director of those staff members that do not have a current first aid certificate. The AL Director will monitor certification status to ensure certification is completed within the first 60 days of employment. If non-compliance is identified, the direct care staff member will be removed from the schedule until certification is obtained. This overall compliance measure will be monitored and reported quarterly to the QAPI Committee.