VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Liza's Residential Care
5084 Langston Court
Virginia beach, VA 23464
(757) 495-9722

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

Inspection Date: April 22, 2021 and April 23, 2021

Complaint Related: No

Areas Reviewed:

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

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 or Virginia. A renewal inspection was initiated on 4/22/2021 and concluded on 4/23/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 5. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 2 resident records, 2 staff records, staff schedules, health care oversight, fire and emergency evacuation drills, and health inspection report submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance (s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-210-F
Description:	Based on record review and discussion the facility failed to ensure direct care staff receive at least two of the required hours of training focus on infection control and prevention annually. Evidence: 1. Staff #1?s date of hire is 10/1/10 and annual training period is 10/1/19-10/1/2020 and Staff #2?s date of hire is 10/29/12 and annual training period is 10/29/19-10/20/20. 2. Staff #1 and Staff #2 did not have at least two hours of training on infection control and prevention annually. 3. Staff #3 acknowledged that the aforementioned staff did not receive at least 2 hours of training on infection control and prevention annually.
Plan of Correction:	The administrator will ensure that the staff has a corresponding training on infection control and prevention for at least 2 hours a year.
Standard #:	22VAC40-73-320-A
Description:	Based on record review and discussion the facility failed to ensure the physical examination report documented the description of the person?s reaction to a known allergy. Evidence: 1. Resident #2?s physical examination report dated 2/10/21 documented a known allergy to Lisinopril; however did not document a description of the reaction. 2. Staff #3 acknowledged Resident #2?s physical examination report dated 2/10/21 did not include the aforementioned information. Based on record review and discussion the facility failed to ensure tuberculosis risk assessment form was obtained within 30 days preceding admission. Evidence: 1. Resident #2?s admission date was 2/17/21; however tuberculosis risk assessment was completed after admission on 2/25/21. 2. Staff #3 acknowledged Resident #2?s tuberculosis risk assessment was not completed within 30 days prior to admission date. Based on record review and discussion the failed to ensure the physical examination report documented a statement that specified whether the individual is or is not capable of self-administering medication. Evidence: 1. Resident #1?s physical examination report dated 1/22/21 did not indicate whether the resident is or is not capable of self-administering medication. 2. Staff #3 acknowledged Resident #1?s physical examination report dated 1/22/21 did not indicate if the resident is or is not capable of self-administering medication.
Plan of Correction:	The administrator will ensure, whatever the resident has an allergy to drugs or food must be documented and the reactions on it. This must be documented on the ISP and physical examination. The administrator will ensure the TB test of the resident must be done within 30 days prior to admission. The Administrator will ensure the resident's physical examination report must include their capacity of self administering their medication or not.
Standard #:	22VAC40-73-350-B
Description:	Based on record review and discussion the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. Evidence: 1. Resident #1?s admission date is 1/27/21 and the sex offender registry inquiry was completed after admission on 2/2/21. 2. Staff #3 acknowledged Resident #2?s sex offender registry inquiry was not completed prior to the admission date
Plan of Correction:	The Administrator will ensure to obtain sex offender inquiry prior to admission of the resident.
Standard #:	22VAC40-73-490-D
Description:	Based on record review and discussion, the facility failed to ensure the licensed heath care professional identified the specific residents for whom the oversight was provided. Evidence: 1. Health Care Oversight dated 12/1/20 to 3/20/21, did not document the names of the residents for whom the oversight was provided. 2. Staff #3 acknowledged that the health care oversight review did not identify the specific residents that were reviewed.
Plan of Correction:	The Administrator will ensure the healthcare oversight must include the name of the residents that were reviewed.
Standard #:	22VAC40-73-970-A
Description:	Based on record review and discussion the facility failed to conduct fire and emergency evacuation drills as required during each shift in a quarter. Evidence: 1. Fire and emergency evacuation drills conducted were dated 1/21/21 at 10am (7am-3pm 1st shift); 2/21/21 at 2pm (7am-3pm 1st shift); and 3/20/21 at 5am (11pm-7am 3rd shift). 2. During January-March 2021 (first quarter); no fire and emergency evacuation drill was conducted on the 3pm-11pm 2nd shift. 3. Staff #3 acknowledged there was no fire and emergency evacuation drill conducted on the 3pm-11pm 2nd shift for the first quarter.
Plan of Correction:	The Administrator will ensure that the monthly fire and emergency evacuation drills must be done on each shift in a quarter.