VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Park at Oak Grove
4920 Woodmar Drive
Roanoke, VA 24018
(540) 989-9501

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: Dec. 16, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 BUILDING AND GROUNDS

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. An announced virtual initial inspection was initiated on 12/16/20 and concluded on 12/16/20. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 58. The Inspector virtually observed the facility physical plant, required postings and the facility first aid kit. All policy and procedures submitted by the facility were reviewed to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-100-A
Description:	Based on a review of the facility infection control polices, the facility failed to ensure that all required information was included in their infection control policy. EVIDENCE: 1. The facility infection control policy reviewed on 12/16/2020 did not contain policies regarding the determination of whether prospective or returning residents have acute infectious disease and use of appropriate measures to prevent disease transmission; Initial training as specified in 22VAC40-73-120 C 4 and annual retraining of staff and volunteers in infection prevention methods, as applicable to job responsibilities and as required by 22VAC40-73-210 F or documentation on the facility staff health program.
Plan of Correction:	1.The facility infection control policy and procedure will be updated to include policies regarding the determination of whether prospective or returning residents have acute infectious disease, use of appropriate measures to prevent disease transmission, and initial training as specified in 22VAC40-73-120 C 4 and annual retraining of staff and volunteers in infection prevention methods, as applicable to job responsibilities and as required by 22VAC40-73-210 F. 2.The Executive Director and/or Wellness Director will review the infection control policies and procedures at least annually to ensure compliance with the standard and to make any necessary updates. 3. The Executive Director or designee will ensure compliance with the standard.
Standard #:	22VAC40-73-300-A
Description:	Based on a review of facility policies, the facility failed to establish procedures for communication among administrators, designated assistant administrators, managers, and designated staff persons in charge. EVIDENCE: 1. The facility was unable to provide procedures for communication among administrators, designated assistant administrators, managers, and designated staff persons in charge on the day of inspection.
Plan of Correction:	1. The facility does have a policy for written communication amongst staff that serves as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents. 2. The Executive Director will update the policy to include procedures for communication among administrators, designated assistant administrators, managers, and designated staff persons in charge. 3. The Executive Director or designee will ensure compliance with the standard.