VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Pearl at Watkins Centre
650 Watkins Centre Parkway
Midlothian, VA 23112
(804) 893-0067

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: June 25, 2019

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

Comments:

An unannounced non-mandated focus inspection was conducted at the facility by two licensing inspectors o 6/25/2019 to follow-up on compliance with plans of correction for risk violations cited during inspections at the facility on 4/3/2019, 4/17/2019 and 5/2/2019. All risk violations previously cited have been corrected as indicated on the plans of correction. Two non-compliances were found during this inspection. The facility has 10 calendar days from receipt of the inspection reports to complete a plan of correction, sign the inspection reports and return them to the licensing office. A copy of the inspection reports shall be retained to be posted at the facility. Results of the inspection are subject to public disclosure and will be posted on the VDSS website within 15 calendar, regardless of whether the plan of correction is completed .Just writing the word ?corrected? is not acceptable. The plan of correction shall include the following: (1) Step(s) the facility will take to correct the violations cited; (2) Measures that will be put in place to prevent reoccurrence of each violation; (3) Person(s) responsible for implementation and monitoring of preventive measures; and (4) Date by which each violation will be corrected.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on a review of three resident files, the service plans did not have a written description of the services to be provided to meet some of the residents' identified needs. Evidence: A review of the individualized service plans for the three residents found that some identified needs lacked a description of services/strategies to be provided by the facility to accomplish/meet the residents' needs.
Plan of Correction:	ED (Executive Director) or designee will review service plans to ensure all have written description of services to be provided to meet resident needs. ED will review monthly and RDO (regional Director of Operations)and RDRC (Regional Director of Resident Care and Services) will perform quarterly audits to ensure written descriptions of services are noted to meet residents' needs.
Standard #:	22VAC40-73-450-E
Description:	Based on a review of three resident files on 6/26/2019, the individualized service plan for one resident was not signed and dated by facility staff. Evidence: A review of the file for resident # 3 found that the current ISP had not been signed or dated by any facility staff. The signature lines were blank.
Plan of Correction:	ED (Executive Director) or designee will review ISPs (individualized service plans) to ensure all are signed by facility staff. RDO (regional Director of Operations)and RDRC (Regional Director of Resident Care and Services) will conduct quarterly audits of the resident ISPs to ensure service plans are signed by facility staff.