VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sun Rise on the South Home Care and Transportation
3000 South Street
South chesterfield, VA 23834
(804) 605-7573

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: June 26, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

An unannounced 60 day mandated monitoring inspection was completed at the facility on 6/26/2019 from approximately 1:00 pm to 3:15 pm by two licensing inspectors. The facility had six residents in care on the day of the inspection. Four resident and three staff files were reviewed for compliance along with other required program documentation. A review of criminal background checks for the three staff files found one file was not in compliance. 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. The provider's responses for the plan of correction was not received as of 7/8/19 will not appear on the violation notice.

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on a review of four (4) resident files, the facility failed to provide a statement to the prospective resident and/or his legal representative that discloses required information about the facility. Evidence: The four resident files reviewed did not have documentation of a disclosure statement.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-120-A
Description:	Based on a review of three (3) staff files on 6/26/2019, orientation was not completed within seven days of employment for one staff. Evidence: The documented hire date for staff # 1 is 6/11/2019. There was no documentation of orientation for staff #1 found during the file reviews.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-250-C
Description:	Based on a review of three (3) staff files on 6/26/2019, one staff did not have a criminal background check completed and one staff did not receive a copy of his/her current job description. Evidence: Verification that staff # 3 has received a copy of a job description was not found during the file reviews. Documentation of the completion of a criminal background check for staff # 1 was not found during the file reviews.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-310-H
Description:	Based on a review of four (4) resident files on 6/26/2019, the physical examinations for two residents did not address the prohibited conditions. Evidence: The file reviews found that he physical examinations in the files of residents # 2 and # 3 did not address prohibited conditions.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-A
Description:	Based on a review of four (4) resident files, a physical examination was not obtained 30 days preceding admission to the facility for two residents. Evidence: The file reviews found that the files for residents # 1 and # 4 did not have documented physical examinations.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-350-B
Description:	Based on a review of four (4) resident files, the facility failed to ascertain prior to admission whether potential residents were registered sex offenders. Evidence: The four resident files reviewed did not have sex offender screenings documented.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-F
Description:	Based on a review of four (4) resident files, a UAI (uniform assessment instrument) was not completed within 90 days prior to admission for one resident. Evidence: Resident # 4 had a UAI on file that was completed on 3/15/2017. The facility was licensed as an assisted living facility on 4/30/2019. The facility did not update the UAI on file or complete a new UAI within 90 days of admission to the licensed facility.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-L
Description:	Based on a review of four resident files, a complete uniform assessment instrument (UAI) was not maintained for one resident. Evidence: The UAI for resident # 1 did not document a level of care as some pages of the UAI were missing.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-A
Description:	Based on a review of four resident files on 6/26/2019, an individualized service plan was not completed for the four residents on or within seven days prior to admission. Evidence: 1. Resident # 1 was admitted to the facility on 5/23/19, the documented completion date of the service plan was 6/17/2019. 2. Resident # 2 was admitted to the facility on 5/29/19, the documented completion date of the service plan was 6/17/2019. 3. Resident # 3 was admitted to the facility on 5/4/19, the documented completion date of the service plan was 6/17/2019. 4. Resident # 4 was admitted to the facility on 8/1/18, the documented completion date of the service plan was 6/17/2019.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-880-B
Description:	Based on an inspection at the facility on 6/26/2019, a temperature of 72 degrees is not being maintained throughout the building. Evidence: Licensing staff measured the temperature in the upstairs dining room, the temperature was 80 degrees.
Plan of Correction:	Not available online. Contact Inspector for more information.