VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Emily Green Shores
500 Westmoreland Avenue
Portsmouth, VA 23707
(757) 399-3442

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Feb. 19, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced focused monitoring inspection was conducted by two Licensing Inspectors on February 19, 2020 from 1:39 p.m. to 3:25 p.m. There were 28 residents in care. The Administrator, Administrative Assistant, and Resident Care Coordinator were present during the inspection. The following topics were discussed: documenting verbal communications with staff and resident/resident?s responsible party, admission of residents, and clarification on physician?s orders. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice. The plan of correction must indicate how the violation will be or has been corrected. Your plan of correction should include: 1. Step(s) to correct the non-compliance 2. Methods to prevent re-occurrence, and 3. Person(s) responsible for implementing each step and/or monitoring any preventive action(s). The plan of correction is due within 10 calendar days.

Violations:

Standard #:	22VAC40-73-510-A
Description:	Based on record review and interview, the facility failed to assist a resident in obtaining and securing services from the local community services board based on the resident?s current evaluation and failed to maintain documentation of the efforts made to obtain the services if they were not available. Evidence: 1. A letter titled ?The Pavilion? was signed and dated by the psychiatrist on 01-29-2020 documenting resident #1 was under the care of a psychiatrist from 12-06-2019 through 01-16-2020. Resident #1 has a diagnosis of Schizophrenia; disorganized type and Unspecified Mood disorder; and has a history of medication non-compliance. The psychiatrist recommended for the resident to follow up with an outpatient psychiatric provider on a regular basis; so that he/she can further monitor the resident?s mental health. 2. Resident #1?s ?Agreement for Mental Health Services? form was signed and dated by the psychiatrist on 01-30-2020 documenting a recommendation for the family to contact Portsmouth Community Services Board (CSB) for case management services and for emergency services. 3. Staff #1 stated that the facility did not assist resident #1 in obtaining services with Portsmouth CSB. Staff #1 could not provide documentation of the reason why services were not obtained, nor the efforts that were made by the facility to obtain the services, as of 02-19-2020. 4. During the inspection, staff #1 contacted resident #1?s family and asked if the family had contacted Portsmouth CSB to arrange for services. Resident #1?s family stated they did not know that they needed to contact Portsmouth CSB. 5. Staff #1 acknowledged the facility did not secure services with the Portsmouth CSB for resident #1.
Plan of Correction:	Administrator/RCC will ensure that documentation is complete on all Admissions requiring Mental Health Services and ensure that assistance be provided if needed with our local Community Service Board and document efforts made to obtain services.