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: March 10, 2020

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

Comments:

An unannounced renewal inspection was conducted at the facility from approximately 10: 50 am to 2:48 pm. The facility reported 30 residents in care, six resident and three staff files were reviewed for compliance along with required program and file documentation. The files were found well organized. Staff was observed engaging in group and individual activities with the residents. The physical plant was found well maintained, odor free and clean. Licensing staff also made medication administration observations and communicated with staff and residents.. All new personnel records were reviewed since the last inspection for criminal history record reports and all were in compliance. Please complete the "plan of correction" and "date to be corrected" for the violation cited on the violation notice and return to the Inspector within 10 days. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1) steps to correct the non-compliance with the standard, 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). See violation notice for non-compliance

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on a review of six resident files and an interview with the facility's administrator on 3/10/2020, there was no documentation to support that the facility provided a disclosure statement to one resident and his legal representative. Evidence: Documentation of the provision of a disclosure statement was not found during a review of the file for resident # 6. The administrator confirmed that the disclosure statement was not in the file.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-260-A
Description:	Based on a review of three staff files and an interview with the facility's administrator, one staff did not secure first aid certification within 60 days of employment. Evidence; The documented hire date for staff # 1 is 11/21/2019. Documentation of current first aid certification was not found during a review of the file for staff # 1 on 3/10/2020.
Plan of Correction:	A 100% Audit has been completed in this area to ensure no other noncompliance. The employee who did not have her First Aid certification has been signed up to attend a class to obtain the required certification, scheduled for April 9th, 2020. The facility is providing a CPR and First Aid class for this employee, as well as any other employees who will be up for renewal soon of these certifications on April 9th, 2020, which will be the date of full compliance. All new hires will be asked to show proof of having their First Aid certification upon hire or be scheduled to attend a class to obtain that certification prior to completing their orientation with tracking of renewals accordingly. ED will review weekly current New Employee files upon completion by BOM and verify checklist completed and CPR compliance met
Standard #:	22VAC40-73-310-D
Description:	Based on a review of six resident files and an interview with the facility's administrator on 3/10/2020, there was no documentation to support that one resident was provided written assurance that the facility has the appropriate license to meet his care needs at the time of admission. Evidence: Evidence: Documentation of the provision of written assurance was not found during a review of the file for resident # 6. The administrator confirmed that the written assurance was not in the file.
Plan of Correction:	A 100% Audit has been completed in this area to ensure no other noncompliance in this area. The Letter of Written Assurance has been sent to the resident?s legal guardian for a signature and confirmation given that the form will be returned within the next seven days. Plan of Correction should be complete no later than March 25th, 2020, which is when the form is expected to be returned by the legal guardian. All new resident files will be audited by the Business Office Manager utilizing New MI Checklist prior to move in to ensure that all paperwork is complete and that there are no missing forms/signatures. Executive Director will review each New Resident File to assure checklist is completed. Regional Director of Operations/Regional Business Office Manager will conduct random monthly audit of 3 current month New Resident Files for results in compliance and recorded in file
Standard #:	22VAC40-73-410-A
Description:	Based on a review of six resident files and an interview with the facility's administrator on 3/10/2020, there was no documentation to support that the facility provided orientation for three residents and their legal representatives. Evidence: Documentation of the orientation was not found during a review of the files for residents #1, # 5 or # 6. The administrator confirmed that the orientation was not in the files.
Plan of Correction:	A 100% Audit has been completed in this area to ensure no other noncompliance in this area. The Community is reaching out to the three residents? legal guardians to ensure that they received orientation within the community and to answer any questions they might have. Plan of Correction will be complete within thirty days of the date of the renewal inspection. We will not only be reaching out to the residents? legal guardians to ensure that they received orientation to the community, but also mailing out forms for them to sign acknowledging as such for the resident?s file. All new resident files will be audited by the Business Office Manager utilizing the New MI Checklist within twenty-four hours of move in to ensure that a full orientation was provided using the New MI Orientation checklist, to both the resident and their legal guardian. Executive Director will review each New Resident File to assure checklist(s) are completed as well as participating as outlined Regional Director of Operations/Regional Business Office Manager will conduct random monthly audit of 3 current month New Resident Files for results in compliance and recorded in file
Standard #:	22VAC40-73-490-A
Description:	Based on review of health care oversight documents and an interview with the facility's administrator, there was no documentation to support that health care oversight had been completed at least every three months for residents who meet the assisted living level of care. Evidence: A review of the facility's health care oversight documents found that the last health care oversight for residents who meet assisted living level of care was completed in November 2019.
Plan of Correction:	A Health Care Oversight review was completed on March 17, 2020 and has been emailed to the Licensing Inspector to verify completion. At Risk meetings conducted with Admin./Wellness team monthly will allow for identifying the need for residents requiring Health Care Oversight Executive Director/Wellness Director will monitor process and completing an audit monthly to ensure that the Record of On-Site Health Care Oversight has been completed and filed for compliance Regional Director of Operations/ Corporate Clinical Support Specialist will be completing an audit quarterly to ensure that the Record of On-Site Health Care Oversight has been completed and filed for compliance