VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Assisted Living at Lucy Corr
6800 Lucy Corr Boulevard
Chesterfield, VA 23832
(804) 748-1511

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: June 9, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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. A monitoring inspection was initiated on 6/9/2020 and concluded on 6/10/2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census is 46. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three (3) resident records, three (3) staff records, medication administration and medical treatment records, physician orders, staff training and credentials, staff schedules, etc. submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Please complete the "plan of correction" and "date to be corrected" for the violations 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 corrections 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). All new personnel records were reviewed since the last inspection for criminal history record reports and all were in compliance.

Violations:

Standard #:	22VAC40-73-260-A
Description:	Each direct care staff member shall maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. To be considered current, first aid certification from community colleges, hospitals, volunteer rescue squads, or fire departments shall have been issued within the past three years. Based on a desk review for three staff, one staff did not have current certification in first aid. Evidence: The desk review found no documentation of current first aid certification for staff # 1.
Plan of Correction:	The facility will ensure that all direct care staff have current first aid certification. Each current direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days or when COVID-19 pandemic restrictions allow. 100% review of current staff first aid certification. Human resources will obtain first aid certification of all direct care staff during new hire onboarding process. The administrator/designee will work with human resources and employee development staff to audit direct care staff first aid certification annually to ensure compliance.
Standard #:	22VAC40-73-320-A
Description:	Based on a desk review of three resident files, the physical examination form for one resident did not address prohibited conditions. Evidence: Resident # 2 was admitted to the facility on 10/15/2019. The resident's admission physical examination dated 9/7/2019 did not address prohibited conditions. 0/
Plan of Correction:	The facility will ensure that each resident's admission physical examination address prohibited conditions. 100% review of current residents' admission physical examinations. Prior to admission the administrator/designee will confirm that page 2 of VDSS document 0325-05-007-9 is is completed by MD. The administrator/designee will conduct an audit annually of resident admission physical examinations to ensure compliance.