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: Nov. 19, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL

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. An complaint inspection was initiated on11/19/2020 and concluded on 12/8/2020 to investigate allegations regarding on-site facility management, holiday visitation and infection control. The identified administrator was contacted by email to initiate the inspection. Based on a review of facility on-site management schedules and emails from facility staff, one of the allegations was determined to be valid. Information gathered during the inspection determined that one allegation was valid and a violation was cited and is documented on the violation notice issued to the facility. The provider's response(s) for the "plan of correction" were not received as of 1/5/2021 and will not appear on this Violation Notice."

Violations:

Standard #:	22VAC40-73-150-F
Complaint related:	Yes
Description:	Based on a review of management schedules for two Virginia licensed assisted living facilities, the facility failed to maintain an administrator on a full-time basis as the on-site agent of the licensee who is responsible for the day-to-day administration and management of the facility. Evidence: 1. On 11/19/2020 the Central Region Licensing office received two calls from family members of residents reporting that the "new" administrator is on- site only 1-2 days a week and that there is no administrator on site on weekends or scheduled to be on site during the upcoming Thanksgiving holiday. 2.The licensing inspector contacted the "new" administrator (staff # 1) using an email address provided by one of the family members. .A response was received from both the identified "new" administrator and the administrator of record at the licensing office (staff # 2) and the VP of Quality Assurance and Risk Management for the licensee. It was reported by all that there has been no changes in administrator since the notification of administrator change that was sent to the licensing office on 10/9/2020. 3. An email was received from staff # 1 on November 19, 2020.Staff # 1 noted in the email "At this time [staff # 2] is the Administrator for the community. At this point, I am providing additional support/coverage as the Senior Executive Director for our communities in Virginia. [Staff # 2] is currently traveling to the community, and I will let him respond with his schedule....I am here 1-2 days a week." A telephone call to the assigned inspector for for facility # 2 and a search of the Virginia Department of Social Services (VDSS) website confirmed that staff # 1 is the administrator for another Virginia licensed assisted facility ( # 2). 4.An email was received from staff # 2 on November 20, 2020 that noted "...I am listed as the Administrator of record at this time and [staff #1] has also been helping provide support coverage as the Senior Executive Director for Virginia on some days that I am not there due to travel, etc.". 5. Licensing staff requested and reviewed management schedules for November 2020 and December 2020 for facility # 1 and found: a. There is no on-site administrator listed on the November 2020 schedule for facility # 1 on the following dates: - 11/2/2020, 11/3/2020, 11/10/2020,11/13/2020, 11/16/2020, 11/17/2020, 11/18/2020, 11/26/2020 and 11/28/2020, These dates note either "The Phoenix at Lake Lanier" or "Holiday" or "Home". Staff # 2 is listed as the on-site administrator with "Travel to Midlothian" noted on 11/4/2020 and 11//19/1/2020. b. There is no on site administrator listed on the December 2020 schedule for facility # 1 for the following dates: 12/1/2020, 12/7/2020. 12/7-11/2020, 12/14/2020, 12/23/2020, 12/24/2020, 12/25/2020, 12/28/2020. These dates note either "The Phoenix at Lake Lanier" or "Holiday" or "Home". Staff # 2 is listed as the on-site administrator with "Travel to Midlothian" noted on December 2, 2020 and December 17, 2020. The Phoenix at Lake Lanier is located in Georgia. The November 2020 and December 2020 schedules submitted by the facility for review did not support the presence an administrator on site on a full-time basis.
Plan of Correction:	Not available online. Contact Inspector for more information.