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: Feb. 9, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Clarification of Standard 40-73-150.F given

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 self reported incident was received by the Department regarding a resident elopement. A complaint investigation was initiated on 2/9/2021. The inspector also did a follow-up on the on site administrator. Evidence gathered during the investigation supported allegations of non-compliance with applicable standards or laws, and the violations are documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-150-B-1
Description:	Based on a remote inspection on 2/9/2021, the facility failed to notify the Department in writing within 14 days of a change in the facility's administrator. Evidence: The licensing administrator was informed during a telephone call with Staff B on 2/4/2021 that the facility had a new administrator in training. During a telephone call to the facility on 2/16/2021, Staff A identified herself as the new administrator. The required written notification has not been received as of 3/19/2021.
Plan of Correction:	Facility will perform written notification to Department of Change in administrator.
Standard #:	22VAC40-73-460-A
Description:	Based on the investigation of a self reported incident, the facility failed to assume general responsibility for the health, safety and well being of residents placing a resident at risk of harm. Evidence: During the complaint investigation of a self reported incident received on 2/9/2021, the incident report documented "Resident observed using a key to go into the business office where he remained for 12 minutes. He then used a fob key card to open the secured door in common area." In an email dated 2/23/2021, staff reported "we have no idea how he got a key" and that the fob key was assigned to a staff member that terminated employment at the facility on 12/20/2021. The facility is in a secure memory care environment for residents with a diagnosis of serious cognitive impairment. Resident # 1's ability to obtain access to the key to the business office and the fob key placed the resident at potential risk of health, safety and well being.
Plan of Correction:	In service all staff: 1.Awareness of keys/fobs to be maintained in secure area. 2. In service BOM (Business Office Manager) and FD (Facility Director) on the importance in Maintaining current record of terminated employees. 3. Reviewed the following topics: Terminated staff keys/fobs shall be collected and deactivated immediately after termination, Any lost keys/fobs will be reported to ED (Executive Director) and or FD; Fobs will be deactivated and locks will be rekeyed to ensure that unauthorized access is prohibited. 4. Audit completed on all currently programmed fobs to ensure all terminated associates fobs were deactivated. 5. Identified that locks to all management office were on same key and these locks were rekeyed.
Standard #:	22VAC40-73-460-D
Description:	Based on an investigation of a self reported incident, the facility failed to provide supervision of resident schedules, care and activities including attention to specialized needs, such as prevention of falls and wandering from the facility. Evidence: A self reported incident was received on 2/9/2021 regarding a resident elopement. The report documented that " resident was observed by RMA (VB) in the foyer area (the opposite side of the secured door) attempting to get back into the community." The report also documented that the facility had camera footage of the incident that was reviewed. The licensing inspector requested screen shots from the facility's administrator on 2/11/2021 of the incident to document the length of time that the resident (#1)was outside of facility. As of 3/19/2021, the requested information has not been received. The facility did not provide the requested screen shots to assist with the investigation or any documentation to support that supervision was provided to prevent wandering from the facility.
Plan of Correction:	Staff educated to conduct 2 hour checks as required and to document in YARDI. Care plans to be reviewed to ensure that each resident is scheduled for 2 hour checks for proper associate documentation.