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 30, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

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 renewal inspection was initiated on 03/30/2021 and concluded on 04/8/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census is 28 residents. 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 records, physician orders, fire and health inspection reports, fire drills, staff schedules, etc. submitted by the facility for compliance. 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.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on a review of three residents files, licensing staff could not determine if one resident was assessed prior to admission to the safe, secure environment by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: The physician assessment form for resident # 1 did not have a complete resident's name (only the first name and an initial), a date of birth for the resident, or an address/telephone number for the individual who completed the form.
Plan of Correction:	Staff to be in-serviced on completion requirements and accuracy of new resident paperwork.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of three resident files, the individualized service plan (ISP) for one resident did not address the identified needs of the resident. Evidence: 1. The individualized service plan submitted for resident # 3 states that the resident is on a "no concentrated sweets" diet, the physician orders submitted by the facility state CCHO (Consistent Carbohydrate diet).The original date of the physician order is 11/25/2019. 2. The physician orders submitted by the facility for resident # 3 state that the antipsychotic is liquid, the individualized service plan submitted states "to be crushed and placed in food". The original date of the physician order is 2/16/2021.
Plan of Correction:	Audits of all special diets to ensure accuracy of ISP to physicial order. Quarterly audits to be completed by dietician.