VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Emily Green Shores
500 Westmoreland Avenue
Portsmouth, VA 23707
(757) 399-3442

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: May 11, 2021 and May 12, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-90 The Criminal History Record Report

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 May 11, 2021 and concluded on May 12, 2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 26. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, activities calendar, staff schedules, menu, fire and emergency drills, criminal record checks submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-290-A
Description:	Based on record review and discussion, the facility failed to maintain a written work schedule that included the names and job classifications of all staff working each shift. Evidence: 1. The April 2021 "Med Tech [Medication Technician]" and "Direct Care" staff schedules did not identify which staff were working each shift. 2. Staff #1 confirmed during discussion that the times of each shift were not specified on the schedules.
Plan of Correction:	RCC will ensure that the staff schedules will be colored coded with shift hours to reflect which staff will be working each shift.
Standard #:	22VAC40-73-680-I
Description:	Based on record review and discussion, the facility failed to ensure the Medication Administration Record (MAR) included the diagnosis, condition, or specific indications for administering the drug. Evidence: 1. Resident #2?s March 2021 MAR was missing the diagnosis, condition, or specific indications for administering the drug for the following medications: Cyanocobalamin 1000mg, Namenda XR 28 mg, and Neurontin 100 mg. 2. Staff #1 confirmed Resident #2's March 2021 MAR was missing the diagnoses, conditions, or specific indications for administering the drug for the three medications.
Plan of Correction:	RCC will review MAR's weekly to ensure each MAR has the appropriate documentation to include the indications.
Standard #:	22VAC40-90-40-C
Description:	Based on record review and discussion, the facility failed to ensure any person required by this chapter to obtain a criminal history record report shall be ineligible for employment if the report contains convictions of the barrier crimes. Evidence: 1. Staff #4?s dates of employment were 03-16-2021 to 04-21-2021 as housekeeping staff. Staff #4?s criminal history record report dated 03-16-2021 contained a barrier crime that made staff ineligible for employment. 2. Staff #1 confirmed dates of employment and that Staff #4 was employed despite ineligibility due to barrier crime conviction.
Plan of Correction:	Administrator will continue to terminate any employee who has a barrier crime record upon receipt of the criminal background check.