VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise at Bon Air
2105 Cranbeck Road
Richmond, VA 23235
(804) 560-7707

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: Dec. 16, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES

Comments:

A remote monitoring was conducted regarding a self-report on December 16, 2021. The Administrator was interviewed via email regarding Administration and Administrative Services.

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on interview with staff, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. Staff #1 reported on 12-15-2021 via email that, "...unfortunately [Staff #2] became ill and tested positive for COVID and also out of the community." 2. The regional licensing office was not notified of the COVID positive reported incident until 12-15-2021 despite Staff #2 testing positive on 12-10-2021. The Central regional office was not notified within 24 hours.
Plan of Correction:	A. With respect to the specific violation cited: On 12/16/2021 the Executive Director (ED) reported to the Licensing inspector by email two events that occurred at the community. Upon identification of the events protocols were promptly followed by the Department Head Team and no negative outcomes from late reporting occurred. B. With respect to how the facility will identify procedure for timely reporting: The ED provided training and material to the Department Head Team on reporting major events as required to Regional Licensing in the absence of the ED. C. With respect to what systemic measures have been put into place to address the stated concern: Upon an event occurring the ED is notified and determines if the event needs to be reported to the Regional Licensing office and follows the reporting procedures. Daily the ED and the Department Head Team review the events that have occurred within the past 24 hours. The events are reported as required to the Regional Licensing office by the ED. In the absences of the ED, a department head team member or a trained designee completes the reporting process. Upon return the ED verifies the reporting process was properly followed. D. With respect to how the plan of correction will be monitored: The verification of this reporting process will be evaluated and confirmed the ED, RCD or designee at Quality Assurance and Performance Improvement (QAPI) meeting for the next 3 months. During and at the end of the 3 months, the QAPI Committee will evaluate the results and determine if additional focus or action is warranted The Executive Director, RCD or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.