VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Discovery Commons Virginia Beach
1628 Old Donation Parkway
Virginia beach, VA 23454
(757) 496-8001

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Nov. 8, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

A renewal inspection was initiated on 11-08-2021 and concluded on 12-01-2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 106. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 5 resident records, 5 staff records, staff schedule, activity calendar, fire and emergency drills, and menus submitted by the facility to ensure documentation was complete. Two inspectors conducted the on-site portion of the inspection on 12-01-2021. An exit interview was conducted with the Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. 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 #:	22VAC40-73-450-C
Description:	Based on documentation review, the facility failed to ensure the Individualized Service Plan (ISP) included a description of the resident?s identified needs based on the Uniform Assessment Instrument (UAI). Evidence: 1. Resident #4?s UAI dated 10-11-2021 documented the need of medication administration by professional nursing staff; however, the current ISP dated 10-11-2021 does not address the need.
Plan of Correction:	ISP for #4 was reviewed by RRD and updated to appropriately reflect this Resident #4 current needs including medication administration. An audit of current residents will be completed by RSD and LGD or designee to ensure that ISP's accurately reflect all residents' needs, and any discrepancies will be corrected at review time. Training will be provided by the Divisional Director of Care to RSD, LGD, RSS, RRD and ED on completing accurate and timely ISPs. For the next 90 days, Executive Director (ED) to check all ISPs after they are updated to ensure they accurately reflect that residents' current needs and any issues will be corrected at time of review.
Standard #:	22VAC40-73-980-B
Description:	Based on observation and interview, the facility failed to ensure a completed first aid kit without expired items in a motor vehicle that is used to transport residents. Evidence: 1. A review of a first aid kit from one of the facility?s vehicles with Staff #7 contained hand cleaner expired 07-2020 and antiseptic wipes expired 12-2019. 2. Staff #6 and Staff #7 acknowledged these two items were expired and removed from the first aid kit.
Plan of Correction:	The first aid kits were audited during survey utilizing the First Aid Kit Checklist available at the community. Those items required to be available per regulatory standard are accounted for in each first aid kit. The ED will provide training to the Engage Life Director (ELD) and Drivers on the items that are required to be available in the first aid kit per regulatory standard, and how to appropriately complete the monthly checklist to assure continued compliance. Using a checklist, the ELD or designee will complete a monthly review of the contents of the first aid kits available on the van to assure appropriate contents are available for continued compliance. ED will randomly audit for the next 90 days to monitor continued compliance of the monthly checklist being utilized.