VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Arden Courts (Richmond)
13800 Bon Secours Drive
Midlothian, VA 23114
(804) 378-5100

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Feb. 22, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

A non-mandated complaint investigation was initiated on 02/09/2022 and concluded on 02/22/2022. A complaint was received by the department against the facility regarding allegations in the areas of Personnel. Facility staff was contacted via email to initiate the investigation. The licensing inspector emailed the facility staff a list of facility documentation regarding the allegations. The inspector was onsite at the facility on 02/22/2022 and interviewed the Regional Director of Operations and the facility?s Director of Nursing. The facility reported that thirty six residents were in care and that the facility is still without a licensed Administrator. The inspector reviewed documentation offered by the facility noting that a licensed facility Administrator was scheduled to start at the facility on 02/23/2022. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law. If you have any questions I can be reached at (804z0 840-0253 or angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-150-A
Complaint related:	Yes
Description:	Based on the interviews conducted the facility failed to ensure that the facility had an administrator of record. Evidence: 02/22/2022: During interviews conducted while on site at the facility the Regional Director of Operations for the facility and the facility?s Director of Nursing confirmed that while residents are in care the facility has been without a licensed facility Administrator since 01/27/2022. The Regional Director of Operations also reported during the interview that a licensed facility administrator was scheduled to start employment on 02/23/2022. For twenty-seven (27) days beginning 01/27/2021 until 02/23/2022 the Licensee did not ensure that an individual was onsite that met the qualifications as the individual that would be responsible for the day to day operation and management of the facility as required in the current Standards for Licensed Assisted Living Facilities.
Plan of Correction:	FACILITY RESPONSE- "RDO and/or designee of ProMedica will provide written notice via email within 14 days alerting both the Virginia Department of Social Services (DSS) and the Virginia Board of Long-term Care Administrators of the absence of the facility?s Executive Director. This notice will include the last working day of the previous ED and identify who the facility is designating as the acting licensed person in charge of the day- today operations of the facility. If the designated person in charge is not a licensed administrator, the acting administrator will be in place for a period of no longer than thirty (30) days. RDO or designee will ensure the community always have a licensed health care professional in the facility at least forty (40) hours a week to oversee the day-to-day operations of the facility"
Standard #:	22VAC40-73-150-B-2
Complaint related:	Yes
Description:	Based on the review of emails received at the department and interviews conducted the facility failed to immediately notify the Virginia Board of Long-Term Care Administrators and the department's regional licensing office that the licensed administrator resigned, and that a new licensed administrator has been employed or that the facility is operating without an administrator licensed by the Virginia Board of Long-Term Administrators, whichever is the case, and provide the last date of employment of the previous licensed administrator. The evidence gathered revealed the following: On 01/04/2022 via an email the previous facility Administrator reported to the Division of Licensing Programs that his last day of employment at the facility would be 01/26/2022. 01/28/2022: P.C with previous facility confirmed that he vacated the position at the facility on 01/26/2022. 02/09/2022: The complainant reported that the facility did not have a licensed Administrator on site. 02/11/2022: Responding to the inspector?s email inquiry the Regional Director of Operations reported via email that facility staff #1 is not licensed in the state of Virginia as an Assisted Living Facility Administrator. 02/28/2022: In response to the inspector?s email inquiry whether the Board Long Term Care Administrators (VLTCA) were notified that the facility is operating without a licensed assisted living facility administrator and if the board was notified prior to 02/11/2022 that the previous facility Administrator?s last day was 01/26/2022; On 02/28/2022 via email a representative with the VLTCA responded-referring to the 02/11/2022 email notification from the previous facility Administrator; ?Our record show that was the only notification.? 02/24/2022: Email and attachment dated 02/24/2022 received from current facility Administrator informing Board Long Term Care Administrators (VLTCA) that her official start date was 02/23/2022.
Plan of Correction:	FACILITY RESPONSE- "RDO, or designee will notify the regional licensing agency within 14 days of the departure of the facility?s administrator. In this notification RDO or designee will identify who the new licensed administrator is or designate the Director of Nursing of the facility as the acting administrator for a period of no longer than 90 days. Within this time ProMedica will employ a new administrator licensed in the state of Virginia. The RDO or designee will contact the regional licensing office as well as the Virginia Board of Long-Term Care Administrators of the employment and start date of the new administrator. RDO or designee will ensure the community always have a licensed health care professional licensed in the state of Virginia in the facility at least forty (40) hours a week to oversee the day-to-day operations of the facility. The RDO or designee will check in with the designated licensed person in charge weekly to ensure they are meeting the required licensing standards required by the state of Virginia."