VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Discovery Village at the West End
2422 University Park Boulevard
Richmond, VA 23233
(804) 554-1555

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: April 4, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-90 The Criminal History Record Report

Comments:

An unannounced renewal inspection was conducted at the facility on April 4, 2022 from 9:29 a.m. to 3:50 p.m. There were 77 residents in care. A tour of the facility was conducted which included the following observations: building and grounds, facility postings, medication administration observation, and the first aid kit. Resident records and staff records were reviewed. Activities and dining was observed. Thank you for your cooperation during this inspection. I can be reached at alex.poulter@dss.virginia.gov or (804) 662-9771.

Violations:

Standard #:	22VAC40-73-1030-B
Description:	Based on record review, the facility failed to ensure within four months of the starting date of employment, direct care staff shall attend six hours of training in working with individuals who have a cognitive impairment. Evidence: 1. The facility has a mixed population on the Assisted Living side of the building. The following three staff did not attend six hours of training in working with individuals who have a cognitive impairment within four months of the starting date of employment: impairment. a. Staff #11?s date of hire was 6-30-2021. b. Staff #12?s date of hire was 9-28-2021. c. Staff #13?s date of hire 11-15-2021. 2. Staff #1 confirmed there was no training hours other than what was submitted which did not include six hours of training on cognitive impairment for the three staff.
Plan of Correction:	Ongoing Dementia training will be conducted to ensure existing staff members receive the required six hours of Dementia training required for employment. Additionally, a full audit was completed to determine which staff members still need the required six hours of training. Those staff members will receive the required training. Going forward, six hours of Dementia training will be conducted for all new hires during orientation, which will occur within the first 30-days of employment. The training will be conducted by the Memory Care Director or designee. The Business Office Manager, Executive Director, or designee, will monitor to ensure the training is completed.
Standard #:	22VAC40-73-250-D
Description:	Based on record review and interview with staff, the facility failed to ensure each staff person shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. Staff #10?s date of hire was 7-17-2017. The last TB screening form was dated 9-10-2020. 2. Staff #1 confirmed this was the most current TB screening on file for Staff #10 and that it hadn?t been completed annually.
Plan of Correction:	An audit was conducted to ensure that all employees have up-to-date risk assessments for Tuberculosis (TB) in their files. Going forward each staff member will annually submit the results of a risk assessment documenting that the individual is free from Tuberculosis (TB). The Business Office Manager, Executive Director, or designee, will track the risk assessments to ensure they are done on an annual basis.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the comprehensive individualized service plan (ISP) included the description of identified needs based on the UAI (uniform assessment instrument), fall risk ratings, and nurses? notes. Evidence: 1. Resident #3 admitted 5-03-2021. Resident #3?s UAI dated 5-26-2021 documented resident requires `human help, physical assistance? for toileting; the ISP documented `mechanical and human help? for toileting. The resident?s UAI documented `mechanical help? for stairclimbing, and the ISP dated 5-31-2021 documented `mechanical and human help? for stairclimbing. The UAI documented `no? for needs help for mobility, and the ISP documented `yes, arm rest, shower chair, toilet seat?? for assistance. 2. Resident #4 admitted 3-18-2020. Resident #4?s Fall Risk Assessment documented falls that occurred 8-10-2021, 8-25-2021, 9-09-2021, and 1-22-2022, although no Fall Risk was identified as a need on the resident?s ISP dated 3-15-2022.
Plan of Correction:	An audit was conducted to ensure that all resident?s individualized service plans (ISPs) and uniform assessment instruments (UAIs) identify needs, include fall risk ratings, and nurses? notes. Going forward, the Director of Health and Wellness, Executive Director, or designee, will ensure that the comprehensive individualized service plan (ISP) includes the description of identified needs based on the UAI (uniform assessment instrument), fall risk ratings, and nurses? notes. Monthly audits will be conducted by the Executive Director or designee to ensure compliance.
Standard #:	22VAC40-73-960-B
Description:	Based on documentation review, the fire and emergency evacuation drawing did not show the areas of refuge, assembly areas, and telephones. Evidence: 1. The fire and emergency evacuation drawing posted did not show the areas of refuge, assembly areas, and telephones.
Plan of Correction:	The fire and emergency evacuation drawing will be updated to show the areas of refuge, assembly areas, and telephones and re-posted within the community.
Standard #:	22VAC40-73-970-E
Description:	Based on documentation review and interview with staff, the facility failed to ensure a record of the required fire and emergency evacuation drills included identity of the person conducting the drill; the method used for notification of the drill; any special conditions simulated; and the time it took to complete the drill; and problems encountered (if any). Evidence: 1. The fire drills dated 1-31-2022, 2-16-2022, and 3-08-2022 did not identify the person conducting the drill, the method used for notification of the drill, any special conditions, nor the time it took to complete the drill. 2. Staff #1 acknowledged the aforementioned drills did not contain the required information.
Plan of Correction:	Going forward the community will use the State form which includes the identity of the person conducting the drill, the method used for notification of the drill, any special conditions stimulated, the time it took to complete the drill, and any problems encountered. The Director of Facility Operations or designee will conduct the monthly drills with the state-required form. The Executive Director or designee will monitor to ensure compliance.
Standard #:	22VAC40-90-40-B
Description:	Based on record review and interview with staff, the facility failed to ensure the criminal history record reports were obtained on or prior to the 30th day of employment for each employee. Evidence: 1. The following staff did not have criminal history record reports (CRC) obtained on or prior to the 30th day of employment/date of hire (DOH): a. Staff #2- DOH: 1-13-2022; CRC: 3-22-2022 b. Staff #3- DOH: 10-18-2021; CRC: 1-31-2022 c. Staff #4- DOH: 10-11-2021; CRC: 12-03-2021 d. Staff #5- DOH: 10-21-2021; CRC: 2-22-2022 e. Staff #6- DOH: 11-02-2021; CRC: 2-22-2022 f. Staff #7- DOH: 11-15-2021; CRC: 2-22-2022 g. Staff #8- DOH: 6-07-2021; CRC: 2-22-2022 h. Staff #9- DOH: 8-12-2021; CRC: 2-22-2022 2. Staff #1 confirmed during interview that the criminal history record reports were not obtained on or prior to the 30th day of employment for the aforementioned employees (Staff #2 through Staff #9).
Plan of Correction:	Going forward, all criminal background checks will be obtained by the Business Office Manager or designee prior to the 30th day of employment for each employee. The Executive Director will audit new employee files to ensure compliance.