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: Jan. 13, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1-13-2023, 11:45 a.m. ? 12:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12-06-2022 regarding allegations in the areas of: Resident Care and Related Services; Additional Requirements for Facilities That Care for Adults with Serious Cognitive Impairments. Number of residents present at the facility at the beginning of the inspection: 89 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services; Additional requirements for facilities that care for adults with serious cognitive impairments. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Poulter, Licensing Inspector at (804) 662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-560-G
Complaint related:	Yes
Description:	Based on interview with staff, the facility failed to ensure a resident?s legal representative was allowed access to the resident?s record. Evidence: During interview, Staff #2 acknowledged that a resident?s Medication Administration Record [MAR]s could be denied to a resident due to concerns for privacy of names of the staff members; however, the MAR is part of the resident?s record that the legal representative has access to. An interview with a legal representative of a resident that was residing in the facility at the time of inspection stated that, ?I have repeatedly asked for mom's MAR document and continuously I'm told they cannot release that information to me even tho [sic] I'm the responsible party for my mom??
Plan of Correction:	All-staff will be trained that the MAR is part of the resident?s record and that the legal representative does have access to the MAR documentation as well as full access to the resident record.