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: Feb. 9, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3-21-2023, 11:30 ? 12p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on January 23, 2023 regarding allegations in the area of Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 88 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the comprehensive ISP included a description of identified needs based upon the uniform assessment instrument (UAI). Evidence: 1. Resident #1 admitted 12-22-2022. Resident #1?s comprehensive ISP dated 1-15-2023 documented under walking, wheeling, stairclimbing, and mobility needs that the resident is ?human help, physical assistance?; however, the UAI dated 1-12-2023 documented the resident needs ?no? help with walking, wheeling, stairclimbing, and mobility. 2. On 2-9-23, Resident #1 was observed by Staff #1 and the licensing representative to be ambulating independently, without the need for an assistive device.
Plan of Correction:	Going forward there will be a two-step process in which the person completing the ISP will need to have it reviewed by either the ED or the DHW to ensure all needs on the UAI match what is listed on the ISP. Additionally, an audit will be conducted to ensure all existing ISPs include a description of the identified needs based upon what is listed on the UAI.