VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harbor's Edge
One Colley Avenue
Norfolk, VA 23510
(757) 233-0475

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

Inspection Date: March 23, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 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: 03/23/2023 from 10:20 am to 12:00 pm. 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 03/14/2023 regarding allegations in the area(s) of: Part III Personnel and Part VI Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 42 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-220-B
Description:	Based on record review and interview, the facility failed to meet the requirements listed under subdivisions A 2 through A 6 of this section in addition to the requirements under subdivision B when private duty personnel who are not employees of a licensed home care organization provide direct care or companion services to residents. Evidence: 1. Resident #1 admitted to the facility on 01/24/2023 with Staff #3 providing private duty services; however, the direct care or companion services provided by Staff #3 is not reflected on the Resident #1's individualized service plan. 2. Staff #2 acknowledged Staff #3 is not an employee of a licensed home care organization and was unable to provide in writing information on the type and frequency of the services to be delivered to Resident #1 by Staff #3. 3. The record for Staff #3 did not contain documentation of Staff #3?s qualifications for the types of direct care or companion services they are responsible for providing to Resident #1. Additionally, the TB evaluation in Staff #3?s record was completed on 07/16/2019 and is not consistent with the requirements of 22VAC40-73-250 D 1 through D 4 regarding tuberculosis that apply to private duty personnel.
Plan of Correction:	Individualized service plan for Resident #1 updated to reflect private duty services being provided by Staff #3. Audit of ISPs done for residents with private duty services to ensure they are updated with services provided. ISP for Resident #1 was corrected on 3/24/2023. Audits and correction of additional ISPs to be corrected by 4/17/2023. Record for Staff #3 corrected to reflect type and frequency of private duty services provided. Clinic staff will conduct 100% audit of all private caregivers for AL/MS residents to ensure records reflect the required information for compliance. The record for Staff #3 was updated with the type of services being provided to Resident #1 by Clinic Manager. Additionally, Staff #3 received an updated TB on 3/28/2023 provided by the Harbor's Edge Clinic nurse. A 100% audit was conducted on all private duty staff providing care for Assisted Living and Memory Support residents to identify any deficiencies in requirements in their records, if applicable. Private duty staff have been notified to report to the clinic to provide updated documents and/or receive an updated TB, if needed. Staff #3 received an updated PPD on 3/28/2023. Additional private duty staff information to be corrected by 4/17/2023.