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: June 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: 06/23/2023 from 10:20 am to 11:00 am. 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 05/24/2023 regarding allegations in the area(s) of: Part III Personnel and Part VI Resident Care and Related Services. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of staff records reviewed: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 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 #:	22VAC40-73-210-B
Description:	Based on record review, the facility failed to ensure all direct care staff attend at least 18 hours of training annually with the exception of direct care staff who are licensed health care professionals or certified nurse aides attend at least 12 hours of annual training. Training also should include at least two of the required hours on infection control and prevention and when adults with mental impairments reside in the facility, at least four of the required hours on topics related to residents' impairments. Evidence: 1. Staff #3 (hire date 7/12/2021) worked as an RMA/CNA; however, Staff #3 did not have at least 12 hours of annual training in their record.
Plan of Correction:	1. Review of all AL/MS education completed by the AL Manager. 2. Notifications sent out to AL/MS staff by the Manager with overdue courses for completion. 3. Manager will be notified monthly via Outlook calendar to audit Relias courses due for completion prior to the end of month. 4. Staff will be made aware of any courses overdue and will be given Time during their shift to complete courses with an expectation that if courses not completed timely, they may be removed from the schedule. 5. This process will occur monthly with reporting to Director of Nursing of the need for any process changes.