VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Pearl at Watkins Centre
650 Watkins Centre Parkway
Midlothian, VA 23112
(804) 893-0067

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: Jan. 9, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 1/9/2024 The Acknowledgement of Inspection form was emailed for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1/8/24 regarding allegations in the areas of: Personnel and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 5 Observations by licensing inspector: Medication pass 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 and Personnel. A violation notice was issued. 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 Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at yvonne.randolph@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-200-C
Complaint related:	Yes
Description:	Based on a review of the staff information sheet and emails, one staff did not meet the direct care staff requirements within two months of employment. Evidence: 1. The staff information sheet received by email on 1-16-23 documented a hire date of 10/3/2 and confirmed that staff # 1 is a direct care staff and has been employed for more than two months. 2. In an email dated 1/18/24, the administrator confirmed that staff # 1 has not met at least one of the direct care qualifications.
Plan of Correction:	File created to ensure that all staff have credentials appropriate for working in ALF in Virginia, including date of certification and date certification expires. Floor staff will complete the necessary certificate training before being permitted to work on unit, either supervised or unsupervised. The individual named, Staff #1, completed PCA training. However, Staff #1, is no longer employed by TP@WC.
Standard #:	22VAC40-73-670-1
Complaint related:	Yes
Description:	Based on a review of the staff information sheet, one staff responsible for medication administration is not licensed by the Commonwealth of Virginia to administer medications or registered with the Virginia Board of Nursing as a medication aide. Evidence: A review of the license verification website for the Virginia Board of Health Professions found that staff # 2 is not listed as a registered medication aide or licensed in the Commonwealth of Virginia to administer medications.
Plan of Correction:	File created to ensure that all staff have credentials appropriate for working in ALF in Virginia, including date of certification and date certification expires. Staff #2 has successfully completed the Medication Technician/Aide class through pharmacy and is awaiting test date for boards. Employees will not pass medications until certificate and license is received by community and reviewed. POC date: Immediate. 02/15/2024. Business Office Manager has also received additional training and learning opportunities to verify validity of licensure, verification process of licensure, and will ensure upkeep of employee files; utilizing a schedule for review processes monthly.