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. 7, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/07/2024 Arrival was 10:00AM to Departure 5:00PM. Present at the was Shelby Haskins, LI and Yvonne Randolph, LI both from the Virginia DSS Office of Licensure and Stephanie Crabbe, Administrator, Discovery Village of the West End. The Acknowledgement of Inspection form was signed by Stephanie Crabbe, Administrator and Shelby Haskins, LI and left at the facility for each date of the inspection. 02/07/2024 at 5:00PM. Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of staff records reviewed:5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: Medication Management Pass, Menus, required postings and the Executive Director was given the opportunity to ask questions. An Exit Interview will be conducted. There were several documents requested during the inspection that weren?t provided during the inspector?s visit that were later provided by email on 2/9/2024. 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at Shelby.Haskins@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-200-D
Description:	Based on review of 5 staff records, it was determined that the facility did not ensure that they obtain a copy of the certificate or other documentation that the staff has one of the requirements to be direct care staff qualified. Evidence: 1. The record for staff #6 did not contain any documentation to demonstrate that staff #6 was direct care qualified. 2. Staff #1 reviewed the record for staff #6 and was unable to provide documentation that staff #6 met one of the requirements for direct care staff during the on-site inspection.
Plan of Correction:	1. Staff member #6 record has been updated to include her direct care qualification documentation. 2. An audit will be completed of all direct care staff members to ensure their direct care qualification documentation is in their staff record. All discrepancies found will be corrected. 3. Executive Director will educate Director of Health and Wellness, Scheduler and Business Office Manager on importance of ensuring direct care qualification documentation is placed in staff records. 4. Business Office Manager/or Designee will conduct an audit of 25% of direct care staff member records will be completed 1x per week for 4 weeks and monthly for 2 months to ensure direct care qualifications are in the record. 5. Completion Date: 6/19/24
Standard #:	22VAC40-73-210-B
Description:	Based on a review of 5 staff records, it was determined that facility did not ensure that all direct care staff complete 18 hours of training annually. Evidence: 1. The record for staff #6, (hire date 01/22/2023) only contained 4 hours of documented annual training. 2. Staff #1 reviewed the record for staff #6 and was unable to provide documentation that staff #6 had completed 18 hours of annual training during the on-site inspection.
Plan of Correction:	1. Staff member #6 has completed 18 hours of annual training and it has been documented in her file. 2. An audit will be completed of all staff member files to ensure 18 hours of annual training is completed and documented. All discrepancies found will be corrected. 3. Executive Director will educate Department Managers on importance of ensuring all staff members have completed 18 hours of annual training. 4. Business Office Manager/or Designee will conduct an audit of 25% of staff records will be completed 1x per week for 4 weeks and monthly for 2 months to ensure annual training is being completed per the standard. 5. Completion Date: 6/19/24
Standard #:	22VAC40-73-720-A
Description:	720 A2 Based on a review of 11 resident records, it was determined that the facility did not ensure that the written Do Not Resuscitate (DNR) order is included in the resident?s individualized service (ISP). Evidence: 1. The record for resident #3 contained an Individualized Service Plan (ISP), but it did not include the physician?s written order for Do Not Resuscitate (DNR). 2. Staff #1 reviewed the record for resident #3 and was unable to provide documentation of an Individualized Service Plan (ISP) with the written Do Not Resuscitate (DNR) order during the onsite inspection.
Plan of Correction:	1. The Individualized Service Plan for resident #3 has been updated to include the physician?s written order for Do Not Resuscitate. 2. An audit will be completed of all resident records to ensure physician?s written orders for Do Not Resuscitate have been included on the Individualized Service Plans. All discrepancies found will be corrected. 3. Executive Director will educate Director of Health and Wellness, Memory Care Director and Health Care Coordinators on importance of including physician?s written orders for Do Not Resuscitate on the resident?s Individualized Service Plans. 4. Director of Health and Wellness/or Designee will conduct an audit of 25% of resident records will be completed 1x per week for 4 weeks and monthly for 2 months to ensure physician?s written orders for Do Not Resuscitate have been included on the resident?s Individualized Service Plan. 5. Completion Date: 6/19/24