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: March 12, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/12/2024 10:20am-12:50pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/03/2024 regarding allegations in the area(s) of: Resident Care and Related Services and Administration and Administrative Services 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: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: Observations by licensing inspector: N/A. Additional Comments/Discussion: The Executive Director was accommodating. The Executive Director provided the necessary documentation that was requested. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) 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 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. 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 #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on a review of one resident record, it was determined that the facility did not ensure that the individualized service plan shall be signed and dated by the resident or his legal representative. Evidence: 1. The individualized service plan (ISP) in the record of resident # 1 was dated 2/7/23 and was not signed or dated by the resident or the legal representative. 2. Staff #1 reviewed the record for resident #1 and was unable to provide documentation of an individualized service plan (ISP) that was signed and dated by the resident or the legal representative.
Plan of Correction:	Resident #1 no longer resides in the community. Going forward the community will ensure that all individualized service plans are signed and dated by the resident or the legal representative. Over the next 90 days, the Executive Director will complete random audits to assure compliance.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on a review of one resident record, it was determined that the facility did not ensure that the individualized service plan (ISP) is updated as needed for a significant change of a resident?s condition. Evidence: 1. Fall risk assessments were completed for resident # 1 on 4/2/23 (23 points) and 4/10/23 (23 points) after documented falls. The fall risk assessment record for each fall had scores that exceeded 10 points. The risk assessment form indicates that a ?score of 10 or more represents high risk.? 2. The most recent individualized service plan (ISP) in the record for resident #1 was dated 2/7/23. This individualized service plan (ISP) was not updated to reflect the change in condition or services to be provided to meet this identified need of being at a risk for a fall after the resident fell on 4/2/23 and 4/10/23.
Plan of Correction:	Resident #1 no longer resides in the community. Going forward the community will ensure that all individualized service plans are updated to reflect a change in condition or services following a fall risk assessment that indicates the resident is at a high risk. Over the next 90 days, the Executive Director will complete random audits to assure compliance.