VIRGINIA DEPARTMENT OF SOCIAL SERVICES

MADONNA HOME INC.
814 W. 37th Street
Norfolk, VA 23508
(757) 623-6662

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: July 17, 2024 and July 19, 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 22VAC40-80 THE LICENSE

Technical Assistance:

Resident Care And Related Services Buildings And Ground

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: An unannounced renewal inspection took place on 07/17/2024 at 10:45 am until 01:30 pm. and 07/19/24 from 07:30am until 08:22 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 14 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: Breakfast, lunch and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. An exit meeting will be conducted to review the inspection findings. 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at lanesha.allen@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-E
Description:	Based on a review of six resident records, it was determined the facility did not ensure the Individualized Service Plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian. Evidence: 1. The Individualized Service Plan (ISP) in the record for Resident?s #2 dated 04/24/24, was not signed and dated by the resident, or the legal guardian and by the facility representative. 2. Staff 4 reviewed the record for resident #2 acknowledged the Individualized Service Plan (ISP) was not signed and dated by the resident, or the legal guardian and by the facility representative.
Plan of Correction:	The ISP for Resident 2 has been signed. Corrected on 7/18/24.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of six resident records, it was determined that the facility did not ensure the individualized service plan (ISP) shall be updated as needed for a significant change of a resident?s condition. 1. The record for Resident 2 contained a physical exam dated 1/19/24, with recommendations for a low salt, low fat diet. 2. The individualized service plan (ISP) in the record for resident #2 was dated 4/24/24 and states ?low regular diet per Dr. orders?. 3. Staff #4 reviewed the record for resident #2 and acknowledged the current dietary orders were not present on the Individualized Service Plan (ISP).
Plan of Correction:	The plan of Correction for Resident 2 was completed on 7/18/24. The facility contacted the resident's Primary Care Physician to clarify Resident 2's diet and corrected the MAR, POS and ISP.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of six resident records, the facility did not ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual. 1. The record for resident #1 contained a review of Resident?s Rights dated 6/13/22 2. The record for resident #4 contained a review of Resident?s Rights dated 1/30/22 3. The record for resident #5 record contained a review of Resident?s Rights dated 6/15/22 4. Staff #4 reviewed the records for Resident #1, Resident #2 and resident #5 acknowledged the annual review of the residents? rights were not completed for those three residents.
Plan of Correction:	The Plan for Correction for Residents 1, 2, 4, and 5 relating to Residents Rights has been signed and updated in each resident's chart. Corrections made on 7/17/24.