VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Alpha House I
4526 Brickwood Meadow Ct.
Petersburg, VA 23803
(804) 861-0596

Current Inspector: Irvin Goode (804) 543-5188

Inspection Date: Feb. 3, 2022 and Feb. 23, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-151 Administration 22VAC40-151 Residential Environment 22VAC40-151 Programs and Services 22VAC40-151 Programs and Services 22VAC40-151 Disaster or Emergency Planning

Technical Assistance:

Discussed the interior of two rooms in the facility that are not accessible to the residents and notes on the Fire Inspection Report dated for 9/15/21. This discussion was based upon standard 520. Discussed the estimated length of stay as it pertains to the individualized service plan as noted in standard 660.B.6. Discussed documentation showing involvement of the resident?s family, if appropriate, for the individualized service plan and the quarterly progress report as noted in standard 660.H.2. Discussed distributing the individualized serviced plan and quarterly progress reports to the resident?s family as noted in standard 660.I. Discussed contacting the division superintendent of the resident?s home locality and documentation of the contact as noted in standard 860.D.

Comments:

An unannounced monitoring inspection was completed by the Licensing Specialist on 2/3/22 from 9:29 a.m. to 6:50 p.m. and 2/4/22 from 10:00 a.m. to 4:45 p.m. The current census is one (1) resident. The following is a listing of the activities for this inspection: Reviewed one current resident records. One of the two discharged records were reviewed. Reviewed medication administration records for both residents. Two personnel records were reviewed. No discrepancies were found with the CRF matrix. Two staff members and one resident were interviewed. An inspection of the interior and exterior of the facility was completed. Other documentation reviewed during this inspection included, but was not limited to the following: emergency drill documentation, menus, staff work schedules, and annual evaluation of services. The Team Leader was available and accessible during the inspection on both dates. A virtual meeting was held at the facility on 2/4/22, which allowed the Program Director to participate in the preliminary findings meeting. The Acknowledgement of Inspection forms were signed and left at the facility. The Program Director was also interviewed by phone on 2/11/22. Upon receipt of this violation notice, a plan of correction is requested for each violation. The Plan of Correction should include, as appropriate: - steps to correct noncompliance of a regulation, - measures to prevent reoccurrence of noncompliance, - person(s) responsible for implementing each step and/or monitoring any preventive measure(s), and - the date by which the noncompliance will be corrected. Be advised that the Violation Notice, including the Plan of Correction and this Summary page will be posted on the VDSS web page and available for review by the general public. Do not write any names or other confidential information into your plan of correction.

Violations:

Standard #:	22VAC40-151-240-B-10
Description:	Violation: Based on review of the personnel record and interview with staff, the facility failed to maintain an up to date personnel record for staff, S1. Findings: 1) The personnel record does not contain a current job description. 2) Staff, S4, searched the personnel record on behalf of staff, S3. This document could not be found. 3) S4 acknowledged there is no job description in S1?s personnel record.
Plan of Correction:	Job description was signed by employee and placed in personnel file on 2/19/2022. Program Director will ensure Job descriptions are signed and placed in employee personnel record upon completion of orientation for new staff.
Standard #:	22VAC40-151-250-C
Description:	Violation: Based on review of the personnel record and interview with staff, the facility failed to ensure that staff, S2, completed an additional 15 hours of annual training applicable to their job duties. Findings: 1) Upon review of the personnel record, S2 completed 12 of the additional 15 hours of annual training. 2) S3 acknowledged the additional 15 hours of annual training had not been completed.
Plan of Correction:	Training opportunities are forwarded to staff on an ongoing basis throughout the year by the Program Director as opportunities become available. Each staff member is responsible for submitting documentation of the attended trainings. The Program Director is responsible for keeping a count of training hours. In this case, the staff member attended training at Longwood College to complete the required training of three additional hours but did not submit documentation of such. It was an oversite of the Program director to request the additional documentation. Employee had provided documentation for 12 of the required 15 hours. Program Director will be more attentive in the future and will monitor number of training hours completed by all staff at least quarterly.
Standard #:	22VAC40-151-750-F
Description:	Violation: Based on review of the medication administration record (MAR) and interviews with staff, the MAR was not maintained as required for medicines, M1 and M2, received by the current resident, CR1. Findings: 1) For the MAR dated for November 2021, the following was missing as it pertains to medication, M1 ? 750.F.3.?Schedule for administration, 750.F.4.?Strength, and 750.F.5.?Route. 2) For the MAR dated for December 2021, the following was missing as it pertains to medication, M1 ? 750.F.4.? Strength and 750.F.5.? Route. 3) For the MAR dated for December 2021, the following was missing as it pertains to medication, M2 ? 750.F.1.?Date the medication was prescribed and 750.F.4.?Strength.
Plan of Correction:	Medication Administration Record requirements for setting up MAR was reviewed with all staff on 2/4/2022 and 2/11/2022 by Program Director. Overnight staff act as quality assurance for our program. Overnight staff was reminded to thoroughly check and make corrections as needed to ensure compliance with state standards.