VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cabrini Children's Center: Commonwealth Catholic Charities
2250 Pump Road
Richmond, VA 23233
(804) 362-0063

Current Inspector: Dawn Espelage (540) 759-8852

Inspection Date: March 9, 2022 and March 10, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-151 22VAC40-151 III. RESIDENTIAL ENVIRONMENT 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 DISASTER OR EMERGENCEY PLANNING

Comments:

An unannounced renewal inspection was conducted on March 9, 2022 from 9:04 a.m. to 4:00 p.m. Two (2) personnel records, to include background investigation information, were reviewed. Three (3) residents were in care. Two residents records were reviewed: one current and one discharged resident record. Other documentation reviewed at this inspection included but was not limited to case management notes, progress notes, emergency drill documentation, and medication administration records. Interior and exterior physical plant inspections were conducted. Administrator A1 responded to questions during the inspection. Preliminary inspection findings were discussed before leaving the facility on March 9, 2022. An acknowledgement form was signed. Exit meeting was held with A1 on March 10, 2022. The licensee should retain a copy to be posted at the facility. Results of the inspection documentation are subject to public disclosure and will be posted on the VDSS web site within 5 days.

Violations:

Standard #:	22VAC40-151-240-A
Description:	Based on review of the personnel records for Staff S1 and Staff S2 and interview with Staff S3, the personnel records were not up-to-date for each employee. Findings: Staff S1 1. The personnel record for S1 did not include the current TB (Tuberculosis screening assessment). 2. S3 confirmed that the current TB screening assessment was not in the personnel record. Staff S2: 1. The personnel record for S2 did not include the current orientation/training record. 2. S3 confirmed that the current orientation/training record for S2 was not in the personnel record.
Plan of Correction:	A meeting will be held on 3/21/22 with Program manager, Training Specialist, and HR representatives to discuss improving the process to ensure documentation makes it to personnel files
Standard #:	22VAC40-151-580-E-1
Description:	Violation: Based on inspection of the discharged residents records and interview with administrator A1, the written records for residents who have discharged were not stored in a metal file cabinet or other metal compartment. Findings: 1. The discharged residents written records were stored in boxes in a locked closet. 2. A1 acknowledged that the written records were not stored in a metal file cabinet or other metal compartment.
Plan of Correction:	Program manager met with Facility manager on 3/15/22 to place order for metal cabinet to be delivered to the shelter.Upon delivery of cabinet, discharge files will be taken out of banker boxes and placed in metal cabinet. .
Standard #:	22VAC40-151-730-B
Description:	Violation: Based on review and interview with administrator A1, the readily accessible written information in the event of a medical or dental emergency for resident R1 had not been completed. Findings: 1. The facility's Critical Information Log had not been assembled for resident R1 at the time of the inspection. 2. A1 confirmed that the readily accessible Critical Information Log had not been completed for R1.
Plan of Correction:	Program Supervisor will implement feedback and develop ?grab-n-go? folders for each client. There will be two sets; one for availability for each vehicle. A process will be implanted to ensure these folders are updated within 24 hours of each admission. Team meeting held to stress importance of completing Grab-N-Go documents on the DOA
Standard #:	22VAC40-151-990-K
Description:	Violation: Based on review of the emergency evacuation drills and interview with Administrator A1, during the three consecutive calendar months from November 2021 to January 2022, at least one evacuation drill was not conducted during each shift. Findings: 1. An emergency evacuation drill was not conducted during any of the day shifts. 2. A1 acknowledged that no drills were conducted during the identified shifts during this timeframe.
Plan of Correction:	Program manager developed schedule to share with team on 3/15/22 to plan for a rotating schedule of evacuation drills. This will be added to Outlook calendar. On 3/10/22 an evacuation drill was held at 10:30AM. On 3/15/22 a review of evacuation procedures was conducted at Team meeting