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: March 29, 2023 and May 16, 2023

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 22VAC40-151 Special Programs 22VAC40-80 The License

Technical Assistance:

Discussed housekeeping and maintenance as noted in the Standards for Licensed Children?s Residential Facilities - 22 VAC 40-151-540.C. Discussed admission procedures as noted in Standards for Licensed Children?s Residential Facilities - 22 VAC 40-151-570.A.1-5. Discussed providing emergency services for any resident experiencing or showing signs of suicidal or homicidal thoughts, symptoms of mood or thought disorders, or other mental health problems as noted in Standards for Licensed Children?s Residential Facilities - 22 VAC 40-151-730.4.

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/29/23 from 10:30 AM ? 6:55 PM, 3/30/23 from 2:15 PM ? 6:59 PM and 3/31/23 from 12:03 PM ? 6:12 PM: This Inspection was conducted simultaneously with the Alpha House II ? Renewal inspection on the previously mentioned dates. 4/5/23 from 2:17 PM ? 4:54 PM: Tour of the physical plant and Preliminary Findings Meeting conducted for both facilities The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents in care at the beginning of the inspection: 4 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident?s records reviewed: 2 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Additional Comments/Discussion: An unannounced monitoring inspection was completed by the Licensing Specialist on the previously mentioned dates and times. The following is a listing of the activities for this inspection: Reviewed one current resident record and one discharged resident record. Reviewed medication administration records. Three personnel records were reviewed. Two staff members and three residents 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, and staff work schedules. The Program Director was available and accessible during the inspection. The Program Director participated in the preliminary findings meeting held at the facility on 4/5/23. An exit meeting was conducted on 5/16/23 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 Michele Freeman, Licensing Inspector at (804) 662-7062 or by email at michele.freeman@dss.virginia.gov

Violations:

Standard #:	22VAC40-151-50-F
Description:	Violation: Based on review of current resident, CR3?s record and interview with staff, the facility failed to comply with its own medication policy. Findings: 1) The ?Alpha House Policy and Procedure for Medication? was reviewed as it pertains to resident refusal, which is considered a medication error. 2) The policy states the following as it pertains to medication errors ? ?Medication errors shall be documented immediately by the staff on duty during the medication error or by the staff member discovering the medication error. A medication error is defined as any medication that is not administered as prescribed in time, dosage, strength, route, or patient.? This document also states the following ? ?Resident refusal of prescribed medication is a medication error.? 3) Upon review of CR3?s Medication Error documents, three were not consistent with the policy. The ?Date & Time of Error? on each form are the following ? 2/17/23 ? 8:00 AM, 1/23/23 - 6:30 AM, and 1/16/23 ? 9:30 PM. It was noticed that at least three staff members did not complete a new form for each resident refusal. Instead, these staff only signed and dated at the bottom of a form that had been completed by another staff member. a) For example, the form dated for 2/17/23 was correctly completed by staff, S6. However, beneath S6?s signature is S3?s signature. S3 noted the following dates on this form by their signature ? 2/25/23 and 2/26/23. S3 did not complete new forms for the above-mentioned dates. b) Second example, the form dated for 1/23/23 was correctly completed by staff, S1. However, beneath S1?s signature is S7?s signature and initials. S7 noted the following dates by their signature ? 1/27/23. S7 noted the following date by their initials - 1/31/23. S7 did not complete new forms for the above-mentioned dates. c) Lastly, the form dated for 1/16/23 was correctly completed by S1. However, beneath S1?s signature is S8?s signature. S8 noted the following date by their signature ? 1/19/23. S8 did not complete a new form for the above-mentioned date. 4) Staff, S3, S7, and S8, failed to comply with the facility?s policy because they did not properly document the error by completing a new form, which includes the need to note the time of the error along with other elements. 5) These forms were discussed with staff, S4, on 3/30/23. S4 acknowledged a new form should have been completed each time the resident refused her medication.
Plan of Correction:	Medication administration policy, and practices including medication error documentation requirements was reviewed with all staff during an in person staff meeting May 18, 2023. It was stressed during the meeting that each time a medication error occurs a new medication error form for each medication must be completed and an example was given of how the document should be completed. Overnight staff was reminded that they are our quality assurance staff and should be double checking daily for medication refills, print documents, and review progress notes, task sheets, and medication log for accuracy/ signatures, etc.
Standard #:	22VAC40-151-120-B
Description:	Violation: Based on review of the facility?s policy and procedure for the written decision-making plan and interview with staff, the facility failed to comply with the intent of the plan. Findings: Due to a limited number of characters in this field, the findings for this violation are on a separate document. These findings are available for review by submitting a Virginia Freedom of Information Act Request.
Plan of Correction:	The Director of Alpha House will revise the change of command for Alpha House no later than June 1, 2023.
Standard #:	22VAC40-151-220-A
Description:	Violation: Based on review of the personnel record and interview with staff, the facility failed to write a job description for each position assigned to staff, S3 and S5. Findings: 1) Staff, S3, was interviewed on 3/29/23. When asked about their job title, S3 mentioned the following, Relief Counselor, Transporter, and Administrator in Training (AIT). 2) S3 was interviewed again on 4/5/23 in order to obtain clarification about the AIT duties. 3) S3 stated their duties include, but are not limited to being trained to do the following- operational tasks, writing service plans, and coordinating appointments. 4) S3?s ?Relief Counselor? job description in S3?s personnel file does not contain the above-mentioned duties. 5) S4 was interviewed on 4/5/23 and shared that S3 and S5 are receiving this type of training. 6) Upon review of S5?s job description, the additional duties listed by S3 are also not in S5?s job description.
Plan of Correction:	Both staff in question does have a job description in their personnel file. Each of the job descriptions includes a statement ?Any other duties necessary for the delivery of service? or ?other duties deemed necessary to meet individual needs of the consumer and the program?. Training staff various aspects of the group home operation strengthens our program and the consistency of the services that Alpha House can provide our consumers. The director of Alpha House appreciates employees that are motivated to learn more about our program and the requirements of service delivery.
Standard #:	22VAC40-151-750-E
Description:	Violation: Based on review of current resident?s, CR1?s, medication administration record and interview with staff, the facility failed to demonstrate medications were administered as prescribed. Findings: 1) The medication administration record (MAR) has a box for staff to initial and note the time for each day of the month that medication is given. 2) The MAR for March 2023 for medication, M1, shows empty boxes for the evening dose on the following dates: 3/5, 3/13, and 3/28. 3) The MAR for March 2023 for medication, M2, shows an empty box on the following date: 3/28. 4) In addition, the ?Alpha House Policy and Procedure for Medication? states the following ? ?Alpha House shall maintain a medication administration record of all medicines received by each resident and shall include: 1. Date the medication was prescribed; Drug name; 3. Schedule for administration; 4. Strength of medication; 5. Route; 6. Identity of individual who administered the medication; 7. Date the medication was discontinued or changed.? 5) These MARs were discussed with staff, S4, on 3/29/23. S4 acknowledged the MARs are incomplete, which demonstrates the medications were not administered as prescribed.
Plan of Correction:	Medication administration policy, and practices including medication error documentation requirements was reviewed with all staff during an in person staff meeting May 18, 2023. It was stressed during the meeting that medications must be administered as directed by the ordering physician and staff administering the medication must sign the medication book acknowledging the medication was administered or a medication error was completed. Staff writing in the shift log that medications were administered must be accompanied by individual resident medication sheets sign by the staff member administering medication. Overnight staff was reminded that they are our quality assurance staff and should be double checking daily for medication refills, medication log book log for accuracy/ signatures, as well as print documents, and review progress notes, task sheets, etc.
Standard #:	22VAC40-151-830-B
Description:	Violation: Based on review of the facility?s policy for ?Pharmacological or Mechanical Restraints? and interview with staff, the language used in this document permits the use of pharmacological restraints, which is prohibited by the standards. Findings: 1) A document titled, ? Chemical or Mechanical Restraints? was provided by staff, S4, during this inspection as an updated policy and procedure document on 3/29/23. The footer of this document states the following ? ?Revised 2023.? 2) This facility?s document uses ?Chemical? in lieu of ?Pharmacological.? 3) This version of the document supports the use of mechanical restraints and states the following- ?The use of mechanical restraints is prohibited except as permitted by other applicable state regulations or as ordered by a court of competent jurisdiction.? 4) S4 was interviewed on 4/5/23 during the preliminary findings meeting about this document. S4 acknowledged this statement was noted on this document. 5) The Licensing Specialist advised S4 that pharmacological and mechanical restraints are prohibited. 6) On 4/6/23, S4 emailed the Licensing Specialist another version of this document that includes this topic. S4 addressed this document was reviewed with staff in November 2022 and the document presented on 3/29/23 was shared in error. However, this version of the document allows the use of pharmacological restraint, which states the following - ?The use of chemical restraints are administered only with written direction and and (sic) supervision of a licensed medical professional. Instructions for medication administration and / or medication therapy shall be followed as ordered by the physician.
Plan of Correction:	Alpha House Prohibitions were rewritten by the director to conform to the standards.
Standard #:	22VAC40-151-840-A
Description:	Violation: Based on review of the facility?s policy document titled, ?Behavior Interventions,? and interview with staff, the facility failed to include all of the required elements. Findings: Due to a limited number of characters in this field, the findings for this violation are on a separate document. These findings are available for review by submitting a Virginia Freedom of Information Act Request.
Plan of Correction:	The Alpha House Behavior intervention plan will be revised by the Director no later than June 1, 2023; to allow for all staff to participate in the Crisis wave training that is schedule for May 25 and May 26, 2023.