Inspectors from the Virginia Department of Behavioral Health and Developmental Services (DBHDS) found that Kempsville Center conducted treatment not found in the treatment plans, which is a violation of patient daily routine regulation. DBHDS cited this deficiency as:
“systemic as the lack of supervision [is] very serious and impacts health and safety.”
Inspectors found “several of the residents participated in the practice of journaling with individual staff at any given time. There is no evidence that journaling with staff is a part of the treatment plan/structured daily routine as required by regulation.”
Additionally, Kempsville Center failed to include information that “may determine admission or denial” in the RTC application for one patient. The same application also failed to include a physician signature authorizing admission to the facility.
The facility agreed to educate admission staff to fill out residential forms in their entirety and have physicians sign all applications before resident admission.
Documentation of staff training was also an issue during this inspection. The facility was unable to provide documentation that employee training was being documented on the transcript for one employee.