VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Edwards Adult Day Center
431 East Commonwealth Blvd
Martinsville, VA 24112
(276) 666-9400

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: May 30, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-61 GENERAL PROVISIONS 22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 SUPERVISION 22VAC40-61 ADMISSION, RETENTION AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUND 22VAC40-61 EMERGENCY PREPAREDNESS 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 SANCTIONS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 CRIMINAL PROCEDURES 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/30/2024 10:22AM until 12:45PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of participants present at the center at the beginning of the inspection: 29 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 2 Number of staff records reviewed: 2 Observations by licensing inspector: noon-time meal, medication storage, medication administration 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-61-230-D
Description:	Based on participant record review and staff interview, the center failed to address a need on a Plan of Care (POC) for a participant. EVIDENCE: 1. The participant assessment (PA) for participant 2, dated 03/06/2024, indicates that the participant requires minimal assistance (MA) with transferring with the guidance of one staff person; however, the POC for the participant, dated 03/06/2024, does not include that the participant needs this assistance. 2. Interview with staff person 3 revealed that the participant does require minimal assistance with transferring; therefore, the POC should include this information.
Plan of Correction:	EADC Nurses will mirror POC to the assessment. A second Nurse will review for any errors.
Standard #:	22VAC40-61-230-F
Description:	Based on participant record review, the center failed to ensure an updated plan of care shall be signed by the participant, family member, or legal representative. EVIDENCE: The plan of care in the record for participant 2, dated 03/06/2024, has not been signed by the participant, a family member or legal representative. This was also noted by staff person 3.
Plan of Correction:	EADC will document and keep a copy of the POC and when it is sent out for signature's. Follow up will be documented until the POC comes back.
Standard #:	22VAC40-61-260-C
Description:	Based on participant record review, the center failed to ensure the subsequent medical evaluation for a participant contained all required components. EVIDENCE: The report of physical examination for participant 2, dated 07/27/2023, does not include the participant?s height, weight, blood pressure, and if the participant can administer their own medications. This was also noted by staff person 3.
Plan of Correction:	EADC Nurses will thoroughly check all physical examinations and if anything is left off they will document and resend to the doctor.