VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Adult Care Center of the Northern Shenandoah Valley, Inc.
411 N. Cameron Street
Suite 100
Winchester, VA 22601
(540) 722-2273

Current Inspector: Jill James (540) 418-2631

Inspection Date: Feb. 24, 2020

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 GROUNDS 22VAC40-61 EMERGENCY PREPAREDNESS 63.2 General Provisions. 63.2 Protection of adults and reporting. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

Answered questions/discussed the following: 1) Reviewed the new standards regarding written requirements for discharge and that individualized plans of care must now be signed by the participant or family member. 2) Ensure staff include the names of participants, not just their initials, who don't participate in the fire drills. 3) Recommended adding vegetables to the emergency food supply, although not required.

Comments:

An unannounced monitoring inspection was conducted on 2/24/20 from approximately 8:55 am to 3:45 pm. A tour was immediately conducted of the interior and exterior of the center. The center was clean and free from any foul odors. The current menu and activities calendar were posted and accurately reflected this inspector's observations. The special diets that were reviewed were served according to the physicians' orders. Upon arrival there were nine participants in care and two staff on duty. Upon departure there were 16 participants in care and five staff and one volunteer on duty. Large and small group activities occurred throughout the day. Medication administration observations were conducted with the registered nurse for one participant. The January and February medication administration records, physicians' orders and medications were reviewed. All medications on site were checked for signed physicians' orders, proper labeling and current expiration dates. Five participant, one discharge, one volunteer and two staff records were reviewed. Selected sections of six additional staff records were also reviewed. Individual interviews were conducted with participants and staff. There were no family members available to interview. The area of noncompliance included one participant's picture was not on file. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.

Violations:

Standard #:	22VAC40-61-250-B
Description:	Based upon record reviews, the center failed to ensure one of six participant records had a current picture on file. Evidence: 1) Participant E (enrolled 2/4/20) did not have a picture on file. 2) On 2/24/20, the LI interviewed the administrative assistant who stated she overlooked taking a picture of participant E.
Plan of Correction:	Each participant will have a picture on file his/her first day of enrollment. The pictures will be taken by the administrative assistant and put in the chart by the RN. To avoid a future recurrence, the administrative assistant will take a picture on assessment day or on the first day and notify nurse that the picture has been taken and is ready for the medical chart. The RN will check off "first day picture" on the chart set-up check list.