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. 8, 2022

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 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2(19.2) Criminal Procedures. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

1. Recommended making two separate columns for date and time on the model fire drill form. 2. Recommended making two separate sections for allergies and allergy reactions on the model physical form.

Comments:

An unannounced renewal inspection was conducted on 2/8/2022 from approximately 10:10 am to 4:15 pm. A tour was immediately conducted of the interior and exterior of the center. The current menu, snack menu and activities calendar were posted and accurately reflected this inspector's observations. The center was clean and free from any foul odors. Upon arrival there were 13 participants in care and five staff on duty. Upon departure there were nine participants in care and five staff on duty. Large and small group activities were observed occurring throughout the day with a variety of options for the participants. Staff were observed assisting participants with meals, activities and ambulation. Medication administration was observed for the only participant receiving medication. The medication administration records and physicians' orders were reviewed for three participants. All medications on site were checked for proper labels and expiration dates. Four participant, one discharge, one volunteer and three staff records were reviewed. Selected sections of two additional volunteers, one participant and four staff records were also reviewed. The areas of non-compliance included first aid certification, volunteer orientation, emergency preparedness plan reviews and resident emergencies reviews. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.

Violations:

Standard #:	22VAC40-61-160-A-1
Description:	Based upon documentation and interviews, the center failed to ensure one of seven staff records reviewed maintained current certification in first aid. Evidence: 1. The first aid certificate on file for staff 2 expired January 2022. 2. On 2/8/2022, the licensing inspector (LI) interviewed the executive director (ED) and administrative assistant (AA) and both stated staff 2 did not have current certification in first aid.
Plan of Correction:	Each staff member will be kept up to date with current CPR/first aid while employed at the center. The AA and ED will complete a list to be posted in both the AA's and ED's offices. To avoid a reoccurrence, the AA and ED will review all expiring certificates on a monthly basis to provide adequate time to set up the renewal training. Staff 2 will receive first aid/CPR renewal on 2/17/2022 with a certified instructor.
Standard #:	22VAC40-61-170-F
Description:	Based upon documentation and an interview, the center failed to ensure volunteer orientation included a review of all required information for three of the three volunteer records reviewed. Evidence: 1. Volunteers 1, 2 and 3 had no documentation on file of completing a review of mandated reporting and participants' rights. 2. On 2/8/2022, the LI interviewed the ED who also reviewed the records for volunteers 1, 2, and 3. She stated there was no documentation on file of them completing training in these two areas.
Plan of Correction:	All volunteer files will be checked to make sure appropriate volunteer orientation has been completed and properly documented. Before their next volunteer time, they will be given a copy of the mandated reporting and participants' rights to sign for their files. To avoid reoccurrence, the ED will make a new checklist (similar to staff files checklist), of what paperwork and documentation needs to be done prior to a volunteer starting at the center.
Standard #:	22VAC40-61-520-C
Description:	Based upon documentation and interviews, the center failed to ensure five of seven staff records reviewed had documentation of completion of a six month review of the emergency preparedness and response plan (EPRP). Evidence: 1. EPRP reviews were completed as follows: Staff 1 on 4/8/2021, 2 on 5/3/2021, 4 on 4/16/2021, 5 on 4/13/2021 and 6 on 3/31/2021. 2. On 2/8/2022, the LI interviewed staff 1 and 5 and both stated a six month review of the EPRP had not been conducted and the review dates on record were the last time reviews were completed.
Plan of Correction:	Each staff member will sign off every six months that they have read through the EPRP. Sign off sheets will be kept in the front of the Emergency Manual by AA desk. When sign offs are completed, copies will be made for the ED. One copy will be kept in the EPRP binder and kept in staff files. To avoid a reoccurrence, the ED and AA will create a chart to be posted in the nurses office, listing when staff are due to review and sign off.
Standard #:	22VAC40-61-560-C
Description:	Based upon documentation and interviews, the center failed to ensure five of seven staff records reviewed had documentation of completion of a six month review of the participant emergencies plan. Evidence: 1. Participant emergency reviews were completed as follows: Staff 1 on 4/8/2021, 2 on 5/3/2021, 4 on 4/16/2021, 5 on 4/13/2021 and 6 on 3/31/2021. 2. On 2/8/2022, the LI interviewed staff 1 and 5 and both stated a six month review of the participant emergencies had not been conducted and the review dates on record were the last time reviews were completed.
Plan of Correction:	Each staff member will sign off every six months that they have reviewed the Participant Emergencies Plan. Sign off sheets will be kept in a folder at the front desk labeled "Participant Emergencies Pan". When sign offs are completed, copies will be made for the ED. One copy will be kept in the staff file and one copy will be kept in the "Participant Emergencies Plan" folder at the front desk. To avoid a reoccurrence, the ED and AA will create a chart to be posted in the nurses office, listing when staff are due to review and sign off.