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: May 1, 2023

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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

Technical Assistance:

1. Reviewed standard 300.E.2 and answered questions. Each participant must have their own bottle of medication for as needed medication administration. The center may not use one bottle purchased by the center to administer to participants. 2. Recommended documenting attempts to obtain advanced directive information if the family does not provide. 3. When completing the six-month care plans and assessments, complete them six months from the initial care plan and assessment date and not the 30-day care plan/assessment date. 4. Bee sting swabs in first aid kit expire October 2023. 5. Ensure all training documentation includes the number of hours and who provided the training.

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: 5/1/2023 from approximately 8:30 am to 5:45 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of participants present at the facility at the beginning of the inspection: 5, 12 total for the day The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 5 Number of staff records reviewed: 4 + selected sections of 5 volunteers Number of interviews conducted with participants: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Medication administration observations, lunch meal, morning snack, activities and staff to participant interactions. Additional Comments/Discussion: All required postings were in place and the menu and activities calendar reflected this inspector?s observations. 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov

Violations:

Standard #:	22VAC40-61-260-B
Description:	Based upon documentation and an interview, the center failed to ensure one of five participants had an initial tuberculin (TB) skin test/assessment completed 30 days prior to admission. Evidence: 1. The initial physical (completed 11/15/2022) for participant 4 did not include a TB skin test/assessment. 2. On 5/1/2023, the licensing inspector (LI) interviewed staff 1 who checked the participant?s record and stated a skin test/assessment was not on file.
Plan of Correction:	Moving forward, TB assessments will be checked by the registered nurse (RN), executive director (ED), and administrative assistant (AA) prior to scheduling an assessment date for incoming/new participants. Furthermore, executive director will ensure that checklist posted in each new enrollment packet is fully completed.
Standard #:	22VAC40-61-300-E-2
Description:	Based upon observations and an interview, the center failed to ensure one medication was labeled with a participant?s name. Evidence: 1. On 5/1/2023, the LI observed staff 1 administer as-needed (PRN) Acetaminophen to participant 2. 2. The bottle of Acetaminophen was not labeled with the participant?s name. 3. On 5/1/2023, the LI interviewed staff 1 who stated the center purchased a bottle of Tylenol and staff administered the PRN medication from that bottle to the participants who had signed physicians? orders. Staff 1 stated the participants were not charged for the PRN Tylenol medication.
Plan of Correction:	The center will provide individual Tylenol bottles for participants who have a valid order from their physician. Each bottle will be labeled with participant?s first and last name and locked in the PRN medication box in the nurse?s office