VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bedford Adult Day Center
1617 Oakwood Street
Bedford, VA 24523
(540) 586-8424

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: Nov. 3, 2021

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. 22VAC40-80 SANCTIONS. 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

Comments:

A renewal inspection was initiated on 11/03/2021 and concluded on 11/08/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 22. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 3 participant records, 3) staff records, activities calendar, staff schedules, Fire and Health inspections, medication management plan submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 11/08/2021. An exit interview was conducted with the Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-61-260-C
Description:	Based on a review of participant records and interviews with staff, the facility failed to ensure that all information was correct on subsequent medical evaluations. EVIDENCE: 1. The physical examination dated 5/3/2021 in the record for participant 1 has documentation that the participant is ambulatory. The participants original physical examination dated 5/16/2016 and most recent participant assessment dated 10/1/2021 both have documentation that participant 1 is not capable of self preservation and requires assistance with direction and prompting to exit in an emergency. A phone interview with staff person 4 on 11/3/2021 expressed that the assessment completed on 10/1/2021 is correct and that participant 1 does require direction and prompting assistance to exit the facility.
Plan of Correction:	According to the physical examination form dated 5/3/21 on participant 1, the participant question, ?Is patient Ambulatory??, was answered, ?Yes?, by the physician. The facility indicated in their assessment of the individual that the individual needs direction and prompt to exit a building in an emergency. The assessment also stated that the individual can walk without assistance (ambulation), but commented that he ?Needs supervision and redirection to prevent getting lost, but ambulates without mechanical or physical assistance. Supervise ambulation, especially when wearing ill-fitting shoes or flip flops. May need hands on assistance when walking on uneven surfaces, such as outdoors.? The Plan of Care indicates, ?Fall precautions-monitor ambulation?, and ?Staff will assist with evacuation from the building in the event of an emergency.? DSS regulation 22VAC40-61-260 states the Physical Examination and Report shall contain?? A statement that specifies whether the individual is considered to be ambulatory or nonambulatory.? The model Physical examination form dated 03/20 contains the DSS definition of ?ambulatory? that addresses the capability of self-preservation, although the DSS definition is not required in the regulation as being part of the physical examination report. The DSS Model Form for Participant Assessment lists ?Ambulatory ability? with the subcategories ?Walking, Using a wheelchair, and Climbing stairs?. It does not reference capability of self-preservation. The DSS model forms and definition are not consistent in their interpretation of the meaning of ?ambulatory?. The Virginia Uniform Assessment Instrument defines Ambulation as ?the ability to get around indoors (walking) and outdoors (mobility), climb stairs and wheel.? It does not mention capability for self-preservation. In this case, although the physician used the standard definition to describe this individual?s abilities rather than the DSS definition, the adult day facility nonetheless addressed the needs of the individual on their assessment and plan of care for the individual and his needs were met at all times. In the future, the facility will include an additional question on the Physical Examination Report that addresses capability of self-preservation, in order to clarify DSS?s conflicting interpretations of the word ?Ambulatory?.
Standard #:	22VAC40-61-300-E-7-d
Description:	Based on a review of participant physician orders and medication administration records (MARs), the facility failed to ensure that all medications were documented on participants MARs. EVIDENCE: 1. Physician orders dated 7/27/2021 in the record for participant 2 has documentation of the prescribed medication Lorazepam 0.5mg, 1 tablet by mouth every 6 hours as needed for anxiety. The October 2021 MAR for participant 2 does not include documentation of the this medication. 2. Physician orders dated 9/7/2021 in the record for participant 3 has documentation of the prescribed medications Triamcinolone Acetonide 1%, apply topically as needed for skin irritation and Acetaminophen 325mg, 1 tablet by mouth as needed for pain or fever. The October 2021 MAR for participant 3 does not include documentation of the these medications.
Plan of Correction:	1. For participant 1, Lorazepam is not to be given at ADC, therefore it will not be listed on the MAR. Family clarified that this PRN medication is to be given only at home. Although the current Physician Order (Medication Sheet) already states the Lorazepam is given by family, the physician will be contacted to clarify that the medication is only to be administered while at home. 2. For participant 3, Triamcinolone Acetonide and Acetaminophen are not to be given at ADC, therefore will not be listed on the MAR. The group home was contacted and clarified that these PRN medications are only to be given at the group home. Although the Physician?s Order (Medication Sheet) already states that all medications are to be administered by residential staff, the physician will be contacted to clarify that these two specific medications will only be given while the participant is at home.