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: April 22, 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. 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:

The LI for the Bedford Adult Day Center conducted an on-site monitoring visit on 04/22/2022 from 9:30am until 12:30pm. A tour of the physical plant was conducted and the morning activity was observed. 18 participants were noted to be attending the center at the time of the inspection. Participant and staff records as well as other forms of facility documentation were reviewed. An exit interview was conducted with the facility Director in which all violations were discussed and opportunities were given for the facility to provide any additional information. Please respond back to your LI with your plan of correction within 10 days of receipt of this notice. If you have any questions or concerns please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-61-220-E
Description:	Based on a review of participant records, the facility failed to ensure that participant assessments were reviewed and updated at least every six months. EVIDENCE: 1. The assessment in the record for participant 1 was last reviewed/updated on 09/08/2021. 2. The assessment in the record for participant 2 was last reviewed/updated on 04/15/2021.
Plan of Correction:	The Director will ensure that all participant assessments are reviewed and updated at least every six months.
Standard #:	22VAC40-61-230-E
Description:	Based on a review of participant records, the facility failed to ensure that participant plans of care (POC) were reviewed and updated at least every six months. EVIDENCE: 1. The POC in the record for participant 1 was last reviewed/updated on 09/08/2021. 2. The POC in the record for participant 2 was last reviewed/updated on 04/15/2021.
Plan of Correction:	The Director will ensure that all participant plans of care are reviewed and updated at least every six months.
Standard #:	22VAC40-61-290-B
Description:	Based on a review of facility documentation, the facility failed to ensure that thier infection prevention policies contained all requried information. EVIDENCE: 1. The facility infection prevention policies did not contain all requires information per this regulations requirements.
Plan of Correction:	The Director will update the facility infection prevention policies and procedures to include all required elements of the standard.