VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Gloucester Adult Day Break
5873 Fiddlers Green Road
Gloucester, VA 23061
(804) 695-9008

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: Jan. 24, 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

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: 1/24/2023 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: 4 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with staff: 1 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 Alyshia E. Walker, Licensing Inspector at (757) 670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-61-220-E
Description:	Based on record review and discussion, the facility failed to ensure the participant assessments be reviewed and updated at least every six months. Evidence: The last assessment review date for participant #1 was 6/14/2022.
Plan of Correction:	All records were reviewed and all participant assessments were reviewed and completed in accordance to DSS regulations. The assessment for participant #1 was reviewed and updated.
Standard #:	22VAC40-61-230-E
Description:	Based on record review and discussion, the facility failed to ensure the participant plan of care be reviewed and updated as significant changes occur and at least every six months. Evidence: The last documented review of the plan of care for participant #1 was 6/21/2022.
Plan of Correction:	All records were reviewed and all participant plans of care were reviewed and completed in accordance to DSS regulations. The assessment for participant #1 was reviewed and updated.
Standard #:	22VAC40-61-260-B
Description:	Based on record review and discussion, the facility failed to ensure the physical examination report on file at the center included all necessary documentation. Evidence: The annual physical for participant # 3 did not include the participant?s ambulatory status, special diet, and restrictions.
Plan of Correction:	All records were reviewed and the physical examinations included all necessary documentation. The physician for participant #3 was contacted and it was requested that the physical examination be updated with the participant's ambulatory status, special diet, and restrictions.
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation, the center failed to post the findings of the most recent inspection of the facility. Evidence: During an inspection of the center with Staff# 1 on 1/24/2023, the findings of the most recent inspection of the center were not observed to be posted. The posted inspection information was from the inspection conducted in December 2020.
Plan of Correction:	The most recent survey results will be posted in the facility.