VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Ascend Health Adult Retreat
6421 Chesterfield Meadows Drive
Chesterfield, VA 23832
(804) 641-0952

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: July 29, 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. 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 July 14, 2021 and concluded on July 16, 2021. The center director was contacted by telephone to initiate the inspection. The director reported that the current census was 6. The inspector emailed the director a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 2 resident records, 2 staff records, activities calendar, menu, staff schedules, and other documentation submitted by the center to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on July 16, 2021. An Acknowledgement of Inspection form was emailed to the director on the date of the 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(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return it to the licensing office within 10 calendar days. Please specify how the violation will be corrected. The plan must contain: 1) step(s) to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation during this inspection. I can be reached at Kimberly.M.Davis@dss.virginia.gov or (804) 662-7578.

Violations:

Standard #:	22VAC40-61-140-B
Description:	Based on a review of staff records, the facility failed to ensure that all staff who do not meet one of the direct care requirements at the time of employment, successfully meet one of the requirements within two months of employment. Evidence: Record for Staff # 1 (date of hire: 5-6-2021) and Staff # 2 (date of hire: 11-16-2020) did not contain documentation of direct care qualifications within two months of employment.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-180-D
Description:	Based on a review of staff records, the center failed to ensure that each staff record contained a criminal record report. Evidence: The record for Staff # 1 (date of hire: 5-6-2021) did not contain a criminal record report.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-180-E-1
Description:	Based on a review of staff records, the center failed to ensure that each staff record contained an initial tuberculosis (TB) examination and report. Evidence: The record for Staff # 1 (date of hire: 5-6-2021) did not contain a TB evaluation and report.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-260-B
Description:	Based on a review of participant records, the center failed to ensure that each participant's record contained a physical examination that addressed all required items and an evaluation for tuberculosis (TB). Evidence: The record for Participant # 2 (date of admission: 5-17-2021) contained a document from the Veterans Health Administration titled, "VHA Medical Documentation" which did not include the following required items regarding the participant: height, weight, blood pressure, a statement that specifies whether the individual is considered to be ambulatory (ambulatory means that participant is physically and mentally capable of self-preservation by evacuating in response to an emergency to a refuge area without the assistance of another person, or from the structure itself without the assistance of another person even if the participant may require the assistance of a wheelchair, walker, cane, prosthetic device or a single verbal command to evacuate) or nonambulatory, or a statement that specifies whether the individual is or is not capable of self-administering medication. The participant's record also did not contain documentation of a TB evaluation.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-80-120-E-2
Description:	Based on on-site observation of the center's postings, the facility failed to ensure that the most recent violation notice was posted. Evidence: The center's most recent violation notice was not posted.
Plan of Correction:	Not available online. Contact Inspector for more information.