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: Feb. 8, 2024

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 22VAC40-80 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 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:

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: 2-8-24 from 9:15 a.m.- 11:15 a.m. 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: 8 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 participants: 1 Number of interviews conducted with staff: 1 Additional Comments/Discussion: Participants were engaged in activities. Facility documentation, facility postings, and the first aid kit were also reviewed. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-757 or by email at Kimberly Davis@dss.virginia.gov

Violations:

Standard #:	22VAC40-61-130-C
Description:	Based on a review of staff records, the center failed to ensure that the director complete 24 hours of training annually. Evidence: The record for the director did not contain documentation of 24 hours of annual training.13 training hours were documented.
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 the name and telephone number of a person to contact in an emergency was maintained in each record. Evidence: The record for Staff # 1 (hire date: 8-14-23) did not contain the name and telephone number of a person to contact in an emergency.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-180-E
Description:	Based on a review of staff records the center failed to ensure that each staff person shall obtain an evaluation by a qualified licensed practitioner that completes an assessment for tuberculosis (TB) in a communicable form no earlier than 30 days before or no later than seven days after employment. Evidence: The record for Staff # 1 (hire date: 8-14-23) contained a TB assessment dated 8-29-23.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-220-E
Description:	Based on a review of participant records the center failed to ensure that the participant assessment shall be reviewed and updated at least every six months. Evidence: The record for Participant # 3 (admit date: 7-24-23) contained an assessment last dated 7-25-23.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-230-E
Description:	Based on a review of participant records the center failed to ensure that the plan of care shall be reviewed and updated as significant changes occur and at least every six months. Evidence: The record for Participant # 3 (admit date: 7-24-23) contained a plan of care last dated 7-25-23.
Plan of Correction:	Not available online. Contact Inspector for more information.