Current Inspector:
Angela Marie Swink
(276) 623-6575
Inspection Date:
Dec. 5, 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 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 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: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/05/2023 8:45am until 1:30pm 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: 24 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with participants: 1 Number of interviews conducted with staff: 3
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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at Cynthia.ball@dss.virginia.gov
Based on participant record review, the facility failed to ensure that a preliminary plan of care was developed prior to or on the date of admission.
EVIDENCE:
1. The record for participant 3, admitted to the facility on 10/01/2023, has documentation that the preliminary plan of care was not developed until 10/12/2023.
Plan of Correction:
Bedford ADC Director and/or Director designee will complete a preliminary plan of care on the ADC form for each PACE participant prior to or on the date of admission. This plan of care will be modified along side the PACE IDT teams plan of care within 30 days of enrollment and every 6 months. This ADC form will be used for all PACE Alternative Care Site folks for continuity in addition to the PACE care plan in cerner. Quality to audit this for 3 months.
Standard #:
22VAC40-61-260-B
Description:
Based on participant record review, the facility failed to ensure that a participant physical examination contained all required information.
EVIDENCE:
1. The record for participant 3, admitted to the facility on 10/01/2023 has a physical examination dated 09/13/2023 that is incomplete as it lacks documentation of any special diet or food intolerances, any therapy, treatments or procedures the individual is undergoing or should receive and by whom, a statement that specifies whether the individual is considered to be ambulatory or non-ambulatory and a statement that specifies whether the individual is or is not capable of self-administering medications.
Plan of Correction:
PACE providers to be educated on ADC requirements using model form as an example and will add completed statements to their prepace & annual H&P - Required statements will be added to H&P prior to admission by providers going forward. Quality department auditing for 3 months.
Standard #:
22VAC40-61-460-H
Description:
Based on observations of the facility physical plant, the facility failed to ensure that hot water at taps available to participants were maintained within a temperature range of 105?F to 120?F.
EVIDENCE:
1. The hot water from the sinks in bathroom 1 and bathroom 2, located across from the facility kitchen were noted to have a temperature reading of 99?F at 9:20am on the day of inspection.
Plan of Correction:
Director of facilities for BMH was on site 12/6/23 morning. The ?blender? that corrects temps between hot/cold seems to be off. The internal thermometer in the blender is not reading correctly, thus dispersing incorrect water temps. System was taken apart and cleaned 12/7/23. Determined a new valve may also be needed. Valve ordered 12/8/23 and will be installed when arrived. We will be checking temperatures weekly until unit reaches consistent reading within range 105-120 degrees for 3 weeks.
Standard #:
22VAC40-61-530-B
Description:
Based on observations made of the facility physical plant, the facility failed to ensure that all required information was included on the facility fire and emergency evacuation drawing.
EVIDENCE:
1. The facility fire and emergency evacuation drawing that was posted by the front door on the day of inspection did not contain information on areas of refuge or assembly areas.
Plan of Correction:
Email sent to marketing to add area of refuge/area of assembly marked on evacuation map. Received 12/8/23 and posted.
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
Find this content at:
http://www.dss.virginia.gov/facility/search/adc.cgi