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: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/01/2023 9am until 11am 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: 11 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 2 Number of interviews conducted with participants: 1 Number of interviews conducted with staff: 2
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.
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 540-309-2968or by email at cynthia.ball@dss.virginia.gov
Based on participant record review, the facility failed to ensure that identified needs were addressed on participant plan of cares (POC).
EVIDENCE: 1. The participant assessment for participant 1 dated 04/04/2023 has documentation that the participant requires stand by assistance and uses a walker for walking and stairclimbing. and supervision with stairs and bathing. The POC reviewed on 11/18/2022 does not address these identified needs.
Plan of Correction:
Will review Participant POC and Assessments and update them to correlate the Participant?s needs appropriately and completely.
Standard #:
22VAC40-61-300-A
Description:
Based on review of participant medication administration records (MAR) and staff interviews, the facility failed to implement a component of its medication management plan.
EVIDENCE: 1. Regarding methods to secure and maintain supplies of each participant?s medications, the facility?s plan states, ?All Meds checked daily and reported to family for refills by the way daily report sheet.?
2. The June 2023 MAR for participant 2 has documentation that the following medications were not administered at 11am on 06/01/2023: Aspirin 81mg, Clopidogrel Bisulfate 75mg and Pantoprazole 40mg. Interview with staff 1 expressed that the medications were not available on-site at the facility to be administered.
Plan of Correction:
Implement procedures to insure an adequate amount of Meds are on hand to give to Participant while attending Center. Chart daily any discrepancies noted, in the MAR and in Progress Notes, along with documenting any communications with the Family, VA, or MD to insure adequate supply of Meds available at Center. Also communicate to the Family, VA, and MD of possible discharge from Center if an adequate supply of Meds can?t be consistently obtained.
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.
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http://www.dss.virginia.gov/facility/search/adc.cgi