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: 06/12/2024 9am until 12pm. 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: 3 Number of staff 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.
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 observations of the facility medication cart, the facility failed to ensure that all medication remained in the original container with the prescription label or direction label attached.
EVIDENCE:
1. On the day of inspection the LI observed a halved orange pill in a plastic cup sitting in the first drawer of the medication cart. There was no prescription or direction label with the medication.
Plan of Correction:
The Director removed the medication from the medication cart on the day of inspection and will in-service all staff on the proper storage of medications in the medication cart.
Standard #:
22VAC40-61-300-E-7-d
Description:
Based on observations of the facility medication cart and participant medication administration records (MARs), the facility failed to ensure that all required documentation was maintained on participant MARs.
EVIDENCE:
1. The record for participant 1 has a physician order dated 04/16/2024 for an EPI Pen. The medication was observed in the medication cart of the day of inspection. The June 2024 MAR for participant 1 does not have any documentation for this medication.
2. The June 2024 MAR for participant 1 has the medications Carbidopa Levodopa 25/100mg and Quetiapine 50mg listed on the MAR but does not include Diagnosis, condition, or specific indications for which the medication is prescribed, the date medication was prescribed, route of administration or the frequency of administration.
3. The June 2024 MAR for participant 2 has the medications Atorvastatin 40mg, B12 1000mcg, D3 2000mg and Aspirin 81mg listed on the MAR but does not include Diagnosis, condition, or specific indications for which the medication is prescribed, the date medication was prescribed, route of administration or the frequency of administration.
Plan of Correction:
The Director will update participants MARs to include all required information and will in-service all staff on proper MAR documentation.
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