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 25, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-60 ADMINISTRATION 22VAC40-60 PERSONNEL. 22VAC40-60 SUPERVISION. 22VAC40-60 BUILDINGS AND GROUNDS. 22VAC40-60 ADMISSION, RETENTION AND DISCHARGE. 22VAC40-60 PROGRAMS AND SERVICES. 22VAC40-60 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:

An unannounced renewal inspection was conducted by two licensing inspectors on July 25, 2019 from 12:10 p.m. to 1:30 p.m. A census of 1 participant was reported. The following items were reviewed/observed during the inspection: tour of the center, sample of 3 participant and 3 staff records, facility documentation, lunch meal/menu, activity schedule, and first aid kit. The director of the center was on-site during the inspection and the participant was engaged in activities. Violations cited are identified in this report. 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 #:	22VAC40-60-600-A
Description:	Based on a review of participant records, the center failed to ensure that each participant record contained a screening for tuberculosis (TB) and a physical examination obtained either within 30 days prior to acceptance for admission or within 30 days prior to admission. Evidence: Record for Participant # 3 did not contain a physical examination or TB screening.
Plan of Correction:	Obtained TB/physical exam from MD of record for Participant # 3. Director will ensure all pre-admission records are obtained before admission.
Standard #:	22VAC40-60-695-A
Description:	Based on a review of participant records, the center failed to ensure that health care monitoring included all required areas of participants' functional status. Evidence: 3 of 3 participant records reviewed did not include the following areas for health care monitoring: -Weight -Hydration -Circulation -Positioning -Skin integrity -Sensory capabilities
Plan of Correction:	All health care monitoring areas will be assessed/tracked in accordance to the Standards and Regulations for Licensed Adult Day Care Centers.
Standard #:	22VAC40-60-1020-D-4
Description:	Based on a review of the center's documentation, the center failed to conduct monthly evacuation drills in accordance with the requirements of the Virginia Statewide Fire Prevention Code. Evidence: The center's most recent evacuation drill was conducted on 5-8-19.
Plan of Correction:	Reviewed Virginia Statewide Fire Prevention Code with staff and displayed documents that need to be completed for monthly evacuation drills.