VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Falls Mills Adult Day Care
234 Angel Lane
Falls mills, VA 24613
(276) 688-5100

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: June 2, 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

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: 06/02/2023, 11:35am to 1:41pm 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: Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations:

Standard #:	22VAC40-61-250-E
Description:	Based on a review of participant records, the center failed to ensure the assessment shall be reviewed and updated at least every six months for one participant. EVIDENCE: 1. The most recent assessment in the record for participant #1 was dated 08/16/2022. There was not a six month update available in the record for participant #1. 2. Per interview with staff #1, the update was completed on 01/24/2023 by a licensed healthcare professional, however a copy was not placed in the record for participant #1.
Plan of Correction:	Participant did see her primary physician on 1/24/23 for the required six month assessment. Copy of assessment was received at that time, but did not get placed in chart. I contacted participant's provider and received a second copy of the note today via fax. Assessment note has been placed in participants chart today, 6/6/23. [SIC]