VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Virginia Tech Adult Day Services
102 Wallace Hall
Blacksburg, VA 24061
(540) 231-3161

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: Feb. 21, 2025

Complaint Related: No

Areas Reviewed:

22VAC40-61 ADMINISTRATION 22VAC40-61 ADMISSION, RETENTION AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES

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: 02/21/2025, 11:20am to 1:21pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 01/31/2025 regarding allegations in the area(s) of: Program and services Number of participants present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 1 Number of staff records reviewed: n/a Number of interviews conducted with participants: n/a Number of interviews conducted with staff: 5 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 #:	22VAC40-61-90-A
Description:	Based on a report from staff, the center failed to report to the regional licensing office within 24 hours of the occurrence of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any participant. EVIDENCE: 1. Staff #5 contacted the licensing inspector (LI) via phone on 01/31/2025 to provide notification that an incident occurred on 10/23/2024 in which a participant exited the center without staff knowledge. 2. Staff #5 reported that due to staff error, this incident was not reported within 24 hours of its occurrence. 3. The written incident report was provided to the LI via fax on 01/31/2025.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-90-C
Description:	Based on a report from staff, the center failed to submit a written report of each incident specified in subsection A of this section to the regional licensing office within seven days from the date of the incident. EVIDENCE: 1. Staff #5 contacted the licensing inspector (LI) via phone on 01/31/2025 to provide notification that an incident occurred on 10/23/2024 in which a participant exited the center without staff knowledge. 2. Staff #5 reported that due to staff error, a written report of this incident was not provided to the regional licensing office within seven days from the date of the incident. 3. The written incident report was provided to the LI via fax on 01/31/2025.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-230-D
Description:	Based on a review of participant records, the center failed to include all required information on the participant plan of care. EVIDENCE: 1. The participant assessment for participant #1, completed on 07/18/2024, states participant #1 ?wanders at times.? 2. The participant plan of care for participant #1, completed on 07/15/2024, addressed areas of history of anxiety and frontotemporal dementia, but did not specifically address the behavior of wandering identified in the participant assessment.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-280-B
Description:	Based on a review of participant records and interviews with staff, the center failed to provide supervision of participant schedules, care, and activities including attention to specialized needs, such as prevention of falls and wandering. EVIDENCE: 1. Participant #1 began attending the adult day program on 07/24/2023. 2. The primary care outpatient note for participant #1 dated 02/29/2024 documents a history of progressive frontotemporal dementia. 3. The preadmission assessment completed 07/13/2023 states participant #1 ?Tries to wander.? The participant assessment for participant #1 completed 07/18/2024 states participant #1 ?wanders at times.? 4. Progress notes maintained by the center document participant #1 left the center on the following dates: 12/07/2023, 01/25/2024, 01/26/2024, 02/20/2024, 08/06/2024 and 10/22/2024. On each of these occasions, center staff observed participant #1 exiting the center and were able to accompany him until he could be redirected back inside the center or wait with him outside until a caregiver could pick him up from the center to take him home. 5. Per incident report dated 10/25/2024, on 10/23/2024, ?During morning programming and a headcount, it was noted that participant #1 was not in the center.? Missing participant protocol was followed, and participant #1 ?was recovered safely within minutes by staff #3.? 6. Per interviews with staff #2, staff #3 and staff #4, it is believed that participant #1 most likely followed a volunteer through the kitchen and out a back door leading to another portion of the building. There are at least three doors through which participant #1 could have exited to the day center parking lot, however staff are not certain which exit he used. 7. Per staff #3, participant #1 was found in a parking lot across the street from the day center parking lot. Staff #2, staff #3 and staff #4 estimate participant #1 was outside the center from approximately five to 10 minutes. 8. Staff #2 reports participant #1 arrived at the facility on 10/23/2024 at 9:36am. According to https://www.wunderground.com/history/daily/us/va/blacksburg/KBCB/date/2024-10-23, the temperature outside ranged from 55 degrees Fahrenheit at 9:35am to 70 degrees Fahrenheit at 12:15pm. Staff #2, staff #3 and staff #4 report participant #1 was wearing jeans, tennis shoes and either a hooded sweatshirt or an insulated flannel shirt/jacket on this date.
Plan of Correction:	Not available online. Contact Inspector for more information.