VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Acadia Care LLC
9285 Critzers Shop Road
Afton, VA 22920
(434) 989-5020

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: Jan. 10, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1-04-2023, 10:20 ? 10:50 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11-10-2022 regarding allegations in the area of: Admission, Retention, and Discharge of Residents Number of residents present at the facility at the beginning of the inspection: 7 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 Alexandra Poulter, Licensing Inspector at (804) 662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-50-B
Complaint related:	No
Description:	Based on record review and interview with staff, the facility failed to ensure there was written acknowledgement of the receipt of the disclosure by the resident or his legal representative in the resident?s record. Evidence: Resident #1?s record did not contain a copy of the disclosure anywhere in the record.
Plan of Correction:	Administrator will ensure a disclosure statement signed by the resident and/or legal guardian is included in the client record at time of admission.
Standard #:	22VAC40-73-310-A
Complaint related:	No
Description:	Based on record review and interview with staff, the facility failed to ensure no resident was admitted or retained who requires a level of care or service or type of service for which the facility is not licensed. Evidence: 1. Resident #1?s Uniform Assessment Instrument [UAI] dated 8-10-2022 documented under Ambulation, ?Walking: Is Not Performed?; however, the facility?s license effective stipulates, ?All residents must be capable of responding to an emergency situation without physical assistance.? 2. The Medicaid Funded Long-Term Care and Supports Authorization form dated 08-10-2022 documented the level of care for Resident #1 as ?Nursing Facility Services?. 3. Staff #1 acknowledged Resident #1 was not an appropriate level of care for the facility during phone interview on 1-04-2023 following the inspection.
Plan of Correction:	Administrator will ensure that all potential resident UAI?s reflect the level of care accepted at the facility. If referring individual states verbally that potential residents level of care is no longer consistent with UAI administrator will request an updated UAI reflecting those changes prior to continuing with conversation about a potential admission. All resident?s residing at the facility will maintain UAI?s that reflect the status of care accepted at the facility including being ambulatory and appropriate for a residential care facility. Residents that no longer meet this level of care will be discharged to facilities that can provide a higher level of care.
Standard #:	22VAC40-73-310-D
Complaint related:	Yes
Description:	Based on record review and interview with staff, the facility failed to ensure that based upon review of the UAI prior to admission of a resident, the assisted living facility administrator shall provide written assurance to the resident that the facility has the appropriate license to meet his care needs at the time of admission. Copies of the written assurance shall be given to the legal representative and case manager, if any, and a copy signed by the resident or his legal representative shall be kept in the resident's record. Evidence: 1. Resident #1 was admitted around approximately 10-20-2022; however, there was no written assurance in the resident?s record. 2. Staff #1 acknowledged no written assurance was provided to the resident during phone interview on 1-04-2023 following the inspection.
Plan of Correction:	Administrator will ensure a written assurance form is provided to all residents and guardians and filed in the client record for reference.
Standard #:	22VAC40-73-380-A
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure prior to or at the time of admission to an assisted living facility, the following personal and social information on a person shall be obtained. Evidence: 1. Resident #1 admitted 10-20-2022 per the ?Regional Discharge Assistance Program Provider Agreement? from Agency #1; however, the following information was not documented in Resident?s file: a. Date of admission per facility, b. Last home address which resident was received from, c. Birthplace, d. Marital status, e. Name, address, and telephone number of all legal representatives, if any; f. If there is a legal representative, copies of current legal documents that show proof of each legal representative's authority to act on behalf of the resident and that specify the scope of the representative's authority to make decisions and to perform other functions; g. Name, address, and telephone number of next of kin, if known (two preferred); h. Name, address, and telephone number of designated contact person authorized by the resident or legal representative, if appropriate, for notification purposes, including emergency notification and notification of the need for mental health, intellectual disability, substance abuse, or behavioral disorder services - if the resident or legal representative is willing to designate an authorized contact person. There may be more than one designated contact person. The designated contact person may also be listed under another category, such as next of kin or legal representative; i. Name, address, and telephone number of the responsible individual stipulated in 22VAC40-73-550 H, if needed; j. Name, address, and telephone number of personal physician, if known; k. Name, address, and telephone number of personal dentist, if known; l. Name, address, and telephone number of clergyman and place of worship, if applicable; m. Name, address, and telephone number of local department of social services or any other agency, if applicable, and the name of the assigned case manager or caseworker; n. Service in the armed forces, if applicable; o. Lifetime vocation, career, or primary role; p. Special interests and hobbies; q. Known allergies, if any; r. Information concerning advance directives, Do Not Resuscitate (DNR) Orders, or organ donation, if applicable; s. Previous mental health or intellectual disability services history, if any, and if applicable for care or services; t. Current behavioral and social functioning including strengths and problems; and u. Any substance abuse history if applicable for care or services. 2. Staff #1 acknowledged during phone interview on 1-04-2023 following the inspection.
Plan of Correction:	Administrator will ensure all required personal and social information is obtained and documented prior to admission and stored in the client record at admission.
Standard #:	22VAC40-73-390-A
Complaint related:	No
Description:	Based on record review and interview with staff, the facility failed to ensure at or prior to the time of admission, there shall be a written agreement/acknowledgment of notification dated and signed by the resident or applicant for admission or the appropriate legal representative, and by the licensee or administrator. Evidence: Resident #1 was at the facility in October 2022 as a resident. There was no resident agreement in Resident #1?s record. Staff #1 acknowledged during phone interview on 1-04-2023 following the inspection.
Plan of Correction:	Administrator will ensure a resident agreement is signed and documented in client record at time of admission
Standard #:	22VAC40-73-410-A
Complaint related:	No
Description:	Based on record review and interview with staff, the facility failed to ensure upon admission, the assisted living facility provided orientation for new residents. Evidence: Resident #1?s record did not contain acknowledgement of having received orientation to the facility, nor did Staff #1 acknowledge that Resident #1 received orientation to the facility including emergency response procedures, mealtimes, and use of the call system.
Plan of Correction:	Administrator will ensure all resident records contain a resident orientation at the time of admission.
Standard #:	22VAC40-73-430-H-1
Complaint related:	No
Description:	Based on record review and interview with staff the facility failed to ensure at the time of discharge, the assisted living facility shall provide to the resident and, as appropriate, his legal representative and designated contact person a dated statement signed by the licensee or administrator. A copy of the written statement shall be retained in the resident's record. Evidence: Resident #1?s record did not contain a discharge statement in the record despite the resident being discharged by the facility shortly after admittance in October, 2022. Staff #1 acknowledged during phone interview on 1-04-2023 following the inspection.
Plan of Correction:	Administrator will ensure a discharge summary is provided to resident and legal guardian and included in client record at notification of discharge.
Standard #:	22VAC40-73-450-A
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: Resident #1 admitted around 10-20-2022, and no preliminary plan of care was in the resident?s record. Staff #1 acknowledged during phone interview on 1-04-2023 following the inspection.
Plan of Correction:	Administrator will ensure an resident ISP plan is included in resident record at the time of admission.