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: Aug. 23, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED 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: 8-23-2023, 10:20 ? 11 AM 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 August 13, 2023 regarding allegations in the area of: Resident Care and Related Services. 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 did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can 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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure that a person?s physical examination contained a description of the person?s reaction to any known allergies. Evidence: Resident #1 admitted 5-04-2023 to the facility. Resident #1?s Report of Resident Physical Examination dated 4-25-2023 documented, ?fish derived products and penicillin? as allergies; however, no allergy reactions were documented on the resident physical examination.
Plan of Correction:	Administrator will ensure that all potential resident and resident physical examinations that list allergies also list the persons reaction to the known allergen. This plan of correction will begin immediately 12/6/23
Standard #:	22VAC40-73-560-H
Description:	Based on record review and interview with staff, the facility failed to ensure the complete resident record was retained for at least two years after the resident leaves the facility. Evidence: 1. Blood pressure logs for the resident as ordered by Resident #1?s physician were not documented in the medication records for the months of May, June, July, and August 2023. 2. Staff #1 stated that the blood pressure was taken per the order; however, the logs were kept separate from the medication administration records and that the blood pressure logs for Resident #1 were not retained.
Plan of Correction:	Administrator will ensure that a complete resident record is retained for a minimum of two years after a resident leaves the facility. This plan of correction will begin immediately 12/6/23
Standard #:	22VAC40-73-640-A
Description:	Based on record review and interview with staff, the facility failed to ensure methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order. Evidence: Resident #1?s MARs dated May through August 2023 documented, ?The months May through August 2023 documented ?Risperidone 2mg ? take 1 tablet by mouth twice daily?; however, the 5-11-2023 physician?s oral order documented, ?Risperidone 2mg ? take 2 tabs PO HS [by mouth, bedtime]? Staff #1 confirmed the medication was given per the 5-11-2023 and that the MAR transcription was incorrect.
Plan of Correction:	Administrator will ensure all medication orders are properly transcribed on a residents MAR within 24 hours of the receipt of a new order. This plan of correction will begin immediately 12/6/23
Standard #:	22VAC40-73-650-C
Description:	Based on record review and interview with staff, the facility failed to ensure physician?s oral orders were reviewed and signed by a physician within 14 days. Evidence: 1. Resident #1?s orders for the following medications were not signed by the physician within 14 days or of oral order: A. Divalproex ER 500 mg ? 2 tabs PO HS B. Trazodone 100 mg ? 1 tab PO HS C. Quetiapine 300 mg ? 1 PO HS D. Risperidone 2 mg ? Take 2 tabs PO HS D/C Risperidone order E. Clonidine 0.2 mg ? 1 PO HS Hold for SBP<100 2. There was no signature within 14 days of the oral order by Resident #1?s physician?s for orders dated 5-11-2023.
Plan of Correction:	Administrator will ensure all oral orders are reviewed and signed by a physician within 14 days. This plan of correction will begin immediately 12/6/23