VIRGINIA DEPARTMENT OF SOCIAL SERVICES

BrightCare Center
10312 Battleview Parkway
Manassas, VA 20109
(703) 330-5836

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: April 23, 2024

Complaint Related: No

Areas Reviewed:

Administration Personnel Supervision Admission, Retention and Discharge Programs and Services Buildings and Grounds Emergency Preparedness

Technical Assistance:

None

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: April 23, 2024, 11:30am-2pm 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: 18 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: 1 Number of interviews conducted with participants: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: The Licensing Inspector observed the Participants during many activities and meals. Additional Comments/Discussion: The Licensing Inspector reviewed the following at the time of inspection: menus, activity calendars and staff training documentation. 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 Laura Lunceford, Licensing Inspector at 540 219-9264 or by email at laura.lunceford@dss.virginia.gov

Violations:

Standard #:	22VAC40-61-60-A
Description:	Based on participant record review and staff interviews, it was determined that the program failed to have current documentation within the Participants records as required. Evidence: Two Participant records did not have documentation of the Adult Day HealthCare Daily Log as required by the policies for the Program.
Plan of Correction:	All Participant records will be audited to ensure compliance. Staff will be re-educated on the policies for the program in reference to documentation that is required.