VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Evergreen Adult Day Healthcare Center
4115 Annadale Road
Suite 207
Annandale, VA 22003
(703) 534-5049

Current Inspector: Alexandra Roberts (804) 845-6956

Inspection Date: May 19, 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 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 SANCTIONS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 CRIMINAL PROCEDURES 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

An unannounced renewal inspection was conducted on 5/19/2023. At the time of entrance there were approximately 24 participants in care and five staff members providing supervision. The Licensing Inspector completed a tour of the physical plant that included the building and grounds of the facility. Renovations have been completed and room measurements were verified to increase capacity. Three participant and three staff records were reviewed. Participant interviews were not conducted because the participants? first language is not English and no interpreters were provided No participants received medications during the inspection. Participants were observed having breakfast. Activities observed included current events, traditional games and morning exercise. Criminal Background Checks of all staff hired since previous inspection were reviewed. An exit meeting was 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 Lynette Storr, Licensing Inspector at (703) 479-4708 or by email at Lyn lynette.storr@dss.virginia.gov

Violations:

Standard #:	22VAC40-61-110-A
Description:	Center failed to ensure that prior to working directly with participants, all staff shall receive staff orientation and initial training. Evidence: Staff #1and Staff #2 did not have documentation that orientation and training was completed prior to working with participants.
Plan of Correction:	Center Director will review each staff member?s record to ensure it is in compliance.
Standard #:	22VAC40-61-180-D
Description:	Center failed to ensure that personal and social data to be maintained on staff includes: a sworn disclosure statement, documentation of qualifications for employment related to the staff person's position, name and telephone number of a person to contact in an emergency. Evidence: Staff #1 hired on 4/14/2023 did not have documentation of a sworn disclosure, emergency contact or verification of staff qualifications in the staff record. Staff #2 hired on 3/31/2023 did not have documentation of a sworn disclosure in the staff record.
Plan of Correction:	Center Director will review each staff member?s record to ensure it is in compliance.
Standard #:	22VAC40-61-180-E-1
Description:	Center failed to ensure that each staff person shall obtain an evaluation by a qualified licensed practitioner that completes an assessment for tuberculosis in a communicable form no earlier than 30 days before or no later than seven days after employment or contact with participants. Evidence: Staff #1 and Staff #2 did not have documentation of a TB screening in the staff record.
Plan of Correction:	Center Director will review each staff member?s record to ensure it is in compliance.