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 2, 2024

Complaint Related: No

Areas Reviewed:

General Provisions Administration Personnel Supervision Admission, Retention and Discharge Programs and Services Building and Grounds Emergency Preparedness

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/02/2024 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: 35 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 4 Number of staff records reviewed: 4 Number of interviews conducted with participants: 1 Number of interviews conducted with staff: 2 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov

Violations:

Standard #:	22VAC40-61-110-B
Description:	Based on staff records review and staff interview, the facility failed to document required orientation and initial training. Evidence: 1. Staff 3, whose date of hire was 12/11/2023, had a blank Staff Orientation and Initial Training record on the date of inspection on 05/02/2024. 2. Staff 4, whose date of hire was 01/02/2024, had 2 of 18 areas of training documented as completed on date of inspection on 05/02/2024.
Plan of Correction:	We have informed the HR department head to ensure that all staff related documents are completed entirely. This includes staff training, orientation, and intake process (background checks, license check, etc.)
Standard #:	22VAC40-61-230-D
Description:	Based on participant record review and staff interview, the facility failed to develop a participant plan of care that described the participant?s needs for 4 out 4 participant records reviewed. Evidence: 1. Participant 1?s six-month assessment completed on 03/27/2024 indicates the participant needs Mechanical Help and Human Help with the following Activities of Daily Living (ADLs): Bathing, Dressing, Toileting and Transferring, as well as needing Supervision and Mechanical Help while eating. The assessment also indicates the participant is Bladder Incontinent weekly or more and needs Mechanical Help and Human Help with Mobility. None of these areas are addressed on the Participant plan of care that was developed on 03/22/2024. 2. Participant 2?s six-month assessment completed on 03/07/2024 indicates the participant needs Mechanical Help and Human Help with the following Activities of Daily Living (ADLs): Bathing, Dressing, Toileting and Transferring. The assessment also indicates the participant is Bladder Incontinent weekly or more and needs Mechanical Help and Human Help with Mobility. None of these areas are addressed on the Participant plan of care that was developed on 02/03/2024. 3. Participant 3?s six-month assessment completed on 03/28/2024 indicates the participant needs Mechanical Help and Human Help with the following Activities of Daily Living (ADLs): Bathing, Dressing, Toileting and Transferring, as well as needing Supervision and Mechanical Help while eating. The assessment also indicates the participant is Bladder Incontinent weekly or more and needs Mechanical Help and Human Help with Mobility. None of these areas are addressed on the Participant plan of care that was developed on 04/04/2024. 4. Participant 4?s six-month assessment completed on 03/27/2024 indicates the participant needs Mechanical Help and Human Help with the following Activities of Daily Living (ADLs): Bathing, Dressing, Toileting and Transferring, as well as Supervision and Mechanical Help while eating. The assessment also indicates the participant is Bladder Incontinent weekly or more and needs Mechanical Help and Human Help with Mobility. None of these areas are addressed on the Participant plan of care that was developed on 03/22/2024.
Plan of Correction:	Meeting was held with management, clinician, and daycare staff regarding post-survey notes on 6/13/2024. We have decided that the clinicians will ensure that the written Plan of Care reflects the DMAS 99 clinical information based on participant's individualized needs. This chart will then be reviewed by the organization administrator to ensure accuracy. The administrator will also ensure the daycare staff is informed of each participant's individualized needs. The daycare staff will take note and cater to each participant's needs based on the generated plan of care. We will initially review all current participant files and update clinical information and plan of are to be accurate. Afterwards, we will proceed with out discussed plan to ensure we are adhering to standard 22VAC-40-61-230 for every new participant.