VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Alexandria Adult Day Services Center
1108 Jefferson Street
Alexandria, VA 22314
(703) 746-5676

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: June 21, 2024

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

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: 06/21/2024 Time In: 12:14 PM Time Out: 2:09 PM 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: 6 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with participants: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: LI toured the physical plant of the facility; and observed participants dining at lunch, and participating in an activity with a collateral contact. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov

Violations:

Standard #:	22VAC40-61-520-C
Description:	Based on facility record review and staff interview, the facility failed to ensure that the center developed and implemented an orientation and semi-annual review on the emergency preparedness and response plan for all staff, participants, and volunteers. 1. The emergency preparedness and response plan?s annual review with staff was completed on 02/14/2024. The plan was not reviewed semi-annually. 2. On 06/21/2024, LI interviewed Staff 3, who stated, ?I was not aware that the plan needed to be reviewed twice a year. I have only known to review this once a year.?
Plan of Correction:	The facility will schedule and conduct semi-annual emergency preparedness and response training sessions with program staff, participants and volunteers. One of these training sessions will be led by the facility itself and scheduled for 10/2/24, while the other will be conducted by the City of Alexandria that operates the facility. Each staff member will attend training online. Documentation of all training sessions will be available for review during the next VDSS inspection.
Standard #:	22VAC40-61-550-A
Description:	Based on facility record review and staff interview, the facility failed to ensure that each building of the center and all vehicles being used to transport participants shall contain a first aid kit. 1. The first aid kit was missing a first aid instructional manual, triangular bandages, flexible gauze, and breathing barriers. 2. On 06/21/2024, the LI interviewed Staff 2 (hire date, 01/21/2022), who stated, ?everything should be here. I check it regularly.? Staff 2 was unable to show expiration dates on the zip lock bags or on the contents within the kit.
Plan of Correction:	The facility failed to show that it had an additional first aid kit presents on-site at the time of the inspection. The kit contains the manual, contents description and expiration dates on the container. Furthermore, a request was submitted on 8/14/24 to purchase a larger first aid kit to ensure compliance with VDSS and safety regulations. Also, the facility has scheduled an in-service training session with program staff to review and ensure proper maintenance and annual checks of the first aid kit. This in-service is scheduled for 9/11/24.
Standard #:	22VAC40-61-550-C
Description:	Based on facility record review and staff interview, the facility failed to ensure that the first aid kit was checked at least annually, and contents were replaced before expiration dates and as necessary. 1. There was an absence of documentation or log that reflected an annual review. 2. On 06/21/2024, LI interviewed Staff 2 (hire date, 01/21/2022), who stated that ?I put everything in zip lock bags to make it more organized.? Staff 2 further stated, ?I do not review with a log.?
Plan of Correction:	The facility failed to show that it had an additional first aid kit presents on-site at the time of the inspection. The kit contains the manual, contents description and expiration dates on the container. Furthermore, a request was submitted on 8/14/24 to purchase a larger first aid kit to ensure compliance with VDSS and safety regulations. Also, the facility has scheduled an in-service training session with program staff to review and ensure proper maintenance and annual checks of the first aid kit. This in-service is scheduled for 9/11/24