VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Stevenson Place
4113 Stevenson Street
Fairfax, VA 22030
(703) 460-6200

Current Inspector: Marshall Massenberg (804) 543-5188

Inspection Date: May 28, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 5/28/2020 and concluded on 6/23/2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 33. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records and 3 staff records. Criminal record checks and sworn statements of all staff hired since last inspection and other documentation submitted by the facility was reviewed to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on record review, facility failed to ensure that health information maintained at the facility shall include documentation that each staff person on or within seven days prior to the first day of work at the facility shall submit the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Staff #1 was hired on 11/5/2019 with a TB dated 11/15/2019 and Staff #3 was hired on 11/26/2019 with a TB dated 12/4/2019, both TB reports were not obtained on or within seven days prior to the first day of work at the facility.
Plan of Correction:	All new hires are required to bring the results of their TB Test with them to their initial meeting with HR, prior to the start of employment.
Standard #:	22VAC40-73-320-A
Description:	320.A Based on record review, facility failed to ensure that any known allergies and description of the person's reactions shall be contained on the physical examination within 30 days preceding admission. Evidence: Resident #3 admitted on 10/1/2019 with a physical examination 9/13/2019 documented allergies to Niacin and Thorazine and the allergic reactions were not documented..
Plan of Correction:	All pre-admission physical exams will be documented on the most current VDSS model form for Report of Resident Physical Examination (02/18). Nursing staff will review the exam form and call the physician for clarification and corrected documentation if allergies are identified without a reaction listed.
Standard #:	22VAC40-73-970-A
Description:	Based on record review, facility failed to ensure that fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). Evidence: The most recent fire drills available for review are dated 12/23/2019, 1/29/2020 and 2/26/2020. State of Emergency Suspension of DSS Licensing Assisted Living Facilities (ALF) Regulation Requirements granted effective 4/14/2020 did not include this standard.
Plan of Correction:	The facility has resumed fire drills effective 6/30/20 and will encourage social distancing and use of facial coverings during the drill procedure.
Standard #:	22VAC40-90-30-B
Description:	Based on record review, facility failed to ensure that the sworn statement or affirmation shall be completed for all applicants for employment. Evidence: Staff #3 was hired on 11/26/2019 with a Sworn Statement dated 12/01/2019 after hired and not an applicant, not signed, and does not list all cases with explanation.
Plan of Correction:	All individuals offered employment will sign and complete the Sworn Statement at their initial meeting with HR, prior to starting employment.