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: Feb. 5, 2021 and Feb. 8, 2021

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 monitoring inspection was initiated on 2/5/2021 and concluded on 2/8/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 36. 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. NOTE: On 12/15/2021, Licensing Inspector was alerted during an audit that the date on this inspection was dated with the year 2020, instead of the correct year 2021. Licensing Inspector has added this note and will have the facility administrator sign a corrected report and add it to the record.

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on record review, facility failed to ensure that each direct care staff member shall maintain current certification in first aid. Evidence: First aid and CPR certifications were not in record for Staff #3.
Plan of Correction:	All new employees will become certified in CPR/FA within 30 days of hire, ensuring completion of the training will be the responsibility of the Director and Assistant Director. The Assistant Director will ensure that staff #3 will complete the certification prior to 3/5/21.
Standard #:	22VAC40-73-320-A
Description:	Based on record review, facility failed to ensure that within the 30 days preceding admission, a person shall have a Physical Examination (PE) and shall contain a risk assessment documenting the absence of tuberculosis in a communicable form. Evidence: Resident #1 was admitted on 12/10/2020 with a PE and TB dated 9/15/2020, older than 30 days.
Plan of Correction:	All new admissions will have a physical exam and TB test completed within 30 days of admission date, with the understanding that the physical and TB test will need to be redone if the admission occurs outside of the 30-day window. The case manager working with the new admission and the Nurse Practitioner will review all physical exams and TB tests to ensure compliance with this standard. 2/16/21
Standard #:	22VAC40-73-450-C
Description:	Based on record review, facility failed to ensure that the comprehensive individualized service plan shall be completed within 30 days after admission. Evidence: Resident #1 was admitted on 12/10/2020 and an ISP was not in record.
Plan of Correction:	All new admissions will have a comprehensive ISP completed by their assigned case manager within 30 days of admission. Interpreter services have been secured and this residents ISP will be completed on 2/18/21 by the assigned case manager.