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 10, 2022 and May 12, 2022

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 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 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

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: The inspection began at 8:40 am on 5/10/2022 and concluded on 5/12/2022 at 2:15 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 (2 records were for discharged residents) Number of staff records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed medication administration and observed residents eating lunch. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at Jamie.Eddy@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based upon a review of records, the facility failed to include on the disclosure statement the following information: whether or not the facility has an on-site emergency electrical power source for the provision of electricity during an interruption of the normal electric power supply. If the facility does have an on-site emergency electrical power source, the statement must include: (i) the terms for which the source will supply power and (ii) whether or not staff of the facility have been trained to maintain and operate the power source. For the purposes of this subdivision, an on-site emergency electrical power supply shall include both permanent emergency electrical power sources and portable power supply sources, provided that such temporary electrical power supply sources remains on the premises of the facility at all times. Written acknowledgement of the disclosure shall be evidenced by the signature or initials of the resident or his legal representative immediately following the on-site emergency electric power disclosure statement. Evidence: The current disclosure statement was observed by the LI and it did not contain information regarding the presence or absence of an emergency electrical power source.
Plan of Correction:	Stevenson Place does not have a permanent or temporary emergency power source on site. In the event of a disruption in the power supply, Stevenson Place has the capability to access and connect to an emergency power supply provided by Fairfax County Facilities Management Division.
Standard #:	22VAC40-73-260-A
Description:	Based upon a review of records, the facility failed to ensure that each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment. Evidence: Staff #3 was hired on 11/8/2021 as an overnight support professional who may provide direct care to residents. According to the employee file of Staff #3, the first aid certification was obtained on 5/10/2022.
Plan of Correction:	All new direct care staff will complete first aid and CPR certification within sixty days of employment. Once completed, each staff will submit a copy of their certification to the Program Director.