VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Providence of Fairfax
9490 Sprague Avenue
Fairfax, VA 22031
(571) 396-0500

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: June 11, 2024

Complaint Related: No

Areas Reviewed:

63.2- (1) GENERAL PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

N/A

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/11/2024: 4:30 PM to 5:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 05/14/2024 and 05/29/2024 regarding allegations in the area of Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 105 The licensing inspector completed a tour of the physical plant that included the resident?s rooms. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. 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 Amanda Velasco, Licensing Inspector at (703) 397 4587 or by email at Amanda.Velasco@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-560-I
Description:	Based on resident record review, the facility failed to ensure that the residents record included a current photo, or a narrative physical description which is updated annually. Evidence: 1. Resident 1?s record contained a face sheet, dated 01/26/2023, with a black and white photo of the resident. 2. Resident 1?s individualized service plan (ISP) dated 06/20/2023 had the same photo in color as the main identifier of the resident.
Plan of Correction:	Immediately, Resident #1 photo was updated in their record. The Executive Director (ED), Director of Nursing (DON), and Assistant Director of Nursing (ADON) have revised our procedure for reporting incidents that occur on Saturdays to comply with the 24-hour reporting requirement. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.