VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Vinson Hall
6251 Old Dominion Dr.
Mc lean, VA 22101
(703) 536-4344

Current Inspector: Marshall Massenberg (804) 543-5188

Inspection Date: Dec. 16, 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 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:

An unannounced renewal study was conducted from 8:45 a.m. - 1:45 p.m. on 12/16/2021. At the time of entrance 20 residents were in care. The sample size consisted of three resident records and three staff records. Four residents and three staff were interviewed. Resident and staff records and other documentation reviewed. Criminal Background Checks of all staff hired since previous inspection conducted on 09/18/2020 were reviewed. Residents were observed eating breakfast and engaging in activities including exercise, art class and resident council. Medication administration was observed with three residents and cart observed for PRN medications. Building and Grounds and postings observed. Violation notice issued, risk ratings reviewed and exit interview held. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again, 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s), and 4) date that that plan of correction will be completed. Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-200-C
Description:	Based on record review, facility failed to ensure that direct care staff shall meet one of the requirements in this subsection. If the staff does not meet the requirement at the time of employment, he shall successfully meet one of the requirements in this subsection within two months of employment. Successful completion of a personal care aide training program approved by the Virginia Department of Medical Assistance Services. EVIDENCE: Staff 3 was hired as a Personal Care Aid on 10/22/2021 and a personal care aide training program has not been completed within two months of employment.
Plan of Correction:	HR Director will obtain copy of the employee #1 Personal Care Aid training records. Additionally, the HR Director will audit 100% of all Personal Care Aid training records immediately. The HR Director will audit 100% of newly hired Personal Care Aid training records for 100% compliance every 3 months.