Current Inspector:
Jacquelyn Kabiri
(703) 397-3017
Inspection Date:
Feb. 14, 2024
Complaint Related:
No
Areas Reviewed:
22VAC40-61 GENERAL PROVISIONS 22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 SUPERVISION 22VAC40-61 ADMISSION, RETENTION, AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUNDS 22VAC40-61 EMERGENCY PREPAREDNESS 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2(19.2) Criminal Procedures. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report
Comments:
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/11/23 (10:10 AM - 2:30 PM) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
At the time of entrance, 73 participants were present. Participants, staff records, and other documentation were reviewed. Background checks for new staff members, hired since the last inspection were reviewed. Participants were observed eating lunch and engaging in activities. An exit meeting was 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.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Based on record review and interview, the center failed to ensure that each direct care staff member maintains current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Each direct care staff member who does not have current certification in first aid as specified, shall receive certification in first aid within 60 days of employment. Evidence: The records for three out of four staff members (Staff #1, Staff #2, Staff #3) did not contain documentation of current first aid certification. Staff #1 was hired as a direct care staff member on 7/31/23. Staff #2 was hired as a direct care staff member on 9/5/23. Staff #3 was hired as direct care staff member on 7/8/23. Staff #5 confirmed that the first aid certifications were not present in the staff member records.
Plan of Correction:
Not available online. Contact Inspector for more information.
Standard #:
22VAC40-61-330-D
Description:
Based on record review and interview, the center failed to ensure that the designated staff person, responsible for managing or coordinating the structured activities program, meets one of the following qualifications:
Be a qualified therapeutic recreation specialist or an activities professional;
2. Be eligible for certification as a therapeutic recreation specialist or an activities professional by a recognized accrediting body;
3. Be a qualified occupational therapist or an occupational therapy assistant;
4. Have at least an associate?s degree in a discipline focusing on the provision of activities for adults; or
5. Have one year full-time work experience within the last five years in an activities program in an adult care setting. Evidence: Staff #4 was reported to be the center's designated staff person, who is responsible for managing the structured activities program. Staff #4's record contained a PCA certificate and First Aid/CPR certification, but it did not contain any documentation to confirm that he met one of the required qualifications for the designated activity staff person.
Plan of Correction:
Not available online. Contact Inspector for more information.
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
Find this content at:
http://www.dss.virginia.gov/facility/search/adc.cgi