Current Inspector:
Alyshia E Walker
(757) 670-0504
Inspection Date:
April 10, 2023
Complaint Related:
No
Areas Reviewed:
22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 SUPERVISION 22VAC40-61 ADMISSION, RETENTION AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUND 22VAC40-61 EMERGENCY PREPAREDNESS 22VAC40-80 THE LICENSE 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
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: 4/10/2023 10:09am- 1:15pm
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
Number of participants present at the facility at the beginning of the inspection: 29 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of participant records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with participants: Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing Inspector observed activities a snack and a meal. 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 Alyshia E. Walker, Licensing Inspector at (757)670-0504 or by email at Alyshia.walker@dss.virginia.gov
Based on staff record review, the center failed to ensure each staff member be screened annually by a qualified licensed practitioner that completes an assessment for tuberculous (TB) in a communicable form.
Evidence:
1. Staff member #1?s most recent TB assessment was dated 6/2/2021.
2. Staff #1 and Staff#2 both acknowledged the TB assessment form in the staff record provided at the time of inspection was dated 6/2/2021.
Plan of Correction:
Staff member #1 will have an updated TB assessment.
Standard #:
22VAC40-61-220-D
Description:
Based on review of participant records, the center failed to ensure that each participant's plan of care contained a description of all needs identified on the participant assessment.
Evidence:
1. The records for Participants #1, #2, #3, #4, #5, and #6 did not include all the items of need identified on the participant assessment.
2. Staff #2 acknowledged the plans of care did not include all identified needs for the identified participants.
Plan of Correction:
The center will continually work with the inspector to ensure it has a correct and thorough understanding of the information required in each participant?s plan of care. The center will update each participant?s plan of care to include all needs identified on the participant assessment.
Standard #:
22VAC40-61-300-B
Description:
Based on observation and interview, the center failed to have at least one pharmacy reference book, drug guide or medication handbook readily accessible that is no more than two years old.
Evidence:
1. Staff #2 provided Licensing Inspectors a drug reference book with a publication date of 2012.
2. Staff #2 acknowledged the drug reference book was more than two years old.
Plan of Correction:
The center will purchase a 2023 drug reference book.
Standard #:
22VAC40-61-300-E-3
Description:
Based on observations made during the inspection of the center, the center failed to have medication kept in a locked compartment or area.
Evidence:
1. Licensing inspector observed Tylenol and Pepto-Bismol in an unlocked cabinet in the center?s office.
2. Staff #2 acknowledged the medications were stored in an unlocked cabinet.
Plan of Correction:
The center has secured the Tylenol and Pepto-Bismol in a locked cabinet.
Standard #:
22VAC40-61-540-A
Description:
Center failed to ensure that fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51).
Evidence:
1. The fire drill record for the center listed a fire drill for the month of March 2023. There were no fire drills listed for January 2023 or February 2023.
2. Staff members #1 and #2 acknowledged the only fire drill conducted in 2023 was conducted in March.
Plan of Correction:
The center understood the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51) to require quarterly fire and emergency evacuation drills based on direction given by corporate management and confirmed by an email from the Fairfax County inspector to the Chantilly center. The center is awaiting a review and final determination of the requirements by its inspector and will comply with the inspector?s determination.
Standard #:
22VAC40-61-550-A
Description:
Based on observations made during the tour of the center and center?s vehicle, the center failed to have all required items included in the first aid kit.
Evidence:
1. The first aid kit located in the center did not include a triangular bandage or bee sting swabs preparation. The first aid kit located in the center?s van did not contain a triangular bandage, bee sting swabs or preparation or an ice pack.
2. Staff #2 acknowledged the first aid kits did not contain all the required items.
Plan of Correction:
The center will purchase all identified missing items required in the first aid kit.
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.
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