VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Agape Adult Day Healthcare Center II
6349 Lincolnia Road
Alexandria, VA 22312
(703) 354-6767

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: June 12, 2025

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 GROUND 22VAC40-61 EMERGENCY PREPAREDNESS

Technical Assistance:

None

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: 06/12/2025 Time in: 12:07 PM Time out: 2:37 PM 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: 169 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: 4 Number of interviews conducted with participants: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector (LI) toured the physical plant of the facility. LI observed participants dining for lunch, engaged in scheduled activities, such as singing, watching television, and games. Additional Comments/Discussion: N/A 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.

Violations:

Standard #:	22VAC40-61-160-A-1
Description:	Based on staff record and staff interview, the facility failed to ensure each direct care staff member maintained current certification in first aid. The certification must either be in adult first aid or include adult first aid. Evidence: 1. Staff 5 (hire date, 09/06/2016, and staff 6 (hire date, 08/14/2023) work as direct care staff and did not have a current first aid certification in their record. 2. At the time of inspection staff 1 confirmed that staff 5 and 6 did not have first aid certification.
Plan of Correction:	Staff 5 and 6 attended CPR training on June 16, 2025.Received Certificated on 6/18/2025.
Standard #:	22VAC40-61-220-E
Description:	Based on participant record review and staff interview, the facility failed to review and update a written assessment for each participant at least every six months. Evidence: 1. A written assessment was reviewed and updated for participant 1, participant 2, participant 3, participant 4, participant 5, and participant 6 on June 21, 2024. 2. On 06/12/2025, LI interviewed staff 1 and staff 2 who confirmed that the written assessments were not reviewed and updated at least every six months.
Plan of Correction:	Due to system update errors, assessments were not updated. Participants 1-6 assessments are up to date now. The system function is working properly, so from now on, no system error will occur.
Standard #:	22VAC40-61-230-E
Description:	Based on participant record review and staff interview, the facility failed to review and update a plan of care for each participant at least every 6 months. Evidence: 1. A plan of car was reviewed and updated for participant 1, participant 2, participant 3, participant 4, participant 5, and participant 6 on June 21, 2024. 2. On 06/12/2025, LI interviewed staff 1 and staff 2 who confirmed that the plan of cares were not reviewed and updated at least every siz months all participants reviewed.
Plan of Correction:	Due to system update errors, PCP were not updated, Participants 1-6 PCP are up to date now.
Standard #:	22VAC40-61-260-C
Description:	Based on participant record review and staff interview, the facility failed to ensure that each participant submitted a report of physical examination annually. Evidence: 1. Participant 1?s (admit date, 07/04/2022) most recent physical examination report was documented as completed on 07/10/2023. 2. Participant 2?s (admit date, 12/01/2021) most recent physical examination report was documented as completed on 06/20/2023. 3. Participant 3?s (admit date, 10/16/2021) most recent physical examination report was documented as completed on 06/26/2023. 4. Participant 4?s (admit date, 02/14/2023) most recent physical examination report was documented as completed on 04/25/2024. 5. Participant 6?s (admit date, 07/01/2022) most recent physical examination report was documented as completed on 09/12/2023. 6. On 06/12/2025, LI interviewed staff 1 and staff 2 who confirmed that physical examination reports were not completed annually for participant 1, 2, 3, 4, and 6.
Plan of Correction:	PE-physical examination reports were filed in separate PE folders. Patient 1?s physical examination on 6/27/2025 (will submit PE form as soon as we receive) PE-physical examination reports were filed in separate PE folders.Patient 2?s physical examination on 1/21/25. Patient 3?s physical examination on 11/21/24. Patient 4?s physical examination on 2/13/25. Patient 6?s physical examination on 11/12/24.
Standard #:	22VAC40-61-520-C
Description:	Based on record review and staff interview, the facility failed to implement a semi-annual review on the emergency preparedness and response plan for all staff, participants, and volunteers. The review was documented by signing and dating. Evidence: 1. Upon request the facility did not provide a semi-annual review on the emergency preparedness and response plan for all staff, participants, and volunteers. 2. On 06/12/2025, LI interviewed staff 1 who confirmed that a semi-annual review on the emergency preparedness and response plan was not documented as completed with all staff, participants, and volunteers.
Plan of Correction:	Semi Annual Review was created. (missing staff signature due to absence)
Standard #:	22VAC40-61-520-D
Description:	Based on record review and staff interview, the facility failed to review the emergency preparedness and response plan annually, documented the review by signing and dating. Evidence: 1. Upon request the facility did not provide an annual review on the emergency preparedness and response plan. 2. On 06/12/2025, LI interviewed staff 1 who confirmed that an annual review of the emergency preparedness was not documented by signing and dating.
Plan of Correction:	Semi-annual started on 6/13/2025, so annual will be created in December 2025.
Standard #:	22VAC40-61-550-A
Description:	Based on LI observation, the facility failed to ensure that the center contained a first aid kit that included scissors, ice pack or ice bag, small operable flashlight, single use gloves, and disposable single use breathing or shields. Evidence: 1. The first aid kit was missing scissors, ice pack or ice bag, small operable flashlight, single use gloves, and disposable single use breathing or shields. 2. Picture evidence taken.
Plan of Correction:	Took a picture of first aid kit with all provided kits. (disposable breathing shield is on the order)