VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Beverly Assisted Living
3408 Beverly Drive
Annandale, VA 22003
(571) 308-3793

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: Sept. 18, 2019

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

Technical Assistance:

When the County Fire and Health Inspections are completed please e-mail a copy to the Licensing Inspector. Discussed ensuring documentation of fire drills quarterly on each shift.

Comments:

An unannounced renewal inspection was conducted on 9/18/19. At the time of entrance six residents were in care with three staff providing care. The sample size consisted of three resident records, three staff records and two individual interviews. Resident and staff records and other documentation were reviewed. Criminal Background Checks of all staff hired since the previous inspection were reviewed. Residents were observed eating breakfast and and engaging in activities including current events, painting nails and watching classic television shows. Medication administration was reviewed. Violation Notice and risk ratings were reviewed during the exit interview held. Thank you for your cooperation and if you have any questions please call 703-479-4708 or contact me via e-mail at lynette.storr@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents shall submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Staff #1 and #3 did not have documentation indicating an absence of tuberculosis in a communicable form.
Plan of Correction:	An updated TB risk assessment will be obtained.
Standard #:	22VAC40-73-950-E
Description:	Facility failed to ensure that a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities is completed. The review shall be documented by signing and dating. Evidence: There is no documentation to indicate that a semi annual review of the emergency preparedness plan was completed.
Plan of Correction:	Owner/Administrator to develop training schedule.
Standard #:	22VAC40-73-990-B
Description:	Facility failed to ensure that the procedures in the plan for resident emergencies required in subsection A of this section shall be reviewed by the facility at least every six months with all staff. Documentation of the review shall be signed and dated by each staff person. Evidence: There is no documentation to indicate that the resident emergency plan is being reviewed with staff.
Plan of Correction:	Owner/Administrator will set up semi annual training dates for the resident emergency plan.