VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Renaissance of Annandale
7112 Braddock Road
Annandale, VA 22003
(703) 256-2525

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Oct. 17, 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 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. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 SANCTIONS.

Technical Assistance:

Please ensure that ISPs reflect the resident's inability to use a call bell and the rounds schedule that will be followed. Please review the facility policy for the completion of the Mental Health Screening Form. Please note: The Administrator's designee that signs off on the appropriateness of placement in a special care unit is required to have the knowledge, skills and abilities to accurately assess the resident for placement.

Comments:

An unannounced renewal study was conducted on 10/17/19. At the time of entrance 39 residents were in care. The sample size consisted of eight resident records, four 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 conducted on 8/9/19 were reviewed. Residents were observed eating breakfast and and engaging in activities. Medication administration was observed. Violations and risk ratings reviewed at the exit interview. 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 #:	22VAC40-73-220-B
Description:	Facility failed to ensure that when private duty personnel who are not employees of a licensed home care organization provide direct care or companion services to residents in an assisted living facility, the requirements listed under subdivisions A 2 through A 6 of this section apply. In addition, before direct care or companion services are initiated, the facility shall meet the requirements of B1 through B3 of this section. Evidence: With the exception of PD#'s name no further required documentation was obtained by the facility.
Plan of Correction:	The Administrator will assign and train staff responsible for private dute aide personnel records.
Standard #:	22VAC40-73-290-B
Description:	Facility failed to ensure that the name of the current on-site person in charge, as provided for in this chapter, is posted in a place in the facility that is conspicuous to the residents and the public. Evidence: Upon the Licensing Inspector's arrival the posted on-site person in charge was not in the facility.
Plan of Correction:	Administrator will conduct training regarding the posting of the on-site person in charge.
Standard #:	22VAC40-73-320-A
Description:	Facility failed to ensure that within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain Any recommendations for care including medication, diet, and therapy. Evidence: Residents #2's admissions physical dated 7/30/19, Residents #4's admissions physical dated 1/10/19, Residents #5's admissions physical dated 9/20/19 and Residents #6's admissions physical dated 5/4/19 indicated that the medication list was attached however there was not an attachment.
Plan of Correction:	Resident Services Director is conducting a 100% resident file review and will ensure that admission physicals are complete.
Standard #:	22VAC40-73-440-D
Description:	Facility failed to ensure that for private pay individuals, the assisted living facility shall ensure that the uniform assessment instrument is completed as required by 22VAC30-110. Evidence: Resident #3's UAI dated 10/1/19 is not signed.
Plan of Correction:	Resident Services Director is conducting a 100% resident file review and will ensure that all UAIs are complete.
Standard #:	22VAC40-73-450-A
Description:	Facility failed to ensure that on or within seven days prior to the day of admission a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: Resident #3 admitted on 9/7/19 did not have documentation to indicate that a preliminary plan of care has been developed.
Plan of Correction:	Resident Services Director is conducting a 100% resident file review and will ensure that all plans of care are documented.
Standard #:	22VAC40-73-450-E
Description:	Facility failed to ensure that the Individualized Service Plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: Resident #2's ISP dated 7/26/19 and Resident #4's ISP dated 6/29/19 are not signed by the resident or his legal representative.
Plan of Correction:	Resident Services Director is conducting a 100% resident file review and will ensure that