VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Arden Courts (Annandale)
7104 Braddock Road
Annandale, VA 22003
(703) 256-0882

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: May 19, 2021

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 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.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 5/19/21 and concluded on 5/21/21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 32. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, medication administration records, local fire and health inspections, and other documentation submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure that each staff member submits the results of a risk assessment, documenting the absence of tuberculosis in a communicable form. The risk assessment shall be provided on or within seven days prior to the first day of work, and shall be no older than 30 days. Evidence: The record for Staff #3, hired 2/9/21, was reviewed during the inspection. The record contained a tuberculosis risk assessment (dated 3/11/21) and a chest x-ray (dated 9/24/20). The record did not contain a tuberculosis risk assessment that was completed within 30 days, prior to Staff #3's hire date.
Plan of Correction:	During a self-audit, prior to the Annual Licensing Renewal Inspection, the results of a risk assessment, documenting the absence of tuberculosis in a communicable form, was noted to be missing for Staff #3. As a result of self-audit, a screening was completed and, the form placed in Staff #3's file. New Administrative Services Coordinator (ASC) stated working on February 17, 2021. On March 1, 2021, the ASC began the process of auditing all employee files in order to identify any missing information. ASC and/or designee will utilize company checklist for all new employees on the first day of orientation, to ensure results of a risk assessment, documenting the absence of tuberculosis in a communicable form, have been obtained/placed in the employee file to remain in compliance with DSS and company regulations and policies. ASC, Executive Director (ED) and/or designee will review each new employee record on the first day of orientation to ensure results of a risk assessment, documenting the absence of tuberculosis in a communicable form, have been obtained.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to obtain a criminal history record report, from the Department of State Police, within 30 days of hiring an employee. Evidence: The criminal history record reports, of new staff members, were reviewed during the inspection. The criminal history report for Staff #4, hired 10/29/20, was dated 3/20/21. The criminal history report for Staff #5, hired 12/28/20, was dated 3/8/21.
Plan of Correction:	During a self-audit, prior to our Annual Licensing Renewal Inspection, the criminal history record reports were noted to be missing for Staff #4 and #5. As a result of the self-audit, the criminal history record reports were obtained and placed in Staff #4 and #5's files. New Administrative Services Coordinator (ASC) started working on February 17, 2021. On March 1, 2021, the ASC began the process of auditing all employee files in order to identify any missing information. ASC and/or designee will utilize company checklist for all new employees prior to the first day of orientation to ensure criminal history record report has been obtained and filed in employee record to remain in compliance with DSS and company regulations and policies. ASC, Executive Director (ED) and/or designee will review each new employee record within 14 days to ensure criminal history record report has been obtained.