VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Elance at Old Town
400 N.Washington Street
Alexandria, VA 22314
(703) 236-1226

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: Sept. 11, 2023

Complaint Related: No

Areas Reviewed:

Administration and Administrative Services Personnel Staffing and Supervision Resident Care and Related Services Resident Accommodations and Related Provisions Building and Grounds

Comments:

Date of Inspection: September 11, 2023 Type of Inspection: Monitoring Inspection Census 49 Number of records reviewed and interviews conducted- 3 records, 2 interviews. If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). The completed corrective action needs to be in the licensing office by September 25, 2023

Violations:

Standard #:	22VAC40-73-1040-A
Description:	Based on staff interview, it was determined that the facility failed to prevent residents from leaving the facility unsupervised. Evidence: On 7/31/2023 Resident A and B left the facility unsupervised and were located by a family member. Residents were unharmed and returned to the facility.
Plan of Correction:	With respect to the specific residents/incidents cited: A. A staff in service on head count procedures was completed on 8/24/23. B. With respect with how the agency will identify residents/situations with the potential for identified concerns: Inspiritas Coordinator will collaborate with ED or designee to perform audit of residents in Memory Care who has private duty aides and provide refresher in service on safety protocol in the secured unit to prevent elopement. C. With respect to systemic measures have been put into place to address the slated concern: Routine staff in service will be provided periodically on missing residents drill. The most recent one was completed on 8/24/23.