VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Benchmark at Alexandria
3440 Berkeley Street
Alexandria, VA 22302
(571) 386-2200

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: Jan. 17, 2024 and Jan. 23, 2025

Complaint Related: Yes

Areas Reviewed:

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 ACCOMMODATIONS AND RELATED 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY

Technical Assistance:

None

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/17/2025 Time In: 11:00 a.m. Time Out: 12:23 p.m. 01/23/2025 Time In: 9:14 am Time Out: 2:34 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/2/2024 regarding allegations in the area(s) of: Personnel, Staffing and Supervision, Admission, Retention and Discharge of Residents, Resident Care and Related Services, Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments, Article 3: Safe, Secure, Environment, and Complaint Investigation Number of residents present at the facility at the beginning of the inspection: 42 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 7 Observations by licensing inspector: Licensing inspector (LI) toured the safe, secure environment. LI observed residents within the safe, secure environment interacting with staff, participating in physical therapy, walking to and from their rooms, and sitting in the common area. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaints but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-1130-A
Complaint related:	No
Description:	Based on record reviews and staff interview, the facility failed to ensure that at least two direct care staff members were awake and on duty at all times in the special care unit who were responsible for the care and supervision of the residents. Evidence: 1. During a review of the special care unit census, July 2024 through January 2025, LI observed that there were six residents present on the unit October through November 2024. 2. The October and November 2024 staff schedule indicated that one staff was scheduled 10/18/2024 and 11/28/2024 on each shift, 7:00 a.m. through 3 p.m., 3:00 p.m. through 11:00 p.m., and 11:00 p.m. through 7:00 a.m. 3. There was one staff scheduled, 3:00 p.m. through 11:00 p.m., and two staff scheduled, 7:00 p.m. through 11:00 p.m. There was one staff scheduled, 11:00 p.m. through 7:00 a.m. 4. On 1/17/2025, LI interviewed staff 5 who confirmed that there was only one staff scheduled on each shift on the safe, secure environment unit in October and November 2024.
Plan of Correction:	1. All residents who resided in the special care unit during the period of October ? November 2024 were reviewed to ensure that their care needs had been met. 2. The scheduler and the Executive Director were educated on regulatory requirements for special care staffing. Effective 6/10/25, the staffing schedule will reflect the appropriate staffing levels. 3. Beginning June 10, 2025, the Executive Director or designee will audit staffing schedules weekly for 90 days, then monthly for three additional months to ensure two staff are scheduled and present each shift in the special care unit to ensure ongoing compliance.
Standard #:	22VAC40-73-430-H-1
Complaint related:	No
Description:	Based on record reviews and staff interview, the facility failed to ensure at the time of discharge a dated statement was provided to the resident, legal representative, and designated contact person. Evidence: 1. Resident 1?s progress notes (12/2/2024) indicated that their legal representative was not provided a written discharge statement. 2. On 1/17/2025, LI interviewed staff 5 who confirmed that the legal representative was not provided a written discharge statement.
Plan of Correction:	1. A complete audit of discharges occurring between October 1, 2024 and March 31, 2025 was conducted. No additional instances of missing discharge statements were identified. 2. Staff involved in discharges will be re-trained by June 30, 2025 on requirements for Virginia discharge documentation standards. 3. Beginning June 2025, the Director of Business Administration or designee will review all discharges bi-weekly for 60 days, then monthly for four months to verify compliance with written discharge documentation and ensure ongoing compliance.