VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Blue Ridge Christian Home
85 Beulah Drive
Raphine, VA 24472
(540) 377-9590

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Dec. 6, 2022

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 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 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 12/06/2022 9:20AM until 12:45PM. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 16 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: medication audit and medication pass Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1030-B
Description:	Based on staff record review and staff interview, the facility failed to ensure a direct care staff person attended six hours of training in working with individuals who have a cognitive impairment within four months of the starting date of employment. EVIDENCE: The record for staff 2, date of hire 05/31/2022, did not include documentation of training within the first four months of employment pertaining to working with residents who have a cognitive impairment. Interview with staff 4 confirmed this was accurate.
Plan of Correction:	The staff member was signed up for online training to the required six hours of training in working with individuals who have a cognitive impairment. To be completed by Jan. 1, 2022
Standard #:	22VAC40-73-120-A
Description:	Based on staff record review, the facility to ensure that orientation for new staff was completed within the first 7 working days of employment. EVIDENCE: 1. The record for staff 1, date of hire 09/19/2022, did not contain documentation of an orientation as of the day of inspection.
Plan of Correction:	Administration located the orientation form signed by the staff member and filed it in the correct employee file. 12/8/2022
Standard #:	22VAC40-73-200-D
Description:	Based on staff record review and staff interview, the facility failed to obtain a copy of the certification issued or other documentation indicating that the staff person has met the requirements to be employed as a direct care staff. EVIDENCE: Interview with staff 4 indicated that staff 2 is a personal care aide and that staff 4?s date of hire was 05/31/2022. The record for staff 2 did not contain a copy of the certification issued or other documentation indicating that staff 2 has obtained the required training to be employed as a personal care aide in an assisted living facility. As of 12/08/2022, the aforementioned documentation was still not received from the facility.
Plan of Correction:	Staff member is enrolled in direct care class which will completed by 12/16/2022
Standard #:	22VAC40-73-210-B
Description:	Based on staff record review, the facility failed to ensure that direct care staff received 18 hours of training annually. EVIDENCE: 1. The record for staff 3, date of hire 06/10/2019, did not contain documentation of staff 3 receiving the required 18 hours of annual training from 06/10/2021 through 06/10/2022.
Plan of Correction:	Staff member will have all 18 hours of annual training by June 10, 2023 which is the anniversary of hire. 12/8/2022
Standard #:	22VAC40-73-260-A
Description:	Based on staff record review and staff interview, the facility failed to ensure a direct care staff member obtained first aid certification within the first 60 days of employment. EVIDENCE: The record for staff 2, date of hire 05/31/2022, contained documentation that the staff person did not obtain first aid certification until 11/09/2022. Interview with staff 4 confirmed this was accurate.
Plan of Correction:	The administration will ensure that direct care staff will be certified in CPR and First Aid in the first 60 days of employment. 12/10/2022
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure that physical examinations were obtained within 30 days prior to the date of admission. EVIDENCE: The physical examination in the record for resident 4, admitted on 08/27/2022, has documentation that the actual examination was completed was 06/10/2022.
Plan of Correction:	An administrative meeting was held to review the admission process. The focus of the meeting was the history and physical. Steps were put into place to ensure that there is proper documentation of physical examinations. 12/8/2022
Standard #:	22VAC40-73-350-B
Description:	Based on resident record review, the facility failed to document in resident records, prior to admission, that the facility ascertained residents were not registered sex offenders. EVIDENCE: 1. Resident 3 was admitted to the facility on 08/25/2022 and resident 4 was admitted to the facility on 08/27/2022; however, the Virginia State Police search that was in the record for the resident did not contain the date that the search was conducted.
Plan of Correction:	Virginia State Police sex offender record will be printed in portrait mode instead of landscape so it will include the date of the search Date: 12/8/2022
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure that identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The record for resident 1 has documentation that the resident has allergies to Amoxicillin and Aricept. The ISP for resident 1, dated 11/29/2022, contains documentation of the allergies listed at the top of the form but does not include information on services to be provided, who, when and where services will be provided and the expected outcome. 2. The uniform assessment instrument (UAI) dated 10/21/2022 in the record for resident 2 contains documentation that the resident requires mechanical and human help assistance with transferring. Interview with staff 4 expressed that the UAI is correct. The ISP dated 10/23/2022 in the record for resident 2 does not address this identified need. 3. The ISP for resident 3, dated 08/25/2022, indicated that the resident has physical therapy ordered by a physician; however, interview with staff 4 revealed that the resident does not receive physical therapy.
Plan of Correction:	1. Record was updated to include allergies documented in the correct section of the ISP 2. ISP was updated to include the need for assistance with transferring 3. The ISP was updated to not include physical therapy Date: 12/8/2022
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review, the facility failed to ensure an individualized service plan (ISP) for a resident was signed by the resident or his legal representative. EVIDENCE: The ISP for resident 5, with a review date of 11/05/2022, was not signed by the resident or the resident?s legal representative.
Plan of Correction:	ISP for resident 5 was mailed to legal representative for signature Date: 12/8/2022 To be corrected by Jan. 1, 2022
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to ensure a medication was administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: Resident 5 has an order for ?Digoxin 0.125MG tablet take two tablets by mouth every morning for heart. Hold if pulse is below 60?. The November 2022 medication administration record (MAR) for the resident indicated that the resident?s pulse was 56 on 11/24/2022; however, the MAR indicated that the aforementioned medication was administered to the resident.
Plan of Correction:	An in-service training was done with the RMAs by the nurse manager. The main focus of training was reading physician?s orders and documentation. Date: 12/10/2022
Standard #:	22VAC40-73-950-E
Description:	Based on document review, the facility failed to ensure a semi-annual review of the facility?s emergency preparedness and response plan was conducted for residents. EVIDENCE: The facility?s semi-annual review of it?s emergency preparedness and response plan, conducted on 06/17/2022, was not completed with residents. Interview with staff 4 confirmed this was accurate.
Plan of Correction:	A plan for the facility to review the emergency preparedness and response plan was made. A designated staff person will meet with the legal representative of each resident, every six months, to review the emergency plan To be corrected by Jan 31, 2022
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review and staff interview, the facility failed to ensure that the criminal history record report was obtained on or prior to the 30th day of employment for each employee. EVIDENCE: Staff 2 was hired 05/31/2022; however, the results of a criminal record report for the staff person were not received until 09/16/2022.
Plan of Correction:	Administration cleared up the clerical error with the VA State Police to continue to be able to submit criminal record checks. Administration will ensure that criminal record checks are complete prior to the 30th day of employment. 12/8/2022