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. 13, 2023

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 of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/13/2023 8:50AM until 2:00PM 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: 14 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: 3 Observations by licensing inspector: breakfast and noon-time meals, activities, medication passes, medication audit. 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 #:	22VAC40-73-250-D
Description:	Based on staff record review and staff interview, the facility failed to ensure each staff person or household member required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. EVIDENCE: Staff person 5 was hired on 05/31/2022. During on-site inspection on 12/13/2023, the most recent TB screening in the record for this staff person was dated 06/03/2022. Interview with staff person 1 confirmed that this was accurate.
Plan of Correction:	Staff person #5 had TB screening on 12/2/2023. The administrator will ensure TB screenings are completed on time.
Standard #:	22VAC40-73-350-B
Description:	Based on resident record review and staff interview, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. EVIDENCE: Resident 5 was admitted to the facility on 04/07/2023 and resident 6 was admitted to the facility on 03/23/2023. During on-site inspection on 12/13/2023, the records for residents 5 and 6 contained Virginia State Police sex offender registry searches dated 10/23/2023 for both residents 5 and 6. Interview with staff person 1 confirmed that this was accurate.
Plan of Correction:	Sex offender registry searches will be done as part of admission before resident arrives at facility. Will correct with future admissions.
Standard #:	22VAC40-73-550-G
Description:	Based on resident record review and staff interview, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual. EVIDENCE: During on-site inspection on 12/13/2023, the record for resident 2 contained documentation that the most recent review of the rights and responsibilities of residents in assisted living facilities for the resident was 08/23/2022. Interview with staff person 1 confirmed that this was accurate.
Plan of Correction:	Administrator will ensure annual review with family is done annually.
Standard #:	22VAC40-73-650-C
Description:	Based on resident record review, the facility failed to ensure physician?s or other prescriber?s oral orders shall be reviewed and signed by a physician or other prescriber within 14 days. EVIDENCE: 1. During on-site inspection on 12/13/2023, the record for resident 2 contained the following telephone/verbal/oral orders taken by staff person 6 dated 08/08/2023, 08/22/2023, 09/28/2023 and 11/09/2023. 2. The aforementioned orders did not contain documentation that a physician or other prescriber reviewed and signed them within 14 days.
Plan of Correction:	Nurse will work with Household MD to get verbal telephone orders signed within 14 days of being written. All orders reviewed with Dr. and signed. Completed 12/21/2023
Standard #:	22VAC40-73-720-A
Description:	Based on resident record review, the facility failed to ensure Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest is included in the individualized service plan (ISP). EVIDENCE: During on-site inspection on 12/13/2023, the record for resident 6 contained a signed DNR, dated 08/23/2023 order; however, the ISP for the resident, dated 03/23/2023, did not contain documentation that the resident has a DNR order.
Plan of Correction:	Resident #6 ISP has been updated and corrected.