VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Birch Ridge (Augusta CO)
54 Imperial Drive
Staunton, VA 24401
(540) 885-0065

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Jan. 22, 2020 and Jan. 23, 2020

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 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.

Technical Assistance:

Discussed the following areas with the acting administrator and nurse and answered questions/made the following recommendations: 1) The first aid for staff A must be completed by 1/26/20. 2) When using the model orientation form, ensure the trainers initial/date each section and do not just fill out the first line/section and then draw a line through the rest. 3) Six month reviews for emergency disaster plans and resident emergencies are due by the end of February. 4) Ensure the listed behaviors and spheres affected on the uniform assessment instruments are also listed on the individualized service plans. 5) Discussed having second shift staff pick up the mail due to the delivery time. 6) Answered questions on standard 70 and reviewed examples of what would be a major incident (anything that threatens the life, health and safety of a resident). 7) Recommended adding first aid and cardiopulmonary resuscitation certifications to the staff schedule rather than keeping a separate list to be updated. 8) Answered questions and clarified giving the medication administration record rather than the physician's order sheet to emergency response staff. 9) Answered questions regarding documentation requirements when an incident occurs (reviewed information in standard 460.F with the acting administrator and nurse). 10) Recommended kitchen staff post the new weekly menu after the last dinner of the week rather than before the first breakfast meal of the week.

Comments:

An unannounced renewal inspection was conducted on 1/22/20 from 7:15 am to 6:30 pm and on 1/23/20 from 7:10 am to 4:30 pm. A tour was immediately conducted of the interior and exterior of the facility. The facility was clean and free from any foul odors. Upon arrival there were 15 residents in care and four direct care staff and one registered medication aide on duty. Medication administration observations were completed with three residents and one registered medication aide. The medication administration records, physicians' orders and medications were reviewed for all three residents. Six resident, one discharge, two contract staff, three volunteer and three staff records were reviewed. Selected sections of five additional resident and three staff records were also reviewed. Individual interviews were conducted with residents, family members, staff and outside agency staff. The areas of noncompliance included the disclosure, volunteer orientation, sworn statements/criminal record checks, tuberculin skin tests/assessments, written agreements, uniform assessment instruments, individualized service plans, activities calendar, storage of treatment supplies and medication administration. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based upon documentation, the facility failed to ensure seven of seven resident records reviewed had documentation of receiving the new disclosure. Evidence: 1) Resident A (admitted 10/22/19) had no documentation on file acknowledging receipt of the disclosure. 2) Residents B, C, D, E, F and G only had a signed acknowledgement for the disclosure from the previous owner.
Plan of Correction:	The most current disclosure will be completed by the new owner and will be signed by each of the residents, including all current residents and new admissions. This process will be completed by the administrator or designee. Administrator is going through all resident charts checking for new disclosure statements with the new owners. The administrator is then reaching out to those residents' PRs that are without the new disclosure to get them to come in and sign one. For those PRs that are out of town, the administrator is faxing, mailing, scanning or emailing the disclosure statement to them for their review and signature. Moving forward, the administrator or designee will meet with each family member on or before the day of move in to get resident agreement and disclosure statements signed.
Standard #:	22VAC40-73-240-F
Description:	Based upon documentation and interviews, the facility failed to ensure three of the three volunteers completed the required orientation. Evidence: 1) Volunteers F, J and K had no documentation on file of completing an orientation that included their duties and responsibilities, resident rights, emergency procedures, infection control, name of their supervisor and reporting requirements. 2) On 1/23/20, the licensing inspector (LI) interviewed staff D and E and both stated this information was not on file.
Plan of Correction:	All volunteers will complete orientation which will include their duties and responsibilities, resident rights, emergency procedures, infection control, name of their supervisor (activities director or administrator in her absence) and their reporting requirements. The activities director, or administrator in her absence, will perform orientation with all current volunteers to ensure orientation and paperwork are current to correct this violation. Moving forward, each volunteer will have their own file with all information listed above that will be kept current by the activities director (or administrator in her absence). A compliance tracker will be put into place to ensure that all records are kept current.
Standard #:	22VAC40-73-250-C
Description:	Based upon documentation and interviews, the facility failed to ensure criminal record checks were completed for six of the 20 staff records reviewed. Evidence: 1) Staff L, M, N, O, P and Q did not have a criminal record check completed and on file. 2) On 1/22/20, the LI interviewed staff D and E and both stated the criminal record checks were not completed.
Plan of Correction:	All staff will have their criminal background checks completed at time of hire. Administrator has sent off for all background checks for all employees that are without one to obtain immediately. Moving forward, all staff will have their criminal background checks completed at time of hire with new hire paperwork by administrator (or designee in her absence). Moving forward, all criminal background checks will be sent off on the date that new hire paperwork is completed by administrator. Administrator is in the process of making a compliance checklist for all items needed in an employee file that will be filled out with each new hire to ensure all necessary paperwork is obtained in a timely manner for each employee file.
Standard #:	22VAC40-73-250-D
Description:	Based upon documentation and an interview, the facility failed to ensure two of the seven staff records reviewed had current tuberculin (TB) skin tests/assessment completed annually and one of seven prior to hire. Evidence: 1) Staff A (hired 11/26/19) had a completed TB test dated 11/27/19. 2) The most current TB tests/assessments on file for staff C was dated 9/17/18 and D 9/26/18. 3) On 1/23/20, the LI interviewed staff D and E and both stated these were the most current TB tests/assessments on file.
Plan of Correction:	Administrator is reviewing all employee charts at this time to ensure compliance and is updating the compliance tracker that was created to ensure that all paperwork is kept current. All staff will have their TB assessments completed upon hire, and then will be added to a compliance tracker which will be monitored and completed by the administrator to ensure that all TB assessments are completed annually.
Standard #:	22VAC40-73-390-A
Description:	Based upon documentation, the facility failed to ensure new agreements with the new owner were completed prior to admission for the only new admission since the last inspection and for 10 of the 10 residents already residing in the facility. Evidence: 1) Resident A (admitted 10/22/19) had no signed written agreement on file. 2) Residents B, C, D, E, F, G, H, I, J and K had no new agreement signed with the new owner.
Plan of Correction:	Resident agreements with the new owners will be signed by each of the residents that were here prior to new ownership. The administrator will ensure all new admissions since the change of ownership also have a signed agreement (which includes all of the required information) on file. This process and monitoring will be completed by administrator or designee. Administrator is going through all resident charts checking for new resident agreements with the new owners. The administrator is then reaching out to those residents personal representatives (PR) that are without the new agreement and disclosure to get them to come in and sign a new agreement and disclosure. For those PRs that are out of town, the administrator is faxing, mailing, scanning or emailing the agreement to them for their review and signature. Moving forward, the administrator or designee will meet with each family member on or before the day of move in to get resident agreement and disclosure statements signed. The administrator will ensure compliance with this standard.
Standard #:	22VAC40-73-440-A
Description:	Based upon documentation and an interview, the facility failed to ensure one of seven resident records reviewed had a uniform assessment instrument (UAI) completed annually. Evidence: 1) The most current UAI on file for resident D (admitted 11/29/17) was dated as completed on 11/26/18. 2) On 1/23/20, the LI interviewed staff D and E and both stated this was the most current UAI on file.
Plan of Correction:	Administrator is in the process of going through each resident chart and updating all UAIs and individualized service plans (ISPs). Each resident will be added to a compliance tracker and the date of the last UAI and ISP will be added to the tracker to ensure that they are updated at least yearly. Moving forward, the administrator or designee will complete frequent chart audits to ensure all UAIs and ISPs are current. Administrator or designee will monitor the compliance tracker to ensure that all UAIs and ISPs remain current.
Standard #:	22VAC40-73-450-F
Description:	Based upon documentation, the facility failed to ensure the ISPs for six of the seven resident records reviewed were updated and included all needs of the residents. Evidence: 1) The ISP (completed 10/20/19) for resident A did not include wound care, tab alarm, mechanical assistance with dressing, assistance with transferring and walking and high risk for falls. Also, the last page of the ISP had another resident's name written at the bottom. 2) The ISP (completed 4/10/19) for resident B did not include two person assist, hospital bed with half rail on right side, tab alarm, palliative care, mechanical assistance with toileting, allergies, assistance needed for stair climbing and fall risk. 3) The ISP (completed 5/15/19) for resident C did not include two person assist, hospital bed with half rails, palliative care, disorientation with the specific spheres affected, allergies and fall risk. 4) The ISP (completed 11/26/19) for resident D did not include hospital bed with half rails on both sides, palliative care, allergies and fall risk. 5) The ISP (completed 2/20/19) for resident E did not include allergies and resident being almost deaf. 6) The ISP (completed 3/5/19) for resident F did not include mechanical assistance with walking, allergies and fall risk.
Plan of Correction:	Administrator is in the process of going through each resident chart and updating all ISPs. Once they are completed, the administrator will reach out to each family member to set up a call or family meeting regarding the changes and for a signature on the ISP. Each resident will be added to a compliance tracker and the date of the last ISP will be added to the tracker to ensure that they are updated at least yearly. Moving forward, the administrator or designee will complete frequent chart audits to ensure all new orders are added to the ISPs and that all ISPs are current. A compliance tracker has been put into place to ensure all ISPs remain current and the administrator or designee will update as needed and keep track of all upcoming ISPs that are due.
Standard #:	22VAC40-73-520-I
Description:	Based upon observations, documentation and an interview, the facility failed to ensure changes/substitutions were documented on the posted activities calendar. Evidence: 1) On 1/22/20, the LI observed the posted activities calendar which listed beauty/spa day from 9:00 am to 11:00 am and music trivia from 10:00 am to 11:00 am. No activities were held until Bingo started at approximately 10:15 am. The activities calendar was not updated to reflect the changes. 2) Interviews with residents and staff indicated changes were not being noted on the posted activities calendar.
Plan of Correction:	Moving forward, the activity director or designee will make sure that all activity schedules are posted in a conspicuous location and are kept current. Moving forward, the activity director or designee will make changes to the activity schedule as they arise to ensure that it is kept current. The administrator will ensure compliance with this standard.
Standard #:	22VAC40-73-660-A
Description:	Based upon observations and an interview, the facility failed to ensure all treatment supplies were kept in a locked storage area. Evidence: 1) On 1/22/20 at approximately 7:20 am, the LI observed the door to the room where the treatment cart was stored unlocked and unattended. The treatment cart was in the room and was also left unlocked and unattended. 2) On 1/22/20, the LI interviewed staff D who stated the night shift medication aide must have left the door unlocked as treatments on her shift did not start until 10:00 am so she had not yet been in the room where the treatment cart was stored.
Plan of Correction:	A new coded lock has been installed on the door to the treatment room to ensure that the door will be locked at all times. The staff on duty will check the door regularly throughout the shift to ensure that it is shut and locked at all times.
Standard #:	22VAC40-73-680-D
Description:	Based upon documentation and interviews, the facility failed to ensure one treatment medication was administered as ordered by the physician. Evidence: 1) Resident D had a signed physician's order to apply 2gm of Diclofenac Sodium 1% Gel to shoulders and back two times a day as needed (PRN) for pain. The medication administration record (MAR) had 10:00 am and 8:00 pm listed as times scheduled and staff were administering the medication as scheduled rather than PRN. The gel was administered twice a day from 12/1/19 through 1/7/20 and there was no documentation on the MAR as to the time, reason medication was given and the effectiveness. 2) On 1/22/20, the LI interviewed staff D and E and both stated staff were administering the gel as a scheduled treatment.
Plan of Correction:	The order was corrected by licensed practical nurse (LPN) on duty on the date of inspection. LPN on duty filled out a medication error report, notified both the resident's doctor and PR. The medication has been moved to the PRN screen in the eMAR and the registered medication aides (RMAs) on staff will be in-serviced by the LPN on the importance of comparing the written order to the order that was entered in by the pharmacy. Moving forward, the RMAs and LPN will double check the orders to the written orders from the physician to the orders that have been entered into the system to ensure that they match. This process will reduce the risk of an error like this happening again. Staff will also be in-serviced quarterly on the merging of orders and the importance of double checking orders from the physician orders to the orders entered in the computer system. The LPN will ensure compliance with this standard.