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: Feb. 11, 2021 , Feb. 16, 2021 and Feb. 17, 2021

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 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:

Answered questions and discussed the following with the administrator: 1) Recommended having the email registered with the state police include the administrator's title rather than the administrator's name. 2) Ensure each blank of the orientation form is initialed and dated rather than drawing a line through them and only initialing and signing the first blank. 3) Reviewed the leniency issued (due to the COVID-19 pandemic) for first aid training. 4) The written assurance must be signed by the resident or legal representative and a copy kept on file. 5) Recommended an audit be conducted of all resident records to ensure all paperwork is completed and on file. 6) Only check "medications administered by lay persons" on the uniform assessment instrument when medication aides administer medications. Staff were checking this section as well as by licensed professionals since they have a part time nurse. 7) Once the new administrator completes the medication aide training, please forward the documentation to this inspector.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 2/11/21 and concluded on 2/17/21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 16. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed two resident and two staff records. activities calendar, menu, staff schedules, fire drills, medication administration records, physicians' orders, medication pharmacy reviews, dietitian's reviews, health care oversights, as well as other documents to ensure documentation was complete. Selected sections of seven resident, six staff and two contract staff records were also reviewed. A virtual inspection and tour were also conducted. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based upon record reviews and an interview, the facility failed to ensure one of three staff completed first aid certification within the required timeframe. Evidence: 1) Staff B (hired 7/18/20) did not have any documentation on file for completion of first aid training. 2) On 2/17/21, the licensing inspector (LI) interviewed the administrator who stated staff B had not completed first aid training.
Plan of Correction:	New administrator has been in communication with a trainer and is in the process of scheduling a cardiopulmonary resuscitation (CPR)/first aid class for staff. Staff B will have her certification completed by 3/19/21. New administrator will ensure all new employees obtain their CPR/first aid certification within the first 60 days (and 90 days during the COVID-19 pandemic). New administrator will maintain a tickler file and will check it the first of each month to ensure compliance.
Standard #:	22VAC40-73-310-D
Description:	Based upon documentation and an interview, the facility failed to ensure four of the eight resident records reviewed had a signed written assurance on file. Evidence: 1) The written assurances on file for resident A (admitted 9/28/20) and D (admitted 2/4/21) were not signed by the residents or their legal representatives; resident C (admitted 6/29/20) and I (admitted 6/29/20) did not have a copy of a written assurance on file. 2) On 2/17/21, the LI interviewed the administrator who stated the written assurances were not completed as required.
Plan of Correction:	New administrator will audit all resident financial files to ensure a written assurance was given and obtain, if needed, signatures by the resident and/or power of attorney by 3/19/2021. Resident D signed the assurance on 2/17/2021. Resident assurances will be signed by resident A and C by 2/25/2021. New administrator will develop a new resident checklist to include the written assurance and will review the checklist prior to each resident's admission to ensure compliance.
Standard #:	22VAC40-73-350-A
Description:	Based upon an interview, the facility failed to ensure registration with the Virginia Department of State Police remained current in order to receive notifications regarding sex offenders who reside in the surrounding area of the facility. Evidence: On 2/17/21, the LI interviewed the administrator who stated she had not reregistered with the Virginia State Police since she was hired (12/28/20). The email address for the facility registration uses the name of the administrator rather than the position title.
Plan of Correction:	New administrator is now currently registered to receive such notifications. Upon any change of administrator, the current administrator will notify the facility's director of operations that the new administrator needs to register with the state police to receive the sex offender notifications. The current administrator will copy the licensing inspector on this notification.
Standard #:	22VAC40-73-350-B
Description:	Based upon record reviews and an interview, the facility failed to ensure three of the seven resident records reviewed had a sex offender registry check completed prior to admission. Evidence: 1) There was no sex offender registry check on file for resident E (admitted 9/2/20). 2) Resident A (admitted 9/28/20) had a sex offender registry checked completed on 11/16/20 and resident F (admitted 9/19/20) had one completed on 9/21/20. 3) On 2/16/21, the LI interviewed the administrator and she stated the above sex offender checks were not completed prior to the residents' admission.
Plan of Correction:	New administrator will audit all resident files to ensure all sex offender checks have been completed and if not, obtain for the resident files by 3/19/2021. Resident E's sex offender check was obtained on 2/17/2021. New administrator will develop a new resident checklist to include the sex offender registry and will review the checklist prior to residents admission to ensure compliance.