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. 31, 2022 and Feb. 1, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Licensing inspector conducted a condensed review of most of the standards and answered questions of the assistant administrator. Reminded assistant administrator that a copy of the direct care/nurses aide, etc. certificate must be on file even if they have the registered medication aide certificate. Both qualifications must be on file in each staff record.

Comments:

The licensing inspector conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 1/10/2022. Interviews were conducted with residents and staff related to allegations of insufficient resident care and staff not having the required training. Staff records and schedules were reviewed. The information gathered during the investigation supports the allegation of staff not having the required training, so the complaint is valid. The investigation, however, did not support the allegation of insufficient resident care. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. If you have any questions, contact your licensing inspector at (540) 430-9258.

Violations:

Standard #:	22VAC40-73-120-A
Complaint related:	No
Description:	Based upon documentation and interviews, the facility failed to ensure 13 of 18 staff completed or had documentation of completion of orientation within the first seven working days of employment. Evidence: 1. The following staff had no documentation of orientation completion in their staff records: Staff 1 (hired 10/26/2021), 3 (hired 10/29/2021), 4 (hired 9/15/2021), 5 (hired 11/10/2021), 6 (hired 11/22/2021), 7 (hired 12/1/2021), 11 (hired 12/21/2021), 12 (hired 11/30/2021), 13 (hired 10/26/2021), 14 (hired 11/19/2021), 15 (hired 10/20/2021), 16 (hired 2/11/2021) and 18 (hired 2/1/2021). 2. On 1/31/2022, the LI interviewed staff 8 and 10 and both stated they were oriented to the floor; however, they were not oriented to the policies. 3. On 2/1/2022, the LI interviewed staff 18 who stated, "Staff were oriented but paperwork was not done as time was spent working the floor." 4. On 2/1/2022, the AA stated the documentation of orientation completion for the staff was not in the staff records and could not be found. 5. On 2/4/2022, the LI conducted a telephone interview with staff 4 who stated she was oriented to all of the areas required; however, there was no documentation of the orientation on file.
Plan of Correction:	The ED and AA to conduct 100% audit on all current staff to ensure all orientation documentation is completed. AA and WC will ensure all staff complete the orientation process, including knowledge of assisted living facility (ALF) policies, as evidenced by completion of all elements on the model orientation form, initials of instructor and signature of employee, that orientation has been completed. The AA will notify the WC of any new hire. The WC will be responsible for conducting the orientation process and report to the AA any employee who has not completed the orientation process within the seven day timeframe. Any employee who fails to complete the orientation process by day seven will be pulled from the schedule until such time that orientation is complete. The AA and WC will perform audits on at least 25% of employee files quarterly to verify compliance with this corrective action. The ED will be responsible for implementing and monitoring the corrective action.
Standard #:	22VAC40-73-200-C
Complaint related:	Yes
Description:	Based upon documentation and an interview, the facility failed to ensure one of 18 staff records reviewed had documentation of completion of direct care aide (DCA) training within 60 days of hire. Evidence: 1. Staff 9 (hired 8/21/2021) had no documentation of direct care aide training completion or any other direct care certification training on file. 2. On 2/4/2022, the LI interviewed staff 9 who stated, "I was in line to complete the class but with the administrative changes I never was able to get into a class as I didn't know when they were available."
Plan of Correction:	The ED to conduct 100% audit on all staff records to ensure direct care aide (DCA) training was completed within 60 days of hire. The ED will enroll staff 9 in the DCA program. The WC will be responsible to enroll new hires without certification into the DCA program within 30 days of date of hire and report to the ED when the class has been scheduled. Any staff who has failed to complete the DCA program within 60 days of hire will be removed from the schedule until the class is completed. The AA and WC will perform an audit on 25% of employee files quarterly to verify compliance with DCA training. The ED will be responsible for implementing and monitoring the corrective action.
Standard #:	22VAC40-73-260-A
Complaint related:	Yes
Description:	Based upon record reviews and interviews, the facility failed to ensure nine of 18 staff had current first aid certification. Evidence: 1. The following staff had no documentation of first aid training on file: 1 (hired 10/26/2021), 2 (hired 7/26/2021), 3 (hired 10/29/2021), 4 (9/15/2021), 5 (hired 11/10/2021), 8 (hired 5/22/2021), 9 (hired 8/21/2021, 16 (hired 2/11/2021) and 17 (hired 11/5/2021). 2. On 1/31/2022, the LI interviewed the AA who stated she could not find first aid certifications on these staff. 3. On 2/4/2022, the LI interviewed staff 4 who stated she had first aid training; however, it expired in January. 4. According to the staff schedules, on the following days there were no staff on duty with first aid certification: 12/4/2021, 12/5/2021, 12/8/2021, 12/10/2021, 12/16/2021, 12/21/2021, 12/30/2021, 1/1/2022, 1/2/2022, 1/6/2022, 1/10/2022, 1/11/2022, 1/12/2022, 1/19/2022, 1/22/2022, 1/23/2022 and 1/28/2022 on the 6:00 am to 2:00 pm shift; 12/2/2021, 12/7/2021, 12/11/2021, 12/12/2021, 12/24/2021, 1/8/2022, 1/12/2022, 1/13/2022, 1/19/2022, 1/22/2022, 1/23/2022 and 1/28/2022 for the 2:00 pm to 10:00 pm shift; 12/6/2021, 12/7/2021, 12/10/2021, 12/13/2021, 12/14/2021, 12/16/2021, 12/17/2021, 12/20/2021, 12/21/2021, 12/24/2021, 12/27/2021, 12/28/2021, 1/3/2022, 1/4/2022, 1/5/2022, 1/7/2022, 1/8/2022, 1/9/2022 through 1/13/2022, 1/15/2022 through 1/18/2022, 1/20/2022, 1/24/2022 and 1/27/2022 on the 10:00 pm to 6:00 am shift.
Plan of Correction:	The ED to conduct 100% audit on all current staff records to ensure first aid certification is obtained prior to employment. The ED will schedule first aid trainings for staff who need initial certification and/or recertification. The first aid training is scheduled for February 8, 2022. The AA will monitor new hires and enroll those without certification into a class within 30 days of hire date. The ED will develop a system to ensure that first aid certifications are current and that re-certifications are obtained prior to expiration. The AA will create an excel spreadsheet to document the expiration date for first aid certification, this spreadsheet will also be shared with the WC on a quarterly basis. The AA and WC will review this spreadsheet quarterly to identify all employees in need of recertification. The AA and WC will perform audits on at least 25% of employee files quarterly to verify compliance with this corrective action. The ED will be responsible for implementing and monitoring the corrective action.
Standard #:	22VAC40-73-260-B
Complaint related:	Yes
Description:	Based upon record reviews and interviews, the facility failed to ensure at least one staff person on duty had current certification in cardiopulmonary resuscitation (CPR). Evidence: 1. The following staff did not have certification in CPR: 2, 3, 4, 5, 6, 7, 8, 9, 12, 14, 15, 16, and 17. 2. According to the staff schedules for December 2021 and January 2022, on the following dates there were no staff with current certification in CPR: 1/1/2022, 1/2/2022, 1/22/2022, 1/23/2022, 1/28/2022 on the 6:00 am to 2:00 pm shift; 12/2/2021, 12/7/2021, 12/11/2021, 12/12/2021, 12/26/2021, 1/8/2022, 1/12/2022, 1/13/2022, 1/19/2022, 1/22/2022, 1/23/2022 and 1/28/2022 on the 2:00 pm to 10:00 pm shift; 12/6/2021, 12/7/2021, 12/10/2021, 12/13/2021, 12/14/2021, 12/16/2021, 12/17/2021, 12/20/2021, 12/21/2021, 12/24/2021, 12/27/2021, 12/28/2021, 1/3/2022, 1/5/2022, 1/7/2022, 1/9/2022 through 1/13/2022, 1/17/2022 1/18/2022, 1/20/2022, 1/24/2022 and 1/27/2022 on the 10:00 pm to 6:00 am shift. 3. On 1/31/2022, the licensing inspector (LI) interviewed the assistant administrator (AA) who confirmed there were no staff on duty during these times that had current certification in CPR.
Plan of Correction:	The executive director (ED) and AA will conduct 100% audit on all current staff records to identify employees in need of initial certification or recertification. The AA will schedule CPR training for staff to obtain initial certification or re-certification. The AA will develop a system to ensure that CPR certifications are current and that re-certifications are obtained prior to expiration. The AA will create a spreadsheet with CPR expiration dates and share with the wellness coordinator (WC) on a monthly basis. The WC will be responsible for notifying staff when certification needs to be renewed and the AA will schedule renewal classes. The WC will be responsible for ensuring that at least one CPR certified staff member is always on duty. CPR certified staff will be identified on the monthly schedule with an asterisk to indicate current certification. The ED and AA will perform audits on at least 25% of the employee files quarterly to verify compliance with this corrective action. The AA will also review the staffing calendar with the WC monthly to ensure compliance. The AA and ED will be responsible for implementing and monitoring the corrective action.