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: Aug. 28, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

1. Highly recommend maintaining a copy of paper MARs as back up to the electronic system. 2. No shifts should be covered solely by agency staff not familiar with the building or the residents. 3. Request copies of the current registration of any medication aides sent from agency. 4. All agency staff should participate in a shortened version of orientation to include emergency procedures.

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/15-8/28/23 A self-report then complaint with additional concerns was received by VDSS Division of Licensing on 8/27/23 and 8/13/23 respectively regarding allegations in the areas failure to provide medication as prescribed and failure to have oversight by a qualified person. The complaint involved the review of medication administration reports, interviews with family, staff and administration as well as collateral parties. Violations were identified related to the complaints and self-report and can be found in the violation portion of this report. All three aspects of the complaint were found to be valid. The evidence gathered during the investigation supported the allegation and self-report of non-compliance with standard(s) or law, and violation(s) were issued. The licensee can 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. An exit meeting was conducted to review the inspection findings. 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 Sharon DeBoever, Licensing Inspector at (540) 292-5930 or by email at sharon.deboever@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-150-B
Complaint related:	No
Description:	The facility failed to name an otherwise qualified person to be the administrator during the absence of the newly named administrator. The Vice president of operations who is otherwise qualified did come to the building after five days to assist in administration.
Plan of Correction:	Plan of correction forthcoming
Standard #:	22VAC40-73-680-C
Complaint related:	No
Description:	On 8/12/23 morning medication for all residents at the facility was administered outside the one hour after parameter due to the lack of a medication aide and the medication aide from the previous shift refusing to stay. This was verified by the resident care coordinator, additional staff, residents, family members and vice president of operations. on 8/27/28 morning medication was not given to any of the residents as per the vice president of operations due to agency staff not being able to log into the computer system and the agency rather than facility administration directing the medication aide not to administer any medication since it was now 9:25am and administration time was 8am.
Plan of Correction:	Plan of correction forthcoming