VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Birch Gardens
12 Royal Drive
Staunton, VA 24401
(540) 886-5007

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Feb. 1, 2021 , Feb. 2, 2021 , Feb. 3, 2021 and Feb. 4, 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 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:

Answered questions/made recommendations regarding the following: 1) When hospice writes orders for as-needed medications, ensure the symptoms that would warrant the medication administration are documented clearly on the orders as medication aides can not assess mild, moderate, severe pain, etc. 2) Once the updated contract for hospice has been resigned by both parties, send a copy to this inspector for review. 3) Once the fire plan has been updated with the fire official's recommendations, resend a copy along with the updated approval to this inspector. 4) Even when the local emergency coordinator does not make any recommendations for change, keep this information with the facility's emergency plan. 5) Due date of criminal record checks is based upon hire date - not start date. Also recommended staff sign a statement that they may not work alone until the criminal record check has been completed and returned.

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 2/1/21 and concluded on 2/4/21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 26. The inspector emailed the administrator a list of items required to compete the inspection. The inspector reviewed four resident, one discharge and four staff records. Selected sections of two additional resident, two contract staff and three facility staff records were also reviewed. The activities calendar, menu, staff schedules, administrator schedule, fire drills, dietary/medication/health care oversight reviews, January and February medication administration records, physicians' orders all criminal record checks for current employees hired since the last inspection, as well as other documents, were reviewed to ensure documentation was complete. 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 #:	22VAC40-90-40-B
Description:	Based upon documentation and an interview, the facility failed to ensure two of the 12 criminal record checks (CRC) reviewed were completed within 30 days of hire. Evidence: 1) The CRC for staff H (hired 8/27/20) had a completion date of 10/21/20; staff I (hired 7/14/20 and started 8/1/20) had a completion date of 8/19/20. 2) On 2/4/21, the LI interviewed the administrator who stated the CRC for staff H was missed and discovered during an audit. He stated he used the start date for staff I instead of the hire date as he thought that was acceptable.
Plan of Correction:	Administrator and/or designee is to ensure all staff members have a completed criminal history record check in their file prior to hire and starting employment. The administrator will be responsible for compliance with this standard.