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. 16, 2024

Complaint Related: No

Areas Reviewed:

Administration and Administrative Services Personnel Staffing and Supervision Admission, Retention and Discharge of Residents Resident Care and Related Services Buildings and Grounds Emergency Preparedness Mixed Population

Comments:

Date of Inspection: February 16, 2024 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 30 Number of records reviewed and interviews conducted- 8 records (staff and resident), 8 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. the Licensing Inspector observed the residents during many activities and meals. The Licensing Inspector reviewed the following at the time of inspection: menus, resident council minutes, activities calendars, pharmacy review, fire drills, dietician report and healthcare oversight.. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations:

Standard #:	22VAC40-73-450-D
Description:	Based on resident record review and staff interview, it was determined that the facility failed to have documentation of a coordinated plan of care on the Individualized Service Plan (ISP) between the facility and the Hospice agency. Evidence: Resident C had no documentation on the ISP dated January 10, 2024 of a coordinated plan of care between the facility and the Hospice agency. Resident D had no documentation on the ISP dated January 1, 2024 of a coordinated plan of care between the facility and the Hospice agency.
Plan of Correction:	The Administrator and/or nursing staff will audit all records to ensure compliance. The ISPs will reflect a coordinated plan of care between the facility and Hospice as required.