VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Regency at Augusta
43 Pinnacle Drive
Fishersville, VA 22939
(540) 213-4400

Current Inspector: Jill James (540) 418-2631

Inspection Date: Sept. 24, 2020

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 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

Answered questions/discussed the following: 1) When using the model orientation form, recommended staff be in-serviced on initialing and dating each blank rather than drawing a line through all of it and only initialing and dating the last blank on each page. 2) Residents who are seriously cognitively impaired are to sign the orientation form - not just the family member. 3) When documenting fall risk on the individualized service plan, also include interventions implemented for the prevention of falls and ensure disorientation is addressed. 4) Deadlines for dementia training are approaching so ensure all staff meet the required number of hours of training. Recommended conducting a training audit. 5) The activity staff member has six months from hire to complete the required activity training for the secured unit. 6) Recommended separating the date and time on the fire drill form to avoid missing any required information. Also, add a section for corrective action taken for any problems noted. (NOTE: The fire drill forms had all required information and there were no problems noted).

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 monitoring inspection was initiated on 9/22/20 and concluded on 9/24/20. The executive director was contacted by telephone to initiate the inspection. The executive director reported that the current census was 8. The inspector emailed the executive director a list of items required to complete the inspection. The inspector reviewed two resident records, two staff records and selected sections of three additional resident, one discharge, two staff and two contract staff records. The inspector also reviewed the menu, activities calendar, dementia training, staff schedule, fire drills and pet immunizations submitted by the facility to ensure documentation was complete. A virtual tour was conducted as part of this inspection as well. Information gathered during the inspection determined non-compliance with the tuberculin skin test/assessment standard and the violation was documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based upon documentation and an interview, the facility failed to ensure one of four tuberculin (TB) skin tests/assessments were completed prior to the first day of work. Evidence: 1) Staff D (first day of work 8/31/20) had a TB assessment dated as completed on 9/1/20. 2) On 9/24/20, the licensing inspector (LI) interviewed the executive director (ED) who stated the TB assessment was not completed prior to the first day of work.
Plan of Correction:	Staff D did not receive a TB assessment prior to his first day of employment on 8/31/2020 but instead had an assessment completed on 9/1/2020. The business office manager (BOM) will obtain all paperwork, including the TB assessment, and ensure it is completed prior to start date. The ED and the director of health and wellness (DHW) will review records of all associates prior to start dates to ensure compliance.