VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Babcock Manor, Inc.
State Route 691
Appomattox, VA 24522
(434) 352-8686

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: Aug. 17, 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 32.1 Reported by persons other than physicians 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. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

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 8/17/2020 and concluded on 8/20/2020. 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 complete the inspection. The inspector reviewed 3 resident records, 3 staff records, Health and Fire Department inspections, employee schedule, health care oversight, fire drill logs and dietitian reviews submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1030-B
Description:	Based on a review of staff records, the facility failed to ensure that direct care staff received 6 hours of training in working with individuals who have cognitive impairments within four months of the start date of their employment. EVIDENCE: 1. The record for staff person 2, hired on 7/29/2019 has documentation of the employee only receiving 4.5 hours of training in working with individuals with cognitive impairments within the first four months of their employment.
Plan of Correction:	The Administrator will also ensure that all new employees receive the required 6 hours of cognitive impairment training within their first four months of employment. At the time of this inspection, staff person 2 was no loner employed at the facility.
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records, the facility failed to ensure that all staff completed a screening for tuberculosis on or within seven days prior to the first day of work at the facility. EVIDENCE: 1. The record for staff person 1, hired on 11/18/2019, has documentation that a screen for tuberculosis was not completed until 3/21/2020. 2. The record for staff person 2, hired on 7/29/2019, has documentation that a screen for tuberculosis was not completed until 8/23/2019.
Plan of Correction:	The Administrator will ensure that all new employees receive a screening for tuberculosis prior to their first day of work and the screening will be maintained in the employees record..
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that all identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The uniform assessment instrument (UAI) dated 5/1/2020 for resident 2 has documentation that the resident is disoriented to all spheres all of the time. The record also has documentation of a physician order dated 6/8/2020 for a physical therapy evaluations and a physician statement dated 8/3/2020 that the resident needs to be on fall precautions. The ISP dated 11/21/19 in the record for resident 2 does not address any of these identified needs.
Plan of Correction:	The Administrator will review resident 2's ISP and will update to reflect all identified needs.
Standard #:	22VAC40-73-450-D
Description:	Based on a review of resident records, the facility failed to ensure services provided by a Hospice agency were included on individualized service plans (ISPs). EVIDENCE: 1. The record for resident 1 has documentation that the resident was admitted to Hospice services on 6/17/2020. The ISP dated 10/6/19 in the record for resident 1 does not include any services that are being provided by the Hospice agency.
Plan of Correction:	The Administrator will update resident 1's ISP to include all Hospice services provided to the resident.
Standard #:	22VAC40-73-620-A
Description:	Based on a review of facility documents, the facility failed to ensure that a oversight for special diets was completed at least every 6 months. EVIDENCE: 1. The last documented over sight for special diets completed at the facility was dated 7/26/2019, which would require that a over sight for special diets to have been completed in January 2020.
Plan of Correction:	The Administrator will contact the contracted Dietitian to schedule a oversight of special diets.