VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Liberty Ridge Memory Support - Pearls of Life
107 Monica Blvd.
Lynchburg, VA 24502
(434) 237-2268

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

Inspection Date: July 8, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

A non-mandated complaint inspection was initiated on 7/8/2021 and concluded on 7/16/2021. A complaint was received by the department regarding allegations in the areas of administrator provisions and staffing. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-1130-C
Complaint related:	Yes
Description:	Based on a review of facility employee schedules, daily assignment sheet and staff interviews, the facility failed to ensure that the required number of staff were present in the facility during the night hours. EVIDENCE: 1. The facility, which is entirely a safe secure unit, was noted to have a census of 60 on the day of inspection, This census requires a minimum of 5 direct care staff to be in the building during the night hours. The daily assignment sheets for June and July 2021 have documentation of only 4 direct care staff being on duty during the night hours on 6/20, 6/21, 6/22, 6/24, 6/25, 6/27, 6/28, 7/3 and 7/5 and only 3 direct care staff being on duty during the night hours on 6/26, 7/2 and 7/4. An interview with staff person 2 expressed that there have been some night shift hours that a minimum of 5 direct care staff was not maintained in the facility
Plan of Correction:	Facility will ensure that staffing, in accordance with census will comply with regulations.
Standard #:	22VAC40-73-290-A
Complaint related:	Yes
Description:	Based on a review of the facility employee schedule, the facility failed to ensure that a written work schedule was maintained for all staff. EVIDENCE: 1. The facility written work schedule for June and July 2021 does not include a written schedule for staff person 1.
Plan of Correction:	Facility will ensure all staff members will be on written schedule.