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: Oct. 9, 2019 and Oct. 10, 2019

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 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

Technical Assistance:

Issues discussed with the administrator: 1) Ensure no lines are drawn through the orientation or rounds forms/logs. Each blank must include the required information. 2) Ensure staff A and B complete the direct care aide class within 60 days of hire. 3) Reviewed the requirements for dementia training and the hours required upon hire (six hours within four months of starting date) for all new direct care staff. 4) Annual reviews of the sex offender registry are due this month. 5) Do not leave information blank, if it does not apply then put N/A in the blank. 6) Recommended adding some more canned meats to the emergency food supply, although the facility had a sufficient supply of frozen cooked meats and peanut butter to provide for the 48 hours on site requirement. 7) Recommended monitoring the temperature in the activities room to ensure compliance (the temperature registered at 71.8 degrees Fahrenheit (F) and must be maintained at 72 degrees F). 8) Medication, dietary, emergency preparedness and resident emergency reviews will be coming up due - make sure you keep within the required time frames. 9) Even though the limited liability insurance was included on the written agreement and disclosure, the actual form that was sent out must be included within each document, it can not be an attachment or just the statement, the whole form must be within the documents.

Comments:

An unannounced non-mandated inspection was conducted on 10/9/19 from approximately 8:00 am to 3:00 pm and on 10/10/19 from approximately 7:45 am to 2:30 pm. A tour was immediately completed of the interior and exterior of the facility. All of the required postings were in place and the facility was clean and free from any foul odors. The posted menu and activities calendar accurately reflected this inspector's observations. There were 31 residents in care and one nurse, one medication aide and three direct care aides on duty. Meals were observed and the special diets reviewed were served according to the physicians' orders. Medication administration observations were completed with three residents. The medication administration records, physicians' orders and medications were reviewed. Individual interviews were conducted with residents, family members and staff. Six resident, one discharge, two contract staff and four staff records were reviewed. Additional selected sections of three staff and 10 resident records were also reviewed. The areas of noncompliance included disclosure statement, staff records, initial physicals, individualized service plans, mental health services, meal consumption logs and documentation of daily rounds. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based upon documentation, the facility failed to ensure a disclosure was signed upon admission by six of six residents. Evidence: Residents A, B, C, D, E and F did not have signed acknowledgements of receipt of the new disclosure statement upon the change of ownership of the facility.
Plan of Correction:	The administrator or designee will complete an audit of all residents' financial files to ensure a new completed disclosure statement is on file. The administrator or designee will meet with each power of attorney (POA) or resident to ensure that a new disclosure statement with the new ownership information is signed by each resident or responsible party. The administrator will be responsible for compliance with this standard.
Standard #:	22VAC40-73-250-C
Description:	Based upon documentation and an interview, the facility failed to ensure all required social data was on file for two of the five staff records reviewed. Evidence: 1) Staff A (hired 10/7/19) and B (hired 9/5/19) did not have any emergency contact information on file. 2) On 10/10/19, the LI interviewed the administrator who stated the information was on the previous application form; however, a new form was created and the section for emergency contact information was deleted on the new form.
Plan of Correction:	The emergency contact information has been completed for all staff and are on file. The administrator will ensure all new employees have their emergency contact information on file prior to their first day of work. The administrator will ensure the emergency contact information is complete and maintain them in each employee file. The administrator will be responsible for compliance with this standard
Standard #:	22VAC40-73-320-A
Description:	Based upon documentation and an interview, the facility failed to ensure the initial physicals included all required information for three of the six residents reviewed. Evidence: 1) The physical for resident C (completed 9/16/19) did not include a telephone number and allergic reaction to Penicillin; for resident D the name, address, telephone number and height; for resident F allergic reaction to Penicillin. 2) On 10/9/19, the licensing inspector (LI) interviewed the administrator who stated this information was not on the physicals or on file.
Plan of Correction:	The administrator or designee will complete an audit of all residents' files to ensure all information on the initial physicals is complete. Prior to any new admissions, the administrator or designee will review the initial physicals and ensure completion by the doctor prior to admittance of any new residents. The administrator will be responsible for compliance with this standard.
Standard #:	22VAC40-73-390-A
Description:	Based upon documentation, the facility failed to ensure new written agreements were completed for three of the six residents' records reviewed. Evidence: Residents A, B and E did not have a new written agreement on file after the facility changed ownership.
Plan of Correction:	The administrator or designee will complete an audit of all residents' financial files to ensure a new completed written agreement is on file. The administrator or designee will meet with each power of attorney (POA) or resident to ensure that a new written agreement is signed by each resident or responsible party with the new ownership information. The administrator will be responsible for compliance with this standard.
Standard #:	22VAC40-73-450-F
Description:	Based upon documentation, observations and an interview, the facility failed to ensure seven of the nine individualized service plans (ISPs) were updated to include all changes in residents' needs. Evidence: 1) The ISP (completed 10/2/19) for resident A did not include right side half rail, which was signed as ordered on 7/5/19 and was observed on the bed. 2) The ISP (completed 9/19/19) for resident B did not specify the physical assistance needed for bathing, toileting, transferring, walking, wheeling, stair climbing and mobility. The uniform assessment instrument (UAI) also indicated mechanical assistance with stair climbing; however, this need was not listed on the ISP. 3) The ISP (completed 10/1/19) for resident D did not include the need for a wander guard. 4) The ISP (completed 12/17/18) for resident E did not include Palliative Care (which started on 5/28/19) and a tab alarm (which was signed as ordered on 5/29/19). 5) The ISP for resident F did not include a bed alarm, which was signed as ordered on 7/5/19. 6) The ISP for resident L did not include physical therapy, which was signed as ordered on 8/20/19, and was still being provided; however, physical therapy which was ordered in 4/19 had been completed but was still listed. The ISP also did not include Palliative Care, two half rails and a hospital bed, which were signed as ordered on 7/8/19. 7) The ISP for resident M listed hospice; however, it did not list the specific services provided. 8) On 10/9/19, the LI interviewed the administrator who stated these needs were not included on the ISPs.
Plan of Correction:	The administrator or designee will complete a facility review of all residents' ISPs for accuracy and to ensure they are current. The administrator and facility licensed practical nurse (LPN) will review all ISPs upon completion to ensure they reflect the current needs and services the residents are receiving. The administrator or designee will review ISPs weekly and update the ISPs to reflect any changes that occur. The administrator or designee will ensure compliance with this standard.
Standard #:	22VAC40-73-510-B
Description:	Based upon a record review and interview, the facility failed to ensure communication procedures were followed for the one resident receiving mental health services. Evidence: 1) A mental health agreement for resident E indicated progress reports would be obtained every six months; however, there were no progress notes on file for the past year. 2) On 10/9/19, the LI interviewed the administrator who stated there were no progress reports completed in the past year for resident E.
Plan of Correction:	The mental health provider has been contacted for an order to discontinue mental health services as the resident is no longer being seen by this provider. The administrator or facility nurse will ensure a mental health progress report is received every six months and kept on file for any resident receiving mental health services. The administrator will ensure compliance with this standard.
Standard #:	22VAC40-73-580-E
Description:	Based upon documentation and interviews, the facility failed to consistently implement the food consumption policy for six of the seven residents' records reviewed. Evidence: 1) The food consumption log for residents A, C and J were blank for the dinner meal on 10/1/19, 10/2/19 and 10/5/19 through 10/8/19; for F, H and I they were blank for the dinner meal on 10/1/19 and 10/2/19. 2) Interviews with staff indicated direct care staff were to document the percentage of the meal that was consumed by each resident for each meal.
Plan of Correction:	The administrator and dining services supervisor met with all staff on 10/25/19 to review the food consumption policy. The administrator will monitor the food consumption logbook a minimum of four times a week to ensure it is being completed per policy. The administrator will verify the food consumption log is 100% complete at the end of the month. The administrator will be responsible for compliance with this standard.
Standard #:	22VAC40-73-930-D
Description:	Based upon documentation and an interview, the facility failed to ensure six of the six residents with an inability to use the call bell had this information included on their ISPs and that all required information was included on the rounds logs. Evidence: 1) The ISPs for residents E, N, M, O, P and Q did not include their inability to use the call bell and the minimal frequency of required rounds. 2) The documented rounds included the shift and each round was numbered as 1, 2 and 3, rather than documenting the time the rounds.were conducted. 3) On 10/10/19, the LI interviewed the administrator who stated he changed the form and the information was no longer included.
Plan of Correction:	The administrator has added the inability to use the call bell system to all residents' ISPs who are unable to effectively use the call bell system. The administrator will ensure call bell information is added to all ISPs of residents who are physically or mentally incapable of using the call bell system. A list has been placed in the logbook to keep a running list of updates that the administrator will add to the ISPs as changes occur. The administrator will review the list daily and will ensure upon admission and as needs change that this inability to use the call bell system is added to all ISPs as appropriate. The rounds log sheets will be updated to include the name of the resident, the date and time of the rounds, and the name of the staff member who made the rounds. The administrator will be responsible for adherence to this standard.