VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Blue Ridge Christian Home
85 Beulah Drive
Raphine, VA 24472
(540) 377-9590

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Jan. 6, 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 SANCTIONS.

Comments:

The LI for Blue Ridge Christian Home conducted an unannounced renewal study at the facility on 1-6-2020 from 9:45am until 2:30pm in conjunction with 3 other LI's and noted 18 residents to be in care. Resident and staff records as well as other forms of facility documentation were reviewed and interviews were conducted with residents and staff. A tour of the facility physical plant was conducted and the mid day medication pass and mid day meal were observed. Please respond back to your LI with a plan of correction within 10 days of receipt of this notice. If you have any questions please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-120-B
Description:	Based on staff record review, the facility failed to ensure that all direct care staff received the orientation and training required within the first seven working days of employment. EVIDENCE: 1. The records for staff person 2, hired on 08/01/2019, and staff person 3 hired on 06/10/2019 had documentation for some of the required orientation but did not contain that staff 2 and staff 3 had been trained in the facility?s organizational structure, handwashing techniques, standard precautions, infection risk-reduction behavior, and other infection control measures specified in 22VAC40-73-100 and the needs, preferences, and routines of the residents for whom they will provide care.
Plan of Correction:	New hire orientation form has been updated to include all of the required components.
Standard #:	22VAC40-73-210-B
Description:	Based on a review of staff records, the facility failed to ensure that staff attend at least 18 hours of training annually. EVIDENCE: 1. The records for staff persons 1 and 2 did not contain documentation that these employees have received 18 hours of annual training.
Plan of Correction:	Staff records are being updated to ensure all staff have required training hours.
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records, the facility failed to ensure that staff annually submitted the results of a screening for tuberculosis. EVIDENCE: 1. The record for staff person 1 has documentation that the most recent screening for tuberculosis was completed in October , 2018. No annual tuberculosis screening was noted for 2019.
Plan of Correction:	TB screenings for all staff have been completed as of 1/8/20.
Standard #:	22VAC40-73-260-A
Description:	Based on staff record review, the facility failed to ensure that all direct care staff received certification in first aid within 60 days of employment and kept current certification in first aid. EVIDENCE: 1. The record for staff person 3, hired on 06/10/2019 has documentation the employee did not receive training in first aid until 10/09/2019, which is past the 60 day from the day on employment requirement per this regulation . 2. The record for staff person 1 did not contain documentation of current certification in first aid.
Plan of Correction:	Adm. will work to ensure all staff be first aid/CPR certified within 60 days of hire.
Standard #:	22VAC40-73-320-A
Description:	Based on review of resident records, the facility failed to obtain a TB evaluation for a new resident within 30 days prior to admission and failed to obtain all required information on the pre-admission physical exam. EVIDENCE: 1. Resident 6 was admitted on 8/13/2019 and the TB test was read on 8/15/2019. 2. The pre-admission physical for resident 6 dated 8/13/2019 lacked a statement to show whether the resident could self-administer medication. 3. The pre-admission physical for resident 2 dated 12/12/2019 lacked a statement to show whether the resident could self-administer medication. 4. The pre-admission physical for resident 3 dated 9/23/2019 lacked a statement to show whether the resident could self-administer medication. The physical for resident 3 showed the resident has allergies to PCN [penicillin], cephalosporin, gabapentin, imipenem, olanzapine, risperidone, sertraline, temazepam, and topiramate. The physical exam did not include reactions to all of these allergens. Reactions were described only for risperidone.
Plan of Correction:	Nurse will update new admission H&P to include reactions to allergies, self-administering medications and will also ensure TB screenings are complete before admission.
Standard #:	22VAC40-73-350-B
Description:	Based on review of resident records, the facility failed to obtain a sex offender screening on a resident prior to admission. EVIDENCE: 1. Resident 3 was admitted on 10/2/2019 and the resident record does not have documentation to support that a sex offender screening was completed.
Plan of Correction:	Adm. will ensure sex offender screenings are complete before admission, resident 3 screening complete.
Standard #:	22VAC40-73-390-A
Description:	Based on review of resident records, the facility failed to have resident agreements that meet current requirements (effective 2/18/2018). EVIDENCE: 1. The resident agreements for residents 2, 3, and 6 have a footer showing the document was updated most recently on 10/7/2008. The agreements for residents 2, 3, and 6, who moved in on various dates in 2019, lack the following required sub-sections of 22 VAC 40-73-390: 1-a, b, f, g, 2, 3, 4-a through n.
Plan of Correction:	Adm. working to get resident agreements updated to contain all components on regulation.
Standard #:	22VAC40-73-450-A
Description:	Based on review of resident records, the facility failed to have a preliminary plan of care (POC) and did not meet the exception to this requirement (doing a comprehensive individualized service plan (ISP)) on or within seven days prior to admission. EVIDENCE: 1. Resident 6 was admitted on 8/13/2019, and the record did not have a preliminary POC. The comprehensive ISP was dated 8/14/2019. 2. Resident 2 was admitted on 12/16/2019 and the record did not have preliminary POC. The comprehensive ISP was dated 12/18/2019. The needs on the ISP were identified 12/18/2019, even though the signature page was done 12/15/2019. Interview with staff person 4 confirms that this was actually done on 12/18/2019.
Plan of Correction:	Nurse will ensure POC is completed and comprehensive ISP complete within 7 days.
Standard #:	22VAC40-73-450-F
Description:	Based on review of resident records, the facility failed to address assessed needs on individualized service plans (ISPs). EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 6, dated 8/13/2019 shows the resident has the following needs: mechanical help and supervision with walking, stair climbing, and mobility. Resident 6 is also assessed as being disoriented to time and place some of the time. The ISP for resident 6, dated 8/14/2019, does not address these needs. 2. The uniform assessment instrument (UAI) for resident 3, dated 10/2/2019 shows the resident requires supervision when stair climbing. The ISP dated 10/2/2019 shows that mechanical assistance only is provided. Supervision is not addressed. 3. The UAI dated 12/18/19 for resident 4 has documentation that the resident is disoriented to some spheres some of the time and requires assistance with medication management. The record for resident 4 also has documentation that the resident is a high risk for falls. The ISP dated 12/18/19 does not reflect these assessed needs. 4. The record for resident 5 has documentation that the resident is a high risk for falls. The ISP dated 7/1/19 does not reflect this assessed need.
Plan of Correction:	ISP's have been updated- Will review all UAI and ISP with oversight nurse to ensure they accurately reflect residents needs.
Standard #:	22VAC40-73-560-I
Description:	Based on review of resident records, the facility failed to have either a photograph or a narrative description of a resident. EVIDENCE: 1. The records for residents 4, 5 and 6 did not contain a photograph or a narrative description of the resident.
Plan of Correction:	Medical records have been updated to include a recent photograph of resident.
Standard #:	22VAC40-73-860-I
Description:	Based on tour of the physical plant, the facility failed to ensure that cleaning supplies and other hazardous materials were in a locked area. EVIDENCE: 1. The door to the beauty shop was unlocked at the time of inspection and the room was unattended. Cabinets that were located in the beauty shop were also noted to be unlocked. One cabinet contained a bottle of Clippercide Spray and another cabinet contained an unlabeled clear spray bottle with an unidentified liquid agent.
Plan of Correction:	Staff safety in-service done with all staff- facility protocols reviewed with all staff pertaining to cleaning supplies and hazardous materials.
Standard #:	22VAC40-73-940-A
Description:	Based on review of facility documentation, the facility to ensure that an annual inspection by the appropriate fire official was completed. EVIDENCE: 1. The most recent fire inspection documentation that was available for review on the day of inspection was dated 9/27/2018.
Plan of Correction:	A plan of correction was not provided for this violation.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to ensure that a criminal history record report was obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The record for staff person 3, hired on 6/10/2019, did not contain documentation that a criminal history record report was obtained for this employee.
Plan of Correction:	Criminal record check is being done for staff person 3 and adm. will ensure all new employees have criminal record check.