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: Jan. 29, 2020 and Jan. 30, 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.

Technical Assistance:

Answered questions and reviewed information in the following areas: 1) Ensure when you are using model forms you are using the most current ones (physical form, disclosure, etc). Also, when an email is sent out to providers from this department, ensure the changes are implemented within the required time frames. 2) When using the model orientation form, remind staff to initial each section and not just initial the first line of each section and draw a line through the rest. 3) Recommended developing a checklist for the dietitian to sign, in addition to the information already provided. 4) Emergency preparedness and resident emergency training are due by the end of February 2020. 5) Annual review of the infection control policy is due by August 2020. 6) Discussed providing the emergency response staff a copy of the physician's order sheet and explained that would not replace providing them with the medication administration record but could give both if wanted to.

Comments:

An unannounced renewal inspection was conducted on 1/29/20 from approximately 7:05 an to 5:40 pm and on 1/30/20 from approximately 7:45 am to 3:15 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 29 residents in care and three direct care staff on duty. Meals were observed and the special diets reviewed were served according to the physicians' orders. Medication administration observations were completed with two residents. The medication administration records, physicians' orders and medications were reviewed. One additional resident's medication administration record, physicians' orders and medications were also reviewed. Individual interviews were conducted with residents, family members and staff. Five resident, one discharge, six staff and two contract staff records were reviewed. Additional selected sections of one staff and nine resident records were also reviewed. The areas of noncompliance included the disclosure form, criminal record checks, initial physicals, sex offender registry checks, individualized service plans, medication administration, resident council, resident rounds and dementia training. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-1030-B
Description:	Based upon documentation and interviews, the facility failed to ensure two of five direct care staff records reviewed had documentation of completing six hours of dementia training. Evidence: 1) Staff C (hired 8/26/19) only completed one hour of dementia training; staff D (hired 8/26/19) only completed two hours of dementia training. 2) On 1/29/20, the Li interviewed the administrator and nurse on duty and both stated these were the only dementia training hours completed by staff C and D.
Plan of Correction:	Staff C and D have competed their dementia training. An audit tool has been created and a 100% audit is being conducted by the administrator to ensure compliance with the training requirements. Also, the orientation process has changed to where new employees are required to have their six hours completed in the first week of employment. This process will be overseen by the facility nurse or designee. The administrator will be responsible for compliance with this standard.
Standard #:	22VAC40-73-1030-D
Description:	Based upon documentation and interviews, the facility failed to ensure two of the two non-direct care staff records reviewed had documentation of completing two hours of dementia training within the first month of hire. Evidence: 1) Staff A (hired 12/20/19) only completed one hour of dementia training; staff I (hired 12/16/19) had no documentation of dementia training. 2) On 1/29/20, the LI interviewed the administrator and nurse and both stated this was the only training completed for staff A and that staff I had not completed any dementia training.
Plan of Correction:	Staff A and I have completed their dementia training. An audit tool has been created and a 100% audit is being conducted by the administrator to ensure compliance with the training requirements. Also, the orientation process has changed to where new non-direct care employees are required to have their two hours completed in their first week of employment. This process will be overseen by the facility nurse or designee. The administrator will be responsible for compliance with this standard.
Standard #:	22VAC40-73-50-A
Description:	Based upon documentation and an interview, the facility failed to ensure the most current disclosure form was implemented and acknowledgment of receipt kept in twelve of twelve resident records reviewed. Evidence: 1) Residents A, B, C, D, E, F, G, H, I, J, K and L had signed disclosures on file; however, they were not on the most current model form that included generator information. 2) On 1/29/20, the LI interviewed the administrator who stated the newest form had not yet been implemented or provided to the residents.
Plan of Correction:	The administrator or designee will complete an audit of all resident financial files to ensure a new completed disclosure statement is on file. The administrator or designee will meet with each power of attorney or resident to ensure that a new disclosure statement is signed by each resident or responsible party with the new ownership and that it includes all required information, including the generator information. The administrator will be responsible for compliance with this standard.
Standard #:	22VAC40-73-250-C
Description:	Based upon record reviews and an interview, the facility failed to ensure three of 13 criminal record checks (CRCs) were completed and on file within 30 days of hire. Evidence: 1) Staff A (hired 12/20/19), B (hired 10/17/19) and I (hired 12/16/19) did not have a completed CRC on file. 2) On 1/29/20, the licensing inspector (LI) interviewed the administrator who stated the CRCs for these staff were not completed and on file.
Plan of Correction:	Administrator has sent off all Virginia State Police criminal history checks. Once they are returned, they will be filed in each employee's chart. Administrator and/or designee is to ensure all staff members have a completed criminal history record check in their file prior to starting employment. 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 for three of the three resident records reviewed included a section for allergic reactions. Evidence: 1) The initial physicals for residents A (completed 11/5/19), E (completed 10/11/19) and F (completed 12/2/19) did not include allergic reactions nor did the physical form being used have a section for this information. 2) On 1/30/20, the LI interviewed the administrator and nurse and both stated this information was not on the initial physicals or on the physical form.
Plan of Correction:	The facility nurse called on 2/21/2020 and received the reactions to the allergies for residents A, E and F and placed that information in the residents' charts. The administrator and facility nurse will review the physical prior to placing in the resident chart to ensure that all required information is present. The administrator and facility nurse will be responsible for compliance with this standard.
Standard #:	22VAC40-73-350-B
Description:	Based upon documentation and an interview, the facility failed to ensure two of six resident records reviewed had a sex offender registry check completed prior to admission. Evidence: 1) Resident A (admitted 12/14/19) had a sex offender registry check completed on 1/24/20 and E (admitted 11/15/19) had one completed on 11/19/19. 2) On 1/30/20, the LI interviewed the administrator who stated the sex offender registry checks for these two residents were not completed prior to admission.
Plan of Correction:	The administrator/designee completed a sex offender screen for residents A and E and will ensure that all new residents have a screening completed prior to admission. The administrator will be responsible for compliance with this standard.
Standard #:	22VAC40-73-450-F
Description:	Based upon documentation, the facility failed to ensure four of the six individualized service plans (ISPs) were updated to include all assessed needs. Evidence: 1) The ISP (completed 1/27/20) for resident A did not include supervision with dressing; for resident C (ISP completed 1/27/20) did not include mechanical and physical assistance with bathing and assistance with mobility; for resident D (ISP completed 8/19/19) did not include mechanical help for dressing, transferring, walking and assistance with eating, a pummel cushion with wheelchair and disorientation to all spheres; also, a wander guard was listed; however, this device was discontinued on 6/12/19; for resident E (ISP completed 11/15/19) did not include wander guard and listed resident as a fall risk; however, the fall risk rating indicated no fall risk.
Plan of Correction:	The administrator or designee will complete a facility review of all resident ISPs for accuracy and to ensure they are current. The administrator and facility 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 #:	22VAC40-73-680-D
Description:	Based upon documentation and observations, the facility failed to ensure one medication for one of two residents was administered according to the physician's order. Evidence: 1) On 1/29/20 at approximately 9:01 am, the LI observed staff C administer two 1,000 unit tablets of Cholecalciferol (Vitamin D-3 from a bottle) and one 2,000IU tablet of Vitamin D-3 (from a bubble pack) to resident A. 2) The physician's order was changed from one 2000IU tablet of Vitamin D-3 to two tablets of 1,000 unit of Vitamin D-3; however, the staff gave both doses.
Plan of Correction:	Resident A's family and physician were notified and a medication error report was completed on 1/29/2020. Staff member C was educated on our policy and procedure for medication administration by the facility nurse. All staff will be re-educated on medication administration policy by the facility nurse. The facility nurse will be responsible for adherence to this standard.
Standard #:	22VAC40-73-830-E
Description:	Based upon documentation and an interview, the facility failed to ensure a written response, regarding actions taken to resolve problems, concerns or recommendations, was provided to the resident council prior to the next meeting. Evidence: 1) The resident council meeting minutes for 11/20/19 listed several concerns; however, there was no documentation stating actions the facility took to resolve the issues. 2) On 1/30/20, the LI interviewed the administrator who stated a written response had not been provided to the residents regarding actions taken to correct the concerns.
Plan of Correction:	A written response was given to each council member on 2/11/2020 in response to the resident council meeting on 11/20/2019. The administrator will meet with the activities director following each resident council meeting. The administrator will develop a written response which addresses all concerns and the actions taken by the facility to correct/address the concerns. The written response will be given to all council members prior to the next resident council meeting. The administrator will be responsible for adherence with this standard.
Standard #:	22VAC40-73-930-D
Description:	Based upon documentation and interviews, the facility failed to ensure documentation on residents with an inability to use the emergency call system was completed for five of five resident records reviewed. Evidence: 1) Residents' D, G, M, N and O were documented as being mentally or physically unable to use the emergency call bell system. 2) The second and third shift rounds during the months of October 2019 through January 2020 had numerous blanks with no documentation as to whether resident was in the hospital, out with family, etc. 3) Neither the inability to use the call bell nor the minimal frequency of daily rounds were documented on the ISPs for residents D, G, M, N and O. 4) On 1/30/20, the LI interviewed staff and residents and all indicated rounds were being conducted; however, the staff admitted they were not consistently documenting the rounds.
Plan of Correction:	The administrator has added to the ISPs the inability to use the call bell system for all residents 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 and will include the frequency of daily rounds. The facility nurse will be reviewing the rounds documentation sheet three times a week to ensure documentation is completed. The administrator will review the documentation weekly and will ensure, upon admission and as needs change, the inability to use the call bell system is added to all ISPs and that the rounds documentation form is completed as required. The administrator will be responsible for adherence to this standard.