VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Retreat at Berryville
450 Mosby Blvd.
Berryville, VA 22611
(540) 837-4447

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: July 16, 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 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 63.2 General Provisions. 63.2 Protection of adults and reporting. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

1. Approval for placement should only be signed by an independent physician in the absence of any of the individuals listed above them and use of a physician requires additional explanation as to why (refer resident A). 2. If an individual does not read (refer resident D) the service plan should be read to him/her and indicated as such on the plan. 3. Code status needs to consistently be on the service plan along with staff signatures (refer resident B). 4. Recommend reviewing documentation procedure(circling initials) with medication aides when a medication is refused or missed.

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 July 16, 2020 and concluded 7/20/2020. The administrator was contacted by email to initiate the inspection. The administrator reported that the current census was 59. Based on the census, the inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 4 staff records and 29 background checks for staff hired since the previous inspection, 4 resident records plus additional medication records based on diagnosis, staff schedules, fire and health inspections, and health care and dietary over site submitted by the facility to ensure documentation was complete.Training records were reviewed as applicable along with fire and emergency drills. Information gathered during the inspection determined non-compliance with applicable standards or law in two areas. Violations were documented and reviewed with the administrator and can be found on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-280-A
Description:	Based on a desk review of the facility schedule and verbal confirmation from the administrator the facility did not have sufficient staff in numbers on various shifts to meet the needs of the individuals. This determination was based in part of the number of residents requiring a two person assist and the needs in the event of an emergency evacuation.
Plan of Correction:	The facility had an unexpected number of staff depart at the same time. The Covid pandemic made it more difficult to hire staff but as of this writing additional staff are being trained for both second and third shift which were the primary areas of weakness. Additional staff will continue to be hired. The administrator assumes responsibility for correction and future compliance.
Standard #:	22VAC40-90-40-B
Description:	Based on a desk review of background checks for staff hired since the previous inspection, only 11 of the 33 had Virginia State Police background checks. All staff did have, however, have a multi state background check which included Virginia. Although very appropriate since a lot of the staff are not Virginia residents, the standard does at this time continue to require a Virginia State Police background check.
Plan of Correction:	The business office will complete Virginia State Police background checks on all current employees as applicable and all future hires. We will continue to use Secure Hire as well. The administrator assumes responsibility for correction and future compliance.