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: Nov. 19, 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 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:

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 on 11/19/2020 and concluded on 11/24/2020. The designated person in charge was contacted by telephone to initiate the inspection. The designated person in charge reported that the current census was 12. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 2 resident records, 2 staff records, staff schedule, fire and emergency drills, and most recent fire inspection submitted by the facility to ensure documentation was complete. The ensure that the facility has a thorough understanding of the standards, the LI had a discussion with the designated person in charge regarding standards 270, 320 A and 690 B. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-270-1
Description:	Based on staff record review and staff interview, the facility failed to ensure that training prior and annually for staff in assisted living facilities that accept, or have in care, residents who are or who may have aggressive behavior included demonstration in self-protection and in the prevention and de-escalation of aggressive behavior. EVIDENCE: 1. The record for staff 1, date of hire 10/14/2017, did not contain documentation of annual training that staff 1 had demonstration in dealing with residents who may have aggressive behavior for the training year 10/14/2019 through 10/13/2020. 2. The record for staff 2, date of hire 09/30/2020, did not contain documentation that staff 2 had demonstration in dealing with residents with aggressive behavior prior to working with residents who may have aggressive behavior. 3. Interview with staff 3 confirmed that staff 1 and 2 did not complete the required demonstration portion of the training.
Plan of Correction:	Annual training updated to include dealing with aggressive behaviors - including a demonstration - All staff will have this training now and their annually.
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure the physical examination was completed as required prior to a resident?s admission. EVIDENCE: 1. The ?REPORT OF ELDERLY PHYSICAL EXAMINATION? for resident 1, dated 07/28/2020, did not contain whether the resident is or is not capable of self-administering medication.
Plan of Correction:	Admission H&P form has been updated to include whether a resident is capable of self adm. meds
Standard #:	22VAC40-73-320-B
Description:	Based on resident record review and staff interview, the facility failed to ensure that tuberculosis (TB) testing was completed annually for residents. EVIDENCE: 1. The record for resident 2, admitted on 07/02/2018, contained documentation that the most recent TB test completed for resident 2 was on 11/30/2018. 2. Interview with staff 3 confirmed that resident 2 did not have a TB test completed in 2019.
Plan of Correction:	TB screenings will be done with six month med reviews by household doctor
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review and staff interview, the facility failed to ensure that the Uniform Assessment Instrument (UAI) was completed as required. EVIDENCE: 1. The private pay uniform assessment instrument (UAI) for resident 2, dated 09/10/2020, showed the resident needs assistance with dressing but does not indicate what kind of assistance with dressing the resident needs. 2. Interview with resident 3 revealed that resident 2 needs mechanical and physical assistance with dressing.
Plan of Correction:	UAI has been updated - all other UAI's and ISP have been reviewed
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure that the Individualized Service Plan (ISP) addressed all of the identified needs. EVIDENCE: 1. The private pay uniform assessment instrument (UAI) for resident 2, dated 09/10/2020, showed the resident has weekly or more bowel incontinence and the resident needs mechanical help with mobility. The ISP for resident 2 does not include these identified needs. 2. The private pay UAI for resident 2, dated 09/10/2020, showed the resident needs mechanical help and physical human help with toileting. The ISP, with an identified need date of 09/10/2020, showed the resident needs ?mechanical assistance of grab bar when toileting?. Interview with staff 3 revealed that the UAI is correct, and the ISP is incorrect. 3. Interview with staff 3 revealed that resident 2 has a DNR order. The ISP for resident 2 does not address that resident 2 has a DNR order.
Plan of Correction:	ISP has been updated to address the identified needs
Standard #:	22VAC40-73-690-B
Description:	Based on resident record review and staff interview, the facility failed to ensure that for each resident assessed for assisted living care, except for those who self-administer all of their medications, a licensed health care professional, practicing within the scope of his profession, performed a review every six months of all the medications of the resident. EVIDENCE: 1. The private pay uniform assessment instrument (UAI) for resident 2, dated 09/10/2020, showed that the resident was assessed as assisted living level of care and needs medications administered by a lay person. 2. The record for resident 2, admitted on 07/02/2018, contained documentation that the last six month review of medications for the resident was conducted on 11/19/2019. 3. Interview with staff 3 confirmed that the last medication review conducted for resident 2 was on 11/19/2019.
Plan of Correction:	Facility working with medical director to do six month medication reviews