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: Dec. 15, 2021

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 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Technical Assistance:

To ensure that the facility had a thorough understanding of the standards, the two licensing inspectors and the Nurse Manager had a discussion regarding standards 450-F, 550-G, 650-A, 940-A and 980-A.

Comments:

The licensing inspector (LI) for Blue Ridge Christian Home, along with another LI, conducted an unannounced renewal study on 12/15/2021 from 9:30am until 1:30pm, finding 13 residents in care. The inspection included a tour of the physical plant, observation of two medication passes, review of the medication storage and resident interviews. Six resident records were thoroughly reviewed, and an additional two were partially reviewed in relation to the observation of the medication pass. Sworn disclosure statements and criminal record checks were examined for all newly hired staff still employed since the facility's last mandated inspection, and the records of three staff were thoroughly examined. Additional facility documentation was surveyed for compliance with the Standards for Assisted Living Facilities. Findings were reviewed with facility staff during the inspection. An exit interview was conducted with the Nurse Manager on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 589-5216.

Violations:

Standard #:	22VAC40-73-1030-B
Description:	Based on staff record review and staff interview, the facility failed to ensure that all direct care staff attended six hours of training in working with individuals who have a cognitive impairment within four months of the stating date of their employment. EVIDENCE: 1. Interview with staff 1 confirmed that the facility does have in care residents that have cognitive impairments. 2. The record for staff 4, date of hire 06/08/2021, did not contain six hours of training in working with individuals who have a cognitive impairment. Interview with staff 1 confirmed that this was accurate.
Plan of Correction:	Facility has signed up w/ online training agency. All staff will be current with training.
Standard #:	22VAC40-73-200-D
Description:	Based on staff record review and staff interview, the facility failed to obtain a copy of the certificate issued or other documentation that indicated that the person has met one of the requirements of standard 200-C 1 through 8. EVIDENCE: 1. The record for staff 2, date of hire 09/24/2021, did not contain a copy of the certificate issued or other documentation indicating that staff 2 has met one of the requirements of 200-C 1 through 8. Interview with staff 1 confirmed that this was accurate.
Plan of Correction:	Staff member has been enrolled in direct care class. Adm. will obtain a copy of applicant's certificate before hiring or enroll applicant in direct care class upon hiring.
Standard #:	22VAC40-73-210-B
Description:	Based on staff record review and staff interview, the facility failed to ensure all direct care staff attended at least 18 hours of annual training. EVIDENCE: 1. The record for staff 2 did not contain documentation that staff 2 had attended 18 hours of annual training for year of 09/10/2020 through 09/09/2021. Interview with staff 1 confirmed that this was accurate.
Plan of Correction:	All staff will be caught up with training. Facility signed up with online training agency.
Standard #:	22VAC40-73-250-D
Description:	Based on staff record review and staff interview, the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility submitted the results of a tuberculosis (TB) risk assessment. EVIDENCE: 1. The record for staff 3, date of hire 09/24/2021, contained documentation that staff 3 did not obtain the results of a TB risk assessment until 10/18/2021. Interview with staff 1 confirmed that this was accurate.
Plan of Correction:	TB risk assessments will be done by the office of the facility's medical director to ensure the results are submitted to facility.
Standard #:	22VAC40-73-260-A
Description:	Based on staff record review and staff interview, the facility failed to ensure that each direct care staff member who does not have current certification in first aid received certification in first aid within 60 days of employment. EVIDENCE: 1. The record for staff 4, date of hire 06/08/2021, contained documentation that staff 4 did not contain certification in first aid until 10/27/2021 which was not within 60 days of employment. Interview with staff 1 confirmed this was accurate.
Plan of Correction:	2 staff members without CPR/First Aid will be enrolled in class by Dec 31, 2021.
Standard #:	22VAC40-73-350-B
Description:	Based on a review of resident records, the facility failed to ascertain prior to admission whether a potential resident is a registered sex offender. EVIDENCE: 1. The record for resident 1, admitted on 11/5/2021 has documentation that a sex offender screen was not completed until 11/18/2021. 2. The record for resident 3, admitted on 01/26/2021 has documentation that a sex offender screen was not completed until 7/23/2021. 3. The record for resident 4, admitted on 7/27/2021 has documentation that a sex offender screen was completed on 12/31/2019.
Plan of Correction:	Sex offender screenings for residents will be part of admission paperwork before resident admit date.
Standard #:	22VAC40-73-390-A
Description:	Based on a review of resident records, the facility failed to ensure all required information was included in resident agreements. EVIDENCE: 1. The signed resident agreements in the records for residents 1, 3 and 4 do not contain all information that is required by this standard.
Plan of Correction:	Resident agreement form will be updated.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of resident records, the facility failed to update resident individualized service plans (ISPs) to address all identified needs. EVIDENCE: 1. A fall risk-rating tool dated 01/26/2021 in the record for resident 3 has documentation that the resident is a high risk for falls. The uniform assessment instrument (UAI) dated 01/25/2021 in resident 3?s record has documentation that the resident requires physical assistance with transfers and that the resident is disoriented to some spheres some of the time with place and time being the spheres affected. Interview with staff 1 expressed that these needs are correct. The ISP dated 01/26/2021 in the record for resident 3 does not address these identified needs. 2. A fall risk-rating tool dated 02/16/2021 in the record for resident 5 has documentation that the resident is a high risk for falls. The UAI dated 02/16/2021 in resident 5?s record has documentation that the resident is disoriented to some spheres some of the time with person, place and time being the spheres affected. Interview with staff 1 express that these needs are correct. The ISP dated 03/12/2021 in the record for resident 5 does not address these identified needs.
Plan of Correction:	ISP will be corrected and submitted to oversight nurse.
Standard #:	22VAC40-73-450-G
Description:	Based on resident record review, the facility failed to ensure that the master individualized service plan (ISP) was filed in resident records. EVIDENCE: 1. The record for resident 1, admitted on 11/5/2021, did not contain an ISP for this resident.
Plan of Correction:	ISP will be returned to resident record. A copy of the ISP to be signed will be mailed but the original will remain in chart.
Standard #:	22VAC40-73-560-I
Description:	Based on a review of resident records, the facility failed to ensure that a resident photo or current narrative description was in the record. EVIDENCE: 1. The record for resident 1, admitted on 11/05/2021, did not contain a photo or narrative description of the resident on the day of inspection.
Plan of Correction:	A photo has been added to resident's chart. If a photo isn't available upon admission, a narrative description will be added to record until a photo is taken.
Standard #:	22VAC40-73-650-E
Description:	Based on a review of resident records, the facility failed to ensure that physician orders were filed in resident records. EVIDENCE: 1. Resident 1 was observed receiving 2 liters of oxygen via a nasal cannula and an oxygen tank on the day of inspection. The record for resident 1 did not contain a physician order for the use of oxygen.
Plan of Correction:	A copy of the O2 order has been added to resident's record.
Standard #:	22VAC40-73-680-D
Description:	Based on a review of resident records and medication administration records (MARs), the facility failed to ensure that all medications were administered in accordance with physician instructions. EVIDENCE: 1. The record for resident 1 has a physician order dated 11/05/2021 for Digoxin 125mcg, 2 tablets every morning for heart, hold if pulse is less than 60 or greater than 110 and call MD. The December 2021 MAR for resident 1 has documentation of the resident?s pulse being 60 at 8am on 12/01/2021. Staff initials are signed as not administering this medication at 8am on 12/01/2021 even though the resident?s pulse was not less than 60.
Plan of Correction:	In service on Medication Admin. was done on 12/16/21. In service focused on reading MD orders and proper documentation.
Standard #:	22VAC40-73-700-2
Description:	Based on observation and staff interview, the facility failed to post "No Smoking-Oxygen in Use" signs when oxygen therapy is provided. EVIDENCE: 1. One licensing inspector (LI) observed resident 1 using oxygen during the day of inspection. There were no "No Smoking-Oxygen in Use" signs posted within the facility. Interview with staff 1 confirmed that there were no "No Smoking-Oxygen in Use" signs within the facility.
Plan of Correction:	No smoking - oxygen in use sign has been posted at bedroom door and posted in common areas where O2 is in use.
Standard #:	22VAC40-73-860-I
Description:	Based on observation, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: 1. Interview with staff 1 confirmed that the facility is a mixed population that includes residents with serious cognitive impairments. 2. At approximately 9:48AM during the tour of the facility's physical plant, the door to the laundry room was found to be unlocked by one licensing inspector (LI). A container of "Dreumex Disinfecting wipes", a container of "latex seam sealer", and a container of "releasable pressure sensitive adhesive" were noted to be located in the laundry room.
Plan of Correction:	Disinfecting wipes will be kept in locked cabinet in laundry room with other cleaning supplies. Seam sealer and adhesive were returned to contractor. In service done with all staff to ensure that in the future, all hazardous materials and cleaning supplies are kept in a locked cabinet.
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation and staff interview, the facility failed to ensure that the findings of the most recent inspection of the facility was posted. EVIDENCE: 1. The findings from the facility's most recent inspection, dated 11/19/2020, was not posted in the facility. Interview with staff 1 confirmed that the findings were not posted.
Plan of Correction:	A copy of the most recent inspection of facility was posted - a copy of the most recent inspection will be posted outside of business office.
Standard #:	22VAC40-90-30-B
Description:	Based on staff record review, the facility failed to ensure that the sworn statement or affirmation was completed for all applicants for employment. EVIDENCE: 1. The record for staff 3, date of hire 09/24/2021, contained documentation that the sworn statement or affirmation was completed after the date of hire on 09/29/2021. The record for staff 4, date of hire 06/08/2021, contained documentation that the sworn statement or affirmation was completed after the date of hire on 06/10/2021. The record for staff 5, date of hire 12/07/2021, contained documentation that the sworn statement or affirmation was completed; however, the document did not include the date it was completed by staff 5.
Plan of Correction:	Administrator will ensure all paperwork for New Hire will be completed before staff is put on schedule. Review of regulations for applicants for employment was done by nurse manager with staff responsible for application processing.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review and staff interview, 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 records for staff 3, date of hire 09/24/2021 and staff 4, date of hire 06/08/2021, did not contain a criminal history record report. Interview with staff 1 confirmed that the facility did not have criminal history records for staff 3 and 4.
Plan of Correction:	Facility signed up with VA state police to do criminal record checks. Adm. to ensure criminal record checks are completed on or prior to 30th day of employment.