VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Elms of Lynchburg
2249 Murrell Road
Lynchburg, VA 24501
(434) 846-3325

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: June 3, 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.

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 monitoring inspection was initiated on 06/03/2020 and concluded on 06/04/2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 54. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, staff schedules, fire and emergency drills, and sworn disclosures and criminal record checks for all newly hired staff since the last mandated inspection submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-210-F
Description:	Based on staff record review and staff interview, the facility failed to ensure all staff had at least two hours of infection control and prevention training annually. EVIDENCE: 1. The record for staff 2, date of hire 09/08/2018, and the record for staff 4, date of hire 08/21/2018, did not contain documentation that staff 2 and 4 had received 2 hours of infection control and prevention training. 2. Interview with staff 1 confirmed that staff 2 and 4 had not received 2 hours of infection control and prevention training.
Plan of Correction:	1. ED or Business office manager will continue to audit employee training hours monthly. These two employees lacked clear documentation on the amount of infection control hours for their annual trainings. Currently, all employees are in compliance with their annual training hours per standard.
Standard #:	22VAC40-73-260-A
Description:	Based on staff record review and staff interview, the facility failed to ensure that direct care staff who do not have current certification in first aid received certification in first aid within 60 days of employment. EVIDENCE: 1. The record for staff 3, date of hire 11/07/2019, contained documentation that certification in first aid was not completed until 02/16/2020. 2. Interview with staff 1 revealed that staff 3 did not have current certification in first aid when hired.
Plan of Correction:	1. ED, Business office manager or designee will audit all employee charts to ensure First Aid certification has been obtained within the 60 day period after hire date and annually.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure that the Individualized Service Plan (ISP) addressed all of the identified needs. EVIDENCE: 1. The record for resident 1 contained a ?Fall Risk Worksheet? dated 02/06/2020. The ?Fall Risk Worksheet? indicated that ?Add the points, any score of 5 or above indicates a high risk for falls.? Resident 1 had 9 points. 2. During inspection, staff 1 sent a list entitled ?Assisted Living Fall Risk (Any Falls Since Admission) updated on 05/30/2020. Resident 1 was listed on the list. 3. The ISP for resident 1 dated 02/07/2020 did not include that resident 1 is a high fall risk, nor did it include interventions/supports to prevent falls. 4. The Uniform Assessment Instrument (UAI) dated 02/07/2020 for resident 1 indicated that resident 1 does not need assistance with mobility. The ISP dated 02/07/2020 for resident 1 indicated mobility as an identified need; ?Services to be provided - *HAS ARTHRITIS IN LEGS* Will move safely in/out of facility?, ?Person who will provide Services ? Staff Family?, ?When and Where Services Will be Provided ? Daily at Facility? and ?Expected Outcomes/Goals ? Ensure safety during mobility. Resident will remain safe?. Interview with staff 1 revealed that the UAI is correct and the ISP is wrong.
Plan of Correction:	1. ED, RCC or designee will review all fall risks and add to the ISP when the score denotes fall risk. All UAIs have been reviewed and updated to remove any "Mobility" need for residents that are able to safely go in and out of the facility. Monthly review of ISPs and UAIs will be completed by the ED, Director of Resident Care of designee.
Standard #:	22VAC40-73-640-A
Description:	Based on record review, the facility failed to implement a medication management policy that addressed all required components. EVIDENCE: 1. The facility?s current medication management policy ?The Elms of Lynchburg Medication Management Policy? does not include standard operating procedures, including the facility?s standard dosing schedule and any general restrictions specific to the facility, methods for monitoring medication administration and the effective use of the MARs for documentation, methods to ensure that MARs are maintained as part of the resident?s record, methods to ensure periodic direct observation of medication administration, methods to ensure that staff who are responsible for administering medications are trained on the facility?s medication management plan and procedures for internal monitoring of the facility?s conformance to the medication management plan.
Plan of Correction:	1. ED will update Medication Management Plan to include missing elements to the current plan in place.
Standard #:	22VAC40-73-680-C
Description:	Based on documentation review, the facility failed to ensure that medications were administered not later than one hour after the facility?s standard dosing schedule. EVIDENCE: 1. The May 2020 medication administration record (MAR) for resident 2 showed documentation that medications scheduled for 8:00 AM on 05/01/2020 (aspiring [OTC] tablet, delayed release (DR/EC), 81 mg; BENEFIBER SF POWDER 1; fluticasone proplonate [OTC] spray, suspension, 50 mcg/actuation; hydrochlorothiazide tablet, 25 mg; levothyroxine tablet, 50 mcg; memantine tablet, 5mg; metoprolol tartrate tablet, 50 mg) were not administered until 9:42 AM as evidenced by documentation charted by staff 10, ?Late Administration; Administered Late Comment: ?. This MAR also showed that the above medications, with the exception of fluticasone proplonate [OTC] spray, suspension, 50 mcg/actuation, scheduled to be administered at 8:00AM on 05/14/2020 were not administered until 10:00AM as evidenced by documentation charted by staff 9, ?Late Administration: ?. 2. The May 2020 MAR for resident 4 showed documentation that the resident?s following medications scheduled for 8:00AM on 05/27/2020 were not administered until 9:27AM as evidenced by documentation charted by staff 8, ?Late Administration: Other Comment?: acetaminophen [OTC] tablet, 325 mg; citalopram tablet, 20 mg; memantine capsule, sprinkle, ER 24 hr, 14 mg; midodrine tablet, 5 mg; levothyroxine tablet, 50 mcg; quetiapine tablet, 25 mg; and Senexon-S (sennosides-docustate sodium) [OTC] tablet, 8.6-50 mg. 3. The May 2020 MAR for resident 1 showed that the resident?s scheduled 1:00PM Phenazopyridine 100 MG on 05/17/2020 was charted at 2:48PM as evidenced by documentation charted by staff 7, ?Late Administration: Other Comment: cl?.
Plan of Correction:	1. All RMAs will complete additional training by ED on timely medication administration and documentation.
Standard #:	22VAC40-73-680-H
Description:	Based on documentation review, the facility failed to document on a medication administration record (MAR) all medications administered to residents at the time the medication was administered. EVIDENCE: 1. The May 2020 MAR for resident 2 showed documentation that the medications scheduled for 8:00AM on 05/04/2020 (aspirin [OTC] tablet, delayed release (DR/EC), 81 mg; BENEFIBER SF POWDER 1; fluticasone proplonate [OTC] spray, suspension, 50 mcg/actuation; hydrochlorothiazide table, 25 mg; and levothyroxine tablet, 50 mcg) were not charted until 10:48 AM, and memantine tablet, 5 mg and metoprolol tartrate tablet, 50 mg, were not charted until 10:49 AM as evidenced by documentation charted by staff 9, ?Late Administration: Other Comment: ON TIME?. This MAR also showed that the above medications, with an exception of fluticasone proplonate [OTC] spray, suspension, 50 mcg/actuation which was discontinued on 05/07/2020, scheduled to be administered at 8:00AM on 05/26/2020, were not charted until 10:12AM as evidenced by documentation charted by staff 9, ?Late Administration: Other Comment: ON TIME?. 2. The May 2020 MAR for resident 2 showed documentation that the medications scheduled for 8:00AM on 05/16/2020 (aspirin [OTC] tablet, delayed release (DR/EC), 81 mg; BENEFIBER SF POWDER 1; hydrochlorothiazide tablet, 25 mg; levothyroxine tablet, 50 mcg; memantine tablet, 5 mg; and metoprolol tartrate tablet, 50 mg) were not charted until 9:27AM as evidenced by documentation charted by staff 7, ?Late Administration: Charted Late Comment: cl?. 3. The May 2020 MAR for resident 3 showed documentation that the medications scheduled for 8:00AM on 05/16/2020 (Escitalopram oxalate 20 MG tablet, Quetiapine 50 MG tablet and Ibuprofen 200 MG) were not charted until 10:23AM as evidenced by documentation charted by staff 8, ?Late Administration: Other Comment: given on time?. 4. The May 2020 MAR for resident 4 showed documentation that the medications scheduled for 8:00AM on 05/04/2020 (acetaminophen [OTC] tablet, 325 mg; citalopram tablet, 20 mg; clonazepam ? Schedule IV tablet, 0.5 mg; levothyroxine tablet, 50 mcg; and Senexon-S (sennosides-docusate sodium) [OTC] tablet, 8.6-50 mg) were not charted until 10:36AM and scheduled 8:00AM memantine capsule, sprinkle, ER 24 hr, 14 mg; midodrine tablet, 5 mg; and quetiapine tablet, 25 mg, were not charted until 10:37AM as evidenced by documentation charted by staff 9, ?Late Administration: Other Comment: ON TIME?. 5. The May 2020 MAR for resident 4 showed documentation that the medications scheduled for 2:00PM on 05/12/2020 (acetaminophen [OTC] tablet, 325 mg and quetiapine tablet, 25 mg) were not charted until 4:08PM as evidenced by documentation charted by staff 9, ?Late Administration: Other Comment: on time?. 6. The May 2020 MAR for resident 4 showed documentation that the medications scheduled for 8:00AM on 05/26/2020 (acetaminophen [OTC] tablet, 325 mg; citalopram tablet, 20 mg; clonazepam ? Schedule IV tablet, 0.5 mg; memantine capsule, sprinkle, ER 24 hr, 14 mg; and midodrine tablet, 5 mg) were not charted until 10:32AM and levothyroxine tablet, 50 mcg; quetiapine tablet, 25 mg and Senexon-S (sennosides-docusate sodium) [OTC] tablet, 8.6-50 mg were not charted until 10:33AM as evidenced by documentation charted by staff 9, ?Late Administration: Other Comment: ON TIME?.
Plan of Correction:	1. All RMAs will attend training with EMAR specialist to ensure accuracy and competency with the electronic system.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for an employee. EVIDENCE: 1. The record for staff 6, date of hire 02/19/2020, contained documentation that the results of a Criminal Record Check were not obtained until 03/26/2020.
Plan of Correction:	1. All new employee's criminal background check documentation will be completed upon hire and a copy of the original document will be added to their file. In the event of the original request be returned to the facility from the Virginia Police, the Business office manager or designee will make copies of any or all documents prior to sending the request back.