VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Heritage Green Assisted Living Communities
201 & 202 Lillian Lane
Lynchburg, VA 24502
(434) 385-5102

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Dec. 21, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION.

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 complaint inspection was initiated on 12/21/2020 and concluded on 01/25/2021. A complaint was received by the department regarding allegations in the areas of administration and administrative services regarding infection control and resident care and related services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-100-A
Complaint related:	No
Description:	Based on document review and staff interview, the assisted living facility failed to implement their infection control program. EVIDENCE: 1. A section of the facility?s infection control policy (ICP) entitled ?COVID-19 Employee Exposure Guidelines? states that ?Healthcare workers should self-monitor for symptoms of COVID-19 because all healthcare workers are at risk. The purpose of self-monitoring is to identify illness early and self-quarantine at home to reduce the potential of transmission to patients and co-workers?. ?What should an Executive Director do if an employee reports illness such as cough, subjective fever, headache, fevers? The Executive Director should advise the employee to STAY HOME and contact their physician. If the physician orders a COVID-19 test, the employee may not report to work until the results of the test are submitted to the Executive Director and results are negative.? Although staff 1 reported a headache beginning on 12/06/2020, staff 1 continued to work in the facility until 12/10/2020 at 3:00PM. Document ?Positive Staff w/ Updates:? provided by staff 1 on 01/04/2021, includes the following information for staff 1: ?Start of symptoms: 12/6 evening?. Interview with staff 1 revealed the following: the symptom that staff 1 had on 12/06/2020 was a ?headache?; a cheek swab COVID-19 test was performed on staff 1 on 12/06/2020 and the results were inconclusive; a COVID-19 rapid test was performed on staff 1 on 12/10/2020 and the results received that evening were positive for COVID-19.
Plan of Correction:	What: On December 6, 2020, Staff #1 received a cheek swab for a Covid-19 PCR test, to adhere with the requirements of testing in response to Newly Identified SARS-CoV-2-infected HCP after a facility employee tested positive for Covid-19. On this same day, Staff #1 had a mild headache which at the time, she believed to be from not eating. When the results of the test were not received after 4 days and Staff #1 now began with a runny nose, she went to get a rapid test which was administered by a walk-in clinic on 12/10/20. The test was positive for SARs COV-2. Staff #1 then self-quarantined in accordance with CDC guidelines. Originally staff #1 attributed the headache to lack of food intake, however after the positive result on 12/10/20, the headache was thought to be symptom onset. While in the community December 6-10 staff #1 performed no direct resident care, practiced spatial distancing of at least 6 feet and maintained source control by wearing a mask at all times and a face shield when in resident areas. How: To reduce the risk of recurrence, the facility will implement the following changes: 1. The facility is now using a different COVID-19 testing laboratory who can provide a faster turnaround time. 2. The symptom screening questionnaire has been updated to include new onset of headache as a screening symptom which may prohibit staff and visitor entry. 3. Staff will be retrained on the CDC's symptoms associated with Covid-19 (Symptoms of Coronavirus CDC) by 2.15.21 4. Staff will be retrained on the facility's work exclusion policy. By 2.15.21 Ongoing: To maintain compliance, the Executive Director or Designee will: 1. Will receive notification from the kiosk in the event a staff person or visitors answers yes to any of the symptom screening questions or if their body temperature is outside the normal range. 2. The Executive Director and or Designee will pull at least twice weekly reports to ensure staff are signing in and out as required. 3. Any staff found to not sign in and out using the kiosk will be educated, counseled and subject to further disciplinary action. 4. Findings will be reviewed monthly and submitted to the QA committee.
Standard #:	22VAC40-73-100-F
Complaint related:	No
Description:	Based on document review and staff interview, the facility failed to follow recommendations made by the Virginia Department of Health (VDH). EVIDENCE: 1. Interview with Collateral 1, epidemiologist with the VDH, revealed that ?(Staff 1) did express concern near the beginning of their outbreak when we initially made contact about separating roommates of positives. (Staff 1) was reluctant because (staff 1) said (staff 1) would have to move the resident?s belongings as well. On 12/10, I made the recommendation to separate the positives from the negatives and, to the extent possible, put like with like (pos/pos, neg/neg) if space was a concern. I did not have any additional notes after 12/10 about there being a problem with housing.? 2. Resident roster for the memory care building, provided by staff 1 on 01/19/2021, included the following: Residents 1 and 2 are roommates; Residents 3 and 4 are roommates; and Residents 5 and 6 are roommates. Document ?Positive Residents with Updates:? provided by staff 1 on 01/04/2021, showed that on 12/17/2020, residents 1, 3, and 5 tested positive for COVID-19, and residents 2, 4, and 6 tested negative for COVID-19; however, the facility did not separate residents testing positive from residents testing negative, as recommended by VDH. Documentation provided by staff 1 showed that space was available to separate these roommates. The facility could have moved residents 1, 3, and 5 into available semi-private rooms on 12/17/2020 that were only being occupied by one resident who had tested positive for COVID-19. Document ?Positive Residents with Updates:? provided by staff 1 on 01/04/2021, showed that on 12/19/2020 resident 4 tested positive for COVID-19 and on 12/24/2020 residents 2 and 6 tested positive for COVID-19.
Plan of Correction:	What: Resident's #3 and #4 are married. On 12/17/20, resident #3's results came back positive, and #4's result came back inconclusive, the facility was notified and did not want the couple separated. Due to the inconclusive results, Resident #4 was retested the same day the inconclusive results were received (12/17) and on 12/19/20 the re-test was positive. The facility did not have a vacant room to create a new warm cohort for Residents #2 and #6 who were considered exposed; therefore, the facility decided the safest decision for all residents in the unit was to maintain these residents in their current apartment. All positive cases were reported to the VDH epidemiologist as required. Residents #2, #4 and #6 remained asymptomatic and met the CDC criteria for discontinuation of Transmission-Based Precautions. There are currently no residents in the SCU on precautions. How: The facility's Executive Director (ED) will ensure that communication between the facility and the epidemiologist is clearly understood. The ED will use the facility communication log to document the date of contact and the guidance provided by the VDH epidemiologist. The ED will also note the day and time of any contacts awaiting a response from the VDH epidemiologist. If the Executive Director is unable to adhere with the recommendation, the VDH epidemiologist will be contacted for further recommendations. Ongoing: The Executive Director will review the log at least weekly and verify recommendations are consistently implemented. Outcomes related to surveillance, prevention, and control of disease and infection will be evaluated by the QA committee.