VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Carriage Hill Retirement
1203 Roundtree Drive
Bedford, VA 24523
(540) 586-5982

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Dec. 23, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-80 COMPLAINT INVESTIGATION.

Technical Assistance:

To ensure the facility had a thorough understanding of standards, the licensing inspector and the acting administrator had a discussion regarding standard 40 A.

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 12/23/2020 and concluded on 02/02/2021. A complaint was received by the department regarding allegations in the area of administration and administrative services in regards to infection control. The executive administrative assistant was contacted by telephone to conduct the investigation. The licensing inspector emailed the executive administrative assistant and the business office manager a list of documentation required to complete the investigation. To ensure that the facility had a thorough understanding of standards, the licensing inspector and the acting administrator had a discussion regarding standard 100 A and 100 F. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. 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:	Yes
Description:	Based on observation during a virtual inspection and, documentation, and interviews, the facility failed to implement their infection control policy. EVIDENCE: 1. ?Infection Control ? VAC 40-73-100 C&D?, the facility?s infection control policy, states on page 1, ?Carriage Hill promotes a safe and healthy environment for residents, staff, and visitors where the acquisition of infection is minimized by adhering to Centers for Disease Control AND OSHA guidelines and precautionary measures.? 2. ?Considerations for Preventing Spread of COVID-19 in Assisted Living Facilities?, published by the CDC on 05/29/2020, includes the following excerpts: ?Everyone in the facility should practice source control. Personnel should wear a facemask (or cloth face covering if facemasks are not available or only source control is required) at all times while they are in the facility? ?Encourage residents to wear a cloth face covering (if tolerated) whenever they are around others, including when they leave their rooms and when they leave the facility.? ?Encourage social (physical) distancing ? instead of communal dining, consider delivering meals to rooms, or staggering mealtimes to accommodate social distancing while dining (e.g., a single person per table).? ?Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic?, published by the CDC on 12/14/2020, showed ?Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19.? 3. During an interview, Collateral 1 reported that she had been informed by multiple staff at the facility that no one (staff) wears masks in the facility because no one in the facility has COVID-19. Collateral 1 also reported that she observed the executive director, the nurses and staff not wearing masks. 4. Interview conducted on 12/28/2020 with staff 3 indicated ?wearing masks was just made mandatory last week due to a complaint? and ?no one was wearing masks prior to one week ago.? 5. Interview conducted on 12/28/2020 with staff 4 indicated ?wearing masks was just enforced in the last week.? And ?no one had been wearing masks until then.? 6. Interviews with staff 3 and 4 revealed that the facility did not have enough masks to provide to staff prior to masks being made mandatory but the facility has a good supply presently. 7. During virtual inspection on 12/23/2020, staff 5 was observed in the memory care building conducting an activity with residents and was not wearing a mask. Interview with staff 1 and 2 revealed that staff 5 does not wear a mask due to asthma. Interview with staff 6 also revealed that staff 5 does not wear a mask due to asthma but administrative staff is working on a solution to this issue. 8. During a virtual inspection conducted by another LI on 12/30/2020, 10 to 15 residents were noted to be sitting at several tables in the dining room near the kitchen door. Some of the tables had 2 to 3 residents each and several residents were noted without masks and were not socially distanced. Lunch had not yet been served.
Plan of Correction:	Plan of correction: 1. Staff were individually contacted and communicated with about the importance of maintaining infection control, including appropriate mask wearing procedures. Tables were added in the dining room to ensure social distancing. Staff was educated by our Resident Care Coordinator on the importance of proper mask wearing, and all PPE, and the risks associated with non-compliance related to this. It is our internal policy that all staff (medically appropriate) wear appropriate PPE while at work. 2. Notices have been posted on the entrances to our buildings advising staff of appropriate PPE guidelines for entering the community. Our break rooms have been set up to accommodate appropriate social distancing. We have ample available PPE for all staff and residents which they can request at any time. 3. Management staff have been educated and tasked to ensure they are watching staff to ensure they are consistently wearing appropriate PPE.