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: Dec. 29, 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

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 12/29/2020 and concluded on 2/23/2021. A complaint was received by the department regarding allegations in the areas of infection control. 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 and a virtual inspection was conducted on 12/29/2020. The evidence gathered during the investigation supported the allegations 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 #:	22VAC40-73-1080-A
Complaint related:	No
Description:	Based on facility documentation and interviews with staff, the facility failed to ensure that all residents placed in a safe secure unit had a serious cognitive impairment due to a primary psychiatric diagnosis of dementia and be unable to recognize danger or protect his own safety and welfare. EVIDENCE: 1. During a virtual inspection conducted on 12/29/2020 it was expressed by staff person 9 that residents 1 through 8 had tested negative for coronavirus and were all currently residing in the facility designated cold unit located on the back hallway of the facility's safe, secure unit. Six of these residents had been moved to the cold unit located in the safe secure unit on 12/22/20 from the facility's Assisted Living hall and did not have proper assessments to determine that they had a serious cognitive impairment due to a primary psychiatric diagnosis of dementia and were unable to recognize danger or protect his own safety and welfare prior to placement in the safe, secure unit. 2. An interview conducted on 1/8/21 with collateral witness 1 expressed that they had not discussed nor made any recommendations to the facility in regards to a facility designated cold unit and expressed concerns to the appropriateness of the set up of the cold unit as it did not have a separate entrance/exit to the unit where anyone coming or going did not have to enter through any other parts of the facility where positive covid-19 cases were present.
Plan of Correction:	All issues have been corrected. Negative tested residents were transferred back to their appropriate rooms. In the event of a reoccuring crisis, the ED and/or designee will confer with the DSS Licensing Inspector and the local Health Department for guidance when options are limited.
Standard #:	22VAC40-73-100-A
Complaint related:	No
Description:	Based on a review of the facility infection control policy, review of staff schedules and interviews, the facility failed to implement their infection control policy in regards to staff who have tested positive for Covid-19. EVIDENCE: 1. The facility infection control policy has documentation under section 21-Coronavirus on page 46 to exclude staff with a coronavirus diagnosis from work for 10 days and at least 24 hours after they are no longer symptomatic and no longer have a fever (off fever reducing medications). 2. During a virtual inspection conducted on 12/29/2020, staff person 4, who tested positive for coronavirus on 12/22/20, was observed working in the facility kitchen that prepares food for all residents who reside in the facility, including residents who are currently negative for coronavirus. 3. The facility employee schedule has documentation of staff person 1, who tested positive for coronavirus on 12/14/20, working in the facility on 12/15/20; staff persons 2 and 3, who both tested positive for coronavirus on 12/16/20, working in the facility on 12/17/20; staff persons 6 and 8, who both tested positive for coronavirus on 12/22/20, working in the facility on 12/23/20; staff person 7, who tested positive for coronavirus on 12/22/20, working in the facility on 12/25/20 and staff person 5, who tested positive for coronavirus on 12/10/20, working in the facility on 12/14/20 and 12/15/20 and again tested positive on 12/22/20, working in the facility on 12/23/20. 4. An interview conducted with staff person 9 on 12/29/20 expressed that the facility was allowing staff who had tested positive for coronavirus to continue to work in the facility during the 10 day exclusion period as long as they were asymptomatic and only worked in areas where residents who were also positive were residing. It was observed that the facility infection control policy did not contain any procedures for positive employees working during this time period. 5. An interview conducted on 1/8/21 with collateral witness 1 expressed that they had not discussed nor made any recommendations to the facility in regards to positive staff continuing to work within the facility during their 10 day exclusion from work period.
Plan of Correction:	All issues have been corrected and all employees are COVID free at this time. The ED and/or designee will monitor and make adjustments to the Infection Control policy and ensure it is carried out as detailed in the policy. All communication with the epidemiologist and/or the local Health Department will be documented as proof of guidance during crisis.
Standard #:	22VAC40-73-40-A
Complaint related:	No
Description:	Based on a review of staff records and facility documentation, the licensee failed to ensure compliance with relevant state law, with other relevant regulations and the facility's own policies and procedures. EVIDENCE: 1. On 7/31/2020 the Division of Licensing Programs (DOLP) sent a letter to all ALF's informing them of the emergency temporary standard (ETS) effective 7/24/2020 from the Virginia Department of Labor and Industry (VDOLI). 2. The records for staff persons 1, 4, 5, 10 and 11 were reviewed on 2/3/2021 and did not contain documentation of written certifications required under code section 16VAC25-220- Emergency Temporary Standard Infectious Prevention: SARS-CoV-2 Virus that Causes COVID-19.
Plan of Correction:	Response to the cited deficiencies do not constitute an admission or agreement by the facility of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies or Corrective Action Report; the Plan of Correction is prepared solely as a matter of compliance with State law. Staff will receive written certification required under code section 16VAC25-220. The ED and/or designee will ensure all staff are trained regarding Safety Precautions to reduce the spread of COVID 19 in conjunction with the COVID training and in-services already in place at the facility.