VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bentley Commons at Lynchburg
1604 Graves Mill Road
Lynchburg, VA 24502
(434) 316-0207

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: Jan. 25, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES

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 1/25/2021 and concluded on 3/30/2021. 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. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. ~

Violations:

Standard #:	22VAC40-73-100-F
Complaint related:	Yes
Description:	Based on interviews with staff and collateral witnesses, the facility failed to follow recommendations made by the Virginia Department of Health to prevent or control transmission of an infectious agent in the facility. EVIDENCE: 1. In discussion with collateral witness 1 on 1/28/2021, it was expressed that recommendations to fit test employees for N95 masks and to use those regularly instead of KN95 were given to the facility on 10/11/2020 by the local Virginia Department of Health. As of 1/26/2021, the day of the virtual inspection, it was expressed by staff person 6 that only 4 employees have been fit tested for N95 mask use. Staff person 7 expressed during the virtual inspection that a train the trainer class was scheduled with 2 employees so N95 mask fit testing can be completed for all required employees.
Plan of Correction:	As of March 11, 2021 all staff eligible to be fit tested had been properly fit tested and provided with N95 masks. Going forward, as recommended by local epidemiologist, all new employees will be fit tested within 14 days of start date if there is no active COVID cases within facility. If there are active COVID cases within facility new employees will be fit tested and provided N95 masks before start date. Any employee deemed ineligible for fit tested due to any reason will not work with any residents that have tested positive for COVID. Employee will also be required to wear both surgical mask and face shield, gloves, gowns and any other PPE required and provided. Any employee that has been or will be deemed ineligible for fit testing will be reported to LI and to local epidemiologist for further instructions.
Standard #:	22VAC40-73-40-A
Complaint related:	Yes
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 through 5 were reviewed on 2/4/2021 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. An interview conducted with staff person 6 expressed that they were unable to verify that this training had been conducted with facility staff.
Plan of Correction:	Administrator has received all training materials required. All staff will receive necessary as required training no later than May 8, 2021. Going forward, all new employees will receive required training within 14 days of start date. All staff will be documented as receiving training and certification of completion will be provided to employee and will also be stored with employee file.