VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cardinal Senior Communities
1350 Longwood Avenue
Bedford, VA 24523
(540) 586-0825

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: April 22, 2021 and April 26, 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 3/11/2021 and concluded on 4/26/2021. A complaint was received by the department regarding allegations in the areas of administration and administrative 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 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:	No
Description:	Based on document review, the facility's written infection control policy is not consistent with COVID-19 recommendations from the federal Centers for Disease Control and Prevention (CDC) guidelines, and the facility failed to implement their infection control policy. EVIDENCE: 1. On 6/23/2020 the Division of Licensing Programs issued a letter requiring facilities to update their infection control programs in response to COVID-19 to address surveillance, prevention, and control of disease and infection. Revisions to infection control plans must be consistent with Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) bloodborne pathogens regulations. In addition, infection control programs should incorporate recommendations from VDSS and the Virginia Department of Health (VDH). 2. The facility's infection control policy has a COVID-19 section that does not address the use of face masks as needed during the COVID-19 pandemic, returning to work after testing positive for COVID-19, or maintaining distancing during the COVID-19 pandemic. 3. The facility failed to implement part of their infection control policy. The page identified as Policy Covid - 19 at the top of the page and Page 1 - NOROVIRUS, states in section 4, "Keep a written record of suspected cases, noting the date of onset, symptoms, and the date symptom free." The spreadsheet (written record) does not record the symptom free date.
Plan of Correction:	I. The facility has updated infection control plans that are consistent with CDC, VDH, VDSS and OSHA required guidelines. II. The administrator will review these updated infection control plans with all current staff and have the plans incorporated into the new hire orientation to ensure all new hires are informed of this information. III. Administrator and/or designee will review the infection control policy and plans in accordance with 22VAC40-73-100 to ensure ongoing compliance.
Standard #:	22VAC40-73-100-C-2
Complaint related:	No
Description:	Based on document review, the facility failed to include most requirements under "Procedures for other infection prevention measures related to Job Duties" in their infection control policy. EVIDENCE: 1. The facility's written infection control policy is lacking the following sections: 100-C-2-a, b, d, e, f, g, and h.
Plan of Correction:	I. The facility's written infection control policy includes information relative to the following sections: 100-C-2-a, b, d, e, f, g, and h. II. The administrator will review these updated infection control plans with all current staff and have the plans incorporated into the new hire orientation to ensure all new hires are informed of this information. III. Administrator and/or designee will review the infection control policy and plans in accordance with 22VAC40-73-100 to ensure ongoing compliance.
Standard #:	22VAC40-73-100-C-4
Complaint related:	No
Description:	Based on document review, the facility failed to have a required section of their infection control plan. EVIDENCE: 1. The facility's written infection control policy lacked the product specific instructions for use of cleaning and disinfecting agents (e.g., dilution, contact time, and management of accidental exposures).
Plan of Correction:	I. The facility's written infection control policy references the MDS binder which includes product specific instructions for use of cleaning and disinfecting agents. II. The administrator will review these updated infection control plans with all current staff and have the plans incorporated into the new hire orientation to ensure all new hires are informed of this information. III. Administrator and/or designee will review the infection control policy and plans in accordance with 22VAC40-73-100 to ensure ongoing compliance.
Standard #:	22VAC40-73-40-A
Complaint related:	Yes
Description:	Based on staff record review, the facility failed to ensure compliance with relevant state laws. EVIDENCE: 1. On 7/31/2020 the Division of Licensing Programs sent a letter to all assisted living facilities informing them of the Emergency Temporary Standard, 16VAC25-220 effective 7/20/2020. Standard 16VAC25-220 became permanent effective 1/27/2021. 2. The facility did not document the written certification records as required under Section 16VAC25-220-80.C for staff 1 through 3.
Plan of Correction:	I. All staff have written certifications as required by 16VAC25-220-80.C. In addition, the facility had written documentation of review of infection control procedures including updates due to covid-19. II. Administrator and/or designee will audit all current employee records to ensure each contain written certifications as required by 16VAC25-220-80.C. III. Administrator and/or designee will monitor new hire records going forward to ensure ongoing compliance.