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: May 20, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

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 renewal inspection was initiated on 05/19/2021 and concluded on 05/26/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 49. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, recent staff schedule, recent health care oversight, recent health department and fire inspections, dates of the past three fire drills, sworn disclosures and criminal record checks for staff hired and still employed since the last mandated inspection and last dietitian review of special diets submitted by the facility to ensure documentation was complete. To ensure that the facility had a thorough understanding of standards, the licensing inspector and Administrator had a discussion regarding standard 290 A and 450 C. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1020-A
Description:	Based on document review and staff interview, the facility failed to ensure that when residents are present, there are at least two direct care staff members awake and on duty at all times. EVIDENCE: 1. The facility serves a mixed population in the assisted living section based on document review. 2. The facility?s schedule and ?Daily Assignment Sheet? showed that on 05/11/2021 staff 5 was the only staff that worked in the assisted living section of the facility on the 11PM ? 7AM shift. Interview with staff 4 confirmed this was accurate. 3. The facility?s schedule and ?Daily Assignment Sheet? showed that on 05/17/2021 staff 8 was the only staff that worked in the assisted living section of the facility on the 11PM-7AM shift. Interview with staff 4 confirmed this was accurate.
Plan of Correction:	ED has instructed scheduler of regulations, copy issued for review - ED/DRC/MCM review regulation and reinforced requirement of staff for all shifts - DRC/MCM will review daily assignment sheets to ensure staffing is adequate.
Standard #:	22VAC40-73-100-C-2
Description:	Based on document review, the facility failed to include all required procedures for other infection prevention measures related to job duties. EVIDENCE: 1. The facility?s written infection control program does not include procedures for 100-C-2 a, e, f and h.
Plan of Correction:	See attached
Standard #:	22VAC40-73-100-C-4
Description:	Based on document review, the facility failed to have a required section in their infection control program. EVIDENCE: 1. The facility written infection control program did not include product specific instructions for use of cleaning and disinfecting agents (e.g, dilution, contact time, and management of accidental exposures).
Plan of Correction:	See attached
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review and staff interview, the facility failed to complete the Uniform Assessment Instrument (UAI) as required. EVIDENCE: 1. The UAI for resident 1 did not contain the correct name of the resident. Interview with staff 4 confirmed that the UAI provided to the licensing inspector was the UAI for resident 1 and did contain the wrong name.
Plan of Correction:	UAI - Name corrected from (name) to (resident's name)
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure that the Individualized Service Plan (ISP) addressed all of the identified needs. EVIDENCE: 1. The private pay uniform assessment instrument (UAI) for resident 1, dated 05/13/2021, showed the resident needs mechanical and physical help with dressing. Interview with staff 4 revealed this is correct. This identified need is not included on the ISP. Resident 1 has an order for continuous oxygen. The ISP does not include the oxygen source. Interview with staff 4 revealed that the resident uses a concentrator. 2. The private pay UAI for resident 3, dated 09/28/2020, showed the resident is ?abusive/aggressive/disruptive ? less than weekly? and is ?argumentative at times?. The ISP, dated 09/28/2020, showed ?wandering, Passive behaviors (less than weekly) argues at times and refuses care often?. Interview with staff 4 revealed that the UAI is correct, and the ISP is incorrect.
Plan of Correction:	Corrections to ISP done immediately Source of oxygen added to ISP immediately UAI - corrected UAI/ISP matches accurately
Standard #:	22VAC40-73-640-A
Description:	Based on document review, the facility failed to ensure that the medication management policy includes all required components. EVIDENCE: 1. The facility's medication management policy, "The Elms of Lynchburg Medication Management Policy" does not include the facility's standard dosing schedule and that medications will be accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order of change in an order. 2. The record for resident 1 contained a physician order, dated 05/18/2021, for Theratears Solution or equivalent ? Instill 2 drops in each eye every 2 hours PRN if eyes are partially open or dry eyes. The May 2021 medication administration record (MAR) for resident 1 did not include this physician?s order.
Plan of Correction:	See attached RX was faxed 05-18-2021 to pharmacy who profile all orders (via escript) Directly from Hospice, then to send copy to TEOL. DRC will check with RX when order is received and check EMAR to ensure transcription is complete.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to ensure that medications were administered in accordance with physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contained hospital discharge instructions, ?Post-Acute Care Transfer Instructions?, dated 05/13/2021, to discontinue some previous prescribed medications that the resident had been taking at the facility prior to being admitted to the hospital that included Atorvastatin 40 MG, Cholecalciferol (Vitamin D3), Loratadine 10MG and Doxazosin 8MG. 2. The May 2021 medication administration record (MAR) for resident 1 included documentation that Atorvastatin 40MG, Cholecalciferol (Vitamin D3), and Loratadine 10MG were administered to the resident on 05/14-15/2021 and 05/17-20/2021, and Doxazosin 8MG was administered to the resident on 05/14/2021.
Plan of Correction:	(DRC) Director of Resident Care will review all orders of any resident upon returning to community. Fax orders to RX - follow up with RX ensure orders are as outlined in discharge summary and according to prescriber. (DRC) Director of Resident Care will reference EMAR to ensure discontinued orders were removed - if not notify RX to ensure of removal. DRC will update RMA of changes in orders provide education
Standard #:	22VAC40-73-680-E
Description:	Based on resident record review, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber were provided according to his instructions, documented and maintained in the resident?s record. EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 05/13/2021, that stated ?Administer 5 Liters oxygen via nasal canula [sic] continuously for comfort. Call Hospice RN (with) questions.? 2. Interview with staff 4 verified that there is no documentation to show that oxygen therapy was provided for resident 1 according to the physician?s instructions.
Plan of Correction:	Resident returned to community via ambulance - on 5lpm oxygen via NC - Hospice nurse in community to admit to GSH services. Hospice nurse managing care spoke with staff - will be available to staff - call if needed or have any questions - any and all concerns were addressed before nurse left community - no call needed - Hospice nurse and community nurse documented O2 in use at time resident returned to community remained in use until D/C 05-20-21 see attached
Standard #:	22VAC40-73-690-B
Description:	Based on resident record review, the facility failed to ensure that for each resident assessed for assisted living care a licensed health care professional, practicing within the scope of his profession, performed a review every six months of all the medications of the resident. EVIDENCE: 1. The uniform assessment instrument for resident 2, dated 01/08/2021, stated that the resident is assessed as assisted living level of care and needs medications administered/monitored by lay person. 2. The most recent medication review was requested for resident 2 on 05/19/2021 at the beginning of the renewal inspection on the R&M 1 form. During exit interview, 05/26/2021, the last medication review was requested again for the resident and has not been received as of 05/27/2021.
Plan of Correction:	Hand written review was sent - which showed no rec. Will resubmit internal form sent and printed from RX consultant.
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to ensure that a valid physician?s order for oxygen contained all the required components. EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 05/13/2021, that showed ?Administer 5 Liters oxygen via nasal canula [sic] continuously for comfort. Call Hospice RN (with) questions.? The order does not contain the oxygen source.
Plan of Correction:	All current staff educated on what should be included in oxygen orders - Hospice RN/MD has also been informed of regulations must state source that supplies oxygen.
Standard #:	22VAC40-73-970-A
Description:	Based on document review, the facility failed to ensure that fire and emergency evacuation drills were conducted for each shift as required in a quarter. EVIDENCE: 1. The ?Record of Required Fire and Emergency Evacuation Drills? for January 2021 through March 2021 contained no documentation that a fire and emergency evacuation drill had been conducted on the third shift.
Plan of Correction:	Fire/emergency drill completed for 3rd shift
Standard #:	22VAC40-90-30-B
Description:	Based on staff record review, the facility failed to ensure that a sworn statement or affirmation (SD) was completed for all applicants for employment. EVIDENCE: 1. Staff 9, date of hire 10/29/2021, completed the SD after employment on 11/02/2020.
Plan of Correction:	No prospects will be hired until completion of onboarding internal HR (BOM) to ensure all required forms are completed accurately and before final date of hire.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to ensure that a criminal history record report was obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The records for staff 10, date of hire 11/13/2020, and staff 11, date of hire 11/16/2020, contained documentation that a criminal history record report was not received until 12/21/2020 for both staff 10 and 11. 2. The record for staff 12, date of hire 04/07/2021, did not contain documentation that a criminal history record report was obtained for this employee.
Plan of Correction:	All background will be resubmitted by June 3rd - hand delivered to VSP Dept.