VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Fork Mountain Adult Home
2925 Fork Mountain Road
Rocky mount, VA 24151
(540) 483-8800

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: May 21, 2019

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 SANCTIONS.

Technical Assistance:

The facility received technical assistance on the following topics: 1) 290A - written work schedule that includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time; 2) 400 - monthly itemized statement to residents or legal representatives; 3) 550G - rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative; & 4) 950C - semi-annual review on the emergency preparedness and response plan for all staff & residents

Comments:

The renewal inspection resulted in 9 violations. At 9:33 am, the inspection commenced and concluded at 3:00 pm. The facility's census was 23 residents. During the inspection the following was reviewed: physical plant walk through; 12 residents and 3 staff records' review; medication pass observation; and interviews. After completing the inspection, the facility and LIs discussed the violations, possible corrective actions and had an open discussion. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain the following: 1) steps to correct the noncompliance with the standard(s); 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on resident record review and staff interview, the facility failed to ensure the physical contained all the required components. Evidence: 1. Resident 4's 10/26/18 physical examination report did not include the allergic reaction to the following substances: a) compasine; b) requip; c) demerol; and d) sulfa. Staff 2 confirmed the facility did not seek clarification from the physician regarding the resident's allergic reactions. 2. Resident 6's 9/12/18 physical examination report did not include the allergic reaction to penicillins. Staff 2 confirmed the facility did not seek clarification from the physician regarding the resident's allergic reaction.
Plan of Correction:	As of 5/29/19 all new residents physical exams will be required to have reaction to meds listed.
Standard #:	22VAC40-73-320-B
Description:	Based on resident record review and staff interview, the facility failed to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. Resident 3 was admitted on 11/24/17. There was no annual TB screening in the record. Staff 2 was unable to locate a subsequent evaluation report. 2. Per Dept. of Health Professions ? 54.1-3408. Professional use by practitioners, the facility did not comply this requirement. Staff 2 confirmed the facility does not have internal procedures to satisfy this requirement thereby making the facility non compliant. The LPN completing the TB screenings for residents 2, 4, and 6 were done outside of the Dept. of Health Professions regulations.
Plan of Correction:	The TB screening for resident #3 was an oversight by the facility and will be monitored by the administrator. Resident #2 had a TB screening on 3/18/19 and is being included w/this paperwork. Resident #4 is not due for a TB screening unil 11/21/19 & resident #6 is nut due for an annual screening until 9/18/19.
Standard #:	22VAC40-73-325-A
Description:	Based on resident record review, the facility failed to ensure a written fall risk rating was completed by the time the comprehensive ISP was completed. Evidence: 1. Residents 2, 4 and 5 did not have completed fall risk rating. Staff 2 was not able to be locate them.
Plan of Correction:	All new resident's will have fall risk ratings moving forward & corrections will be made to existing resident files.
Standard #:	22VAC40-73-440-A
Description:	Based on residents' records review and staff interview, the facility failed to ensure the uniform assessment instrument (UAI) in accordance with Assessment in Assisted Living Facilities (22VAC30-110). Evidence: 1. Resident 2's 1/8/19 UAI assessed both no help and requires physical assistance for bathing. 2. Resident 3's 11/2/18 UAI assessed no assistance with dressing and physical assistance with dressing. Staff 2 confirmed the resident requires supervision. In addition, the UAI assessed professional nursing staff is required to administer medication, although, the UAI specifies med tech. Staff 2 confirmed a lay person administers the medication. 3. Resident 4's 1/2/19 UAI assessed professional nursing staff to administer medication. The facility listed med tech to administer the medication, which are not professional nursing staff. For wheeling and stair climbing, the resident was assessed as is not performed. Staff 2 confirmed the resident was assessed incorrectly. For stair climbing, the resident requires physical and mechanical help and no assistance with wheeling. In addition, the UAI assessed no assistance with mobility but the ISP assessed physical assistance. 4. Resident 5's 3/22/19 UAI assessed professional nursing staff to administer medication. The facility listed med tech to administer the medication, which are not professional nursing staff. In addition, stair climbing is assessed as no assistance. Staff 2 confirmed the resident was assessed incorrectly.
Plan of Correction:	Residents 2, 3, 4, & 5 UAI's have been corrected by facility. The dressing needs & med. administration & stair climbing were corrected for each resident.
Standard #:	22VAC40-73-450-C
Description:	Based on residents' record review and staff interview, the facility failed to ensure the comprehensive individualized service plan (ISP) had a written description of what services will be provided to address identified needs. Evidence: 1. Resident 3's 12/24/18 ISP denotes physical assistance with dressing and supervision with dressing. Staff 2 confirmed the resident can dress herself. 2. Resident 4's 1/2/19 UAI assessed assistance with bowel and bladder but the 1/2/19 ISP does not address those activities. 3. Resident 6's 9/18/18 UAI assessed mechanical help with stair climbing and assistance with bladder. The ISP did not address these identified needs. The facility did not identify any services to be provided to address the resident's mod fall risk assessment.
Plan of Correction:	Resident 3, 4, & 6's ISP's have been corrected by the facility. The administrator plans to use the state issued format for ISP's moving forward.
Standard #:	22VAC40-73-640-A
Description:	Based on medication cart audit and staff interview, the facility failed to successfully implement their medication management plan. Evidence: 1. Resident 13 discharged on 5/5/19; however, the medication cart contained resident 13's Lorazepam .5mg tab. Staff 1 confirmed the facility retained the medication weeks after the resident discharged.
Plan of Correction:	The facility contacted Hospice and talked with them about the requirement of timely removal of medications for residents that are on Hospice and pass away. Medication was removed & discarded.
Standard #:	22VAC40-73-650-A
Description:	Based on documentation review, the facility changed medication without a valid order from a physician or other prescriber. Evidence: 1. Resident 4 's Cozzaar 100 mg tablet was discontinued on 4/29/19. The facility administered the medication on 4/30/19, per the April 2019 MAR.
Plan of Correction:	The medication was already removed from the med cart. The signature on 4/30/19 was done in error. Reminded staff to closely check dates before initialing through an in-service.
Standard #:	22VAC40-73-680-G
Description:	Based on medication cart review and staff interview, the facility failed to ensure over-the-counter medication remained in the original container, labeled with the resident's name, or in a pharmacy-issued container, until administered. Evidence: 1. The LI audited the medication cart in staff 1's presence. Equate acetaminophen 500 mg tablets container was in the cart unlabeled. Staff 1 did not know whose medication it was. Staff 1 confirmed the facility maintained resident nonspecific medication in the cart.
Plan of Correction:	No medications will be kept in the med cart without proper labeling.
Standard #:	22VAC40-73-980-A
Description:	Based on physical plant observation and staff interview, the facility failed to ensure a complete first aid kit did not have expiration dates that have already passed, on items contained within the kit. Evidence: 1. The LI and staff 2 reviewed the first aid kit together. It contained hand cleaner, which expired on 8/10/2015. Staff 2 confirmed the first aid kit contained expired items.
Plan of Correction:	A new hand sanitizer was placed in the first aid kit and a new checklist for each month was added to the kit.