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 20, 2020

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 monitoring inspection was initiated on 5/18/2020 and concluded on 5/20/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 25. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, health care oversight, fire inspection report, Health Department inspection report, Fire and Emergency drill logs, staff schedules, and the dietitian oversight report were reviewed, submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-290-A
Description:	Based on document review, the facility failed to note which staff person in charge on the written schedule. EVIDENCE: 1. The staff schedule for May 8 through May 21 showed that staff 5 was scheduled to be in charge on second shift on May 8 through 11, but also that staff 5 called out on May 8 through 11. The schedule did not show who was in charge instead.
Plan of Correction:	The Administrator was on the schedule from 5/8 - 5/11/20 and was in charge during staff 5's absence.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review and interview, the facility failed to ensure that a uniform assessment instrument (UAI) for a resident was completed in accordance with Assessment in Assisted Living Facilities (22VAC30-110). EVIDENCE: 1. The UAI for resident 3 dated 10/26/2019 showed this resident needs physical assistance with stair climbing. The individualized service plan (ISP) and interview with staff 4 revealed the resident needs mechanical and physical assistance.
Plan of Correction:	THe UAI for resident 3 was corrected to show mechanical assistance needed for stair climbing as well as the physical assistance.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to address assessed needs on comprehensive individualized service plans (ISP). EVIDENCE: 1. The UAI for resident 1 dated 2/6/2020 showed this resident needs help with taking medication. Resident 1 was admitted on 2/6/2020 and the comprehensive ISP dated 2/6/2020 does not address the need to have medications administered by lay people (RMAs).
Plan of Correction:	The ISP for resident 1 was updated to match the UAI showing the medication is administered by lay people (RMA's).
Standard #:	22VAC40-73-450-D
Description:	Based on resident record review, the facility failed to show what services are provided by hospice on a resident's individualized service plan (ISP). EVIDENCE: 1. The ISP for resident 3 dated 10/26/2019 showed this resident gets hospice services beginning 4/30/2020. The services are not specific. The description of services to be provided is, " Hospice will help out" without stating what needs they are helping with.
Plan of Correction:	The ISP for resident 3 has been updated to show the specific services that Hospice is providing.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to update individualized service plans (ISP) with assessed needs. EVIDENCE: 1. The UAI for resident 2 dated 8/3/2019 showed this resident needs help with taking medication. The ISP dated 8/3/2019 did not address the need to have medications administered by lay people (RMAs). 2. The UAI for resident 3 dated 10/26/2019 showed this resident needs help with taking medication. The ISP dated 10/26/2019 did not address the need to have medications administered by lay people (RMAs).
Plan of Correction:	The ISP for residents 2 and 3 was updated to match the UAI showing the medication is administered by lay people (RMA's).
Standard #:	22VAC40-73-550-G
Description:	Based on staff record review, the facility failed to have evidence that a staff person had an annual review of Resident Rights and Responsibilities. EVIDENCE: 1. The file for staff 1, hired 2/13/1997, had no documentation to support that an annual review of Resident Rights and Responsibilities had been done.
Plan of Correction:	The annual review sign-in sheet is being provided which shows every employee attended a Policy & Procedure review which includes a review of Resident Rights for 2020.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to administer medication in accordance with the physician's or other prescriber's instructions. EVIDENCE: 1. The hospital discharge orders dated 4/30/2020 for resident 3 showed that the resident should no longer be taking carvedilol 6.25 mg, and the May 2020 medication administration record (MAR) showed it was administered on May 1 through 19, 2020. The hospital discharge orders dated 4/30/2020 for resident 3 showed that the resident should no longer be taking robafen (Robitussin or guaifenesin) and it showed up on the May 2020 MAR as to be given as needed. The hospital discharge orders dated 4/30/2020 for resident 3 showed that the resident should be taking Xarelto 20 mg tablet, take 15 mg daily. The order doesn't match itself. The May 2020 MAR showed the resident is given 15 mg daily. The hospital discharge orders dated 4/30/2020 for resident 3 showed that the resident should be taking glucagon 1 mg IM as needed (Unconscious patient with glucose 60 mg/dl or lower). This medication was not on the medication administration record (MAY) for May 2020. The hospital discharge orders dated 4/30/2020 for resident 3 showed that the resident should be taking melatonin 3 mg, and it did not appear on the May 2020 MAR. The hospital discharge orders dated 4/30/2020 for resident 3 showed the resident should be taking furosimide 20 mg once a day. The May 2020 MAR showed the resident was administered 40 mg once a day. The hospital discharge orders dated 4/30/2020 for resident 3 showed that the resident should be taking glucosamine 1500 complex and the May 2020 MAR showed that the dose is a lower dose, 1350.
Plan of Correction:	The Administrator made the proper medication changes in the medication cart for resident 3 & gave the information in her verbal report when there was a shift change. In error she failed to write discontinued over the medications in the MAR & to write in the new meds along with MG adjustments on two of the meds. All of these orders have been corrected on the MAR.
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to have an order for oxygen for a resident who uses oxygen. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 3 dated 10/26/2019 and other facility documents showed this resident uses oxygen. The oxygen order was not in the hospital discharge orders dated 4/30/2020.
Plan of Correction:	The hospital discontinued the Oxygen order. The resident was place on Hospice care the same day & their protocol requires an oxygenator [sic] be kept at the facility for the resident.