VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Runk & Pratt of Forest
208 Gristmill Drive
Forest, VA 24551
(434) 385-0297

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Jan. 21, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-80 COMPLAINT INVESTIGATION.

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 01/21/2021 and concluded on 02/25/2021. A complaint was received by the department regarding allegations in the areas of personnel and resident care and related 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 one of the allegations 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 #:	22VAC40-73-1130-A
Complaint related:	No
Description:	Based on document review, the facility failed to ensure that, except during night hours, when 20 or fewer residents are present, at least two direct care staff members are awake and on duty at all times in each special care unit (SCU) who are responsible for the care and supervision of the resident and for every additional 10 residents, or portion thereof, at least one more direct care staff member shall be awake and on duty in the unit. EVIDENCE: 1. Document, ?Census Report by Head Count For the Month of: 2021-01?, showed the facility?s census count as follows: 62 on 01/12, 01/14 and 01/15/2021; 61 on 01/13, 01/16, and 01/17/2021; 60 on 01/18/2021; and 59 on 01/19/2021. Based on the census, there should have been 7 direct care staff on duty at all times during the day hours on 01/12 ? 01/18/2021, and 6 direct care staff on duty at all times during the day hours on 01/19/2021. Interview with staff 10 revealed that the day hours for the facility are 7AM ? 3PM. 2. Timesheets for facility staff for the time period 01/10/2021 ? 01/24/2021 showed that on 01/14/2021 there were only 6 direct care staff on duty; however staff 12 did not start work until 11:29AM and staff 14 did not start work until 10:00AM meaning that during day shift on 01/14/2021 there were at times less than 6 direct care staff on duty at all times. 3. Timesheets for facility staff for the time period 01/10/2021 ? 01/24/2021 showed that on 01/15/2021 there were only 6 direct care staff on duty; however staff 16 did not start work until 1:05PM and staff 13 only worked from 7:06AM until 10:54AM meaning that during day shift on 01/15/2021 there were at times less than 6 direct care staff on duty at all times. 4. Timesheets for facility staff for the time period 01/10/2021 ? 01/24/2021 showed that on 01/16/2021 and 01/18/2021 there were only 6 direct care staff on duty at all times. 5. Timesheets for facility staff for the time period 01/10/2021 ? 01/24/2021 showed that on 01/19/2021 there were 7 direct care staff that worked; however, staff 12 did not start work until 11:36AM and staff 14 did not start work until 11:05 AM meaning that during day shift on 01/19/2021 there were at times less than 7 direct care staff on duty.
Plan of Correction:	Administrator or Designee will ensure staffing is appropriate for numbers of residents residing in facility.
Standard #:	22VAC40-73-1130-C
Complaint related:	No
Description:	Based on document review, the facility failed to ensure during night hours that when more than 40 residents are present, at least four direct care staff members plus at least one more direct care staff member for every additional 10 residents, or portion thereof, shall be awake and on duty at all times in each special care unit and shall be responsible for the care and supervision of the residents. EVIDENCE: 1. Document, ?Census Report by Head Count For the Month of: 2021-01?, showed the facility?s census as follows: 62 on 01/12, 01/14 and 01/15/2021; 61 on 01/13, 01/16 and 01/17/2021; 60 on 01/18/2021; and 59 on 01/19/2021. Based on the census, there should have been 7 direct care staff on duty at all times during the night hours on 01/12-01/18/2021, and 6 direct care staff on duty at all times during the night hours on 01/18/2021 and 01/19/2021. Interview with staff 10 revealed that the night hours for the facility are 11PM ? 7AM. 2. Timesheets for facility staff for the time period 01/10/2021 ? 01/24/2021 showed that only three direct care staff worked on the 11PM ? 7AM shift beginning at 11PM on the following dates: 01/15/2021 and 01/16/2021; only four direct care staff worked on the 11PM-7AM shift beginning at 11 PM on the following dates: 01/12/2021, 01/14/2021 and 01/19/2021; and only five direct care staff worked on the 11PM- 7AM shift beginning at 11PM on the following dates: 01/13/2021 and 01/18/2021. 3. Timesheets for facility staff for 01/17/2021 showed that four direct care staff worked during the 11PM ? 7AM shift; however the timesheet for staff 9 showed that staff 9 started work on 01/17/2021 at 11:56 PM and stopped work on 01/18/2021 at 2:27 AM meaning that only three direct care staff worked the full shift.
Plan of Correction:	Administrator or Designee will ensure staffing is appropriate for number of residents in facility.
Standard #:	22VAC40-73-290-A
Complaint related:	Yes
Description:	Based on document review and staff interview, the facility failed to maintain a written work schedule that included the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time, and noted any absences, substitutions, or other changes. EVIDENCE: 1. Interview with staff 10 revealed that the excel spreadsheet schedule provided to licensing representative during the complaint investigation is the document that the facility refers to when looking to see who is scheduled to work. 2. The facility?s schedule for 01/12/2021 through 01/19/2021 showed the following: Staff 4 worked on 01/13/2021, Staff 3 and 4 worked on 01/14/2021 and 01/15/2021, Staff 9 worked on 01/16/2021, Staff 5 worked on 01/18/2021 and Staff 6 and 8 worked on 01/19/2021. However, timesheets for the pay period 01/10/2021 ? 01/24/2021, for staff 3, 4, 5, 6, 8 and 9 showed that these staff did not work on these dates. 3. The facility?s schedule for 01/12/2021 through 01/19/2021 showed that staff 7 did not work on 01/16/2021 and 01/17/2021. However, timesheets for the pay period 01/10/2021 ? 01/24/2021 for staff 7 showed that staff 7 worked on 01/16/2021 and 01/17/2021. 4. The facility?s schedule for 01/12/2021 through 01/19/2021 does not indicate which direct care staff is in charge during the following shifts; day shift: 01/13/2021, 01/18-19/2021; evening shift: 01/13/2021 and 01/18/2021; and night shift: 01/13/2021 and 01/16-18/2021.
Plan of Correction:	Administrator or Designee will ensure staffing work written schedule shall include person(s) in charge and shall include the name and job classifications of all staff.
Standard #:	22VAC40-73-650-A
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure or treatment was not stopped or changed with a valid order from a physician. EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 12/04/2020, for ?Daily temps + O2 sats *Notify Nursing if Temp >99F and if O2 sats are <91% for monitoring?. 2. The January 2021 medication administration record (MAR) for resident 1 showed that this physician?s order had an end date of 01/08/2021 and staff stopped initialing for this order after 01/08/2021; however, there was no physician order to discontinue this. 3. The January 2021 MAR for resident 1 showed the following was started for resident 1 on 01/09/2021: ?VITALS: TEMP AND OXYGEN SAT. (VITALS: TEMP AND OXYGEN SAT.) CHECK AND RECORD TEMPERATURE AND OXYGEN SATURATION EVERY 4 HOURS 7AM ? 11 PM FOR MONITORING?; however, there was no physician?s order to do so.
Plan of Correction:	Administrator DON/Designee will ensure a discontinue order is written and is in effect before a new order starts.
Standard #:	22VAC40-73-700-1
Complaint related:	No
Description:	Based on resident record, the facility failed to ensure 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 01/18/2021, that showed ? O2 @ 2LPM NC Continuosly for comfort. If pt removes may leave off.? The order does not contain the oxygen source.
Plan of Correction:	Day of inspection all oxygen orders changed to reflect the source.
Standard #:	22VAC40-73-700-5
Complaint related:	Yes
Description:	Based on document and staff record review, the facility failed to ensure that all direct care staff responsible for assisting residents who use oxygen supplies have had training or instruction in the use and maintenance of resident-specific equipment. EVIDENCE: 1. The record for resident 1 contained a physician?s order for oxygen, dated 01/18/2021. 2. The document ?Runk & Pratt Pearls of Life Resident Daily Staffing Assignments? shows that on 01/18/2021, staff 1 was assigned to work the third shift on hall were resident 1 resided. 3. The police report, dated 01/19/2021, showed that ?(Staff 2) located (resident 1) care giver for the evening, (staff 1).? and noted ?(Collateral 1) asked (Staff 1) if she looked at the oxygen tank when she went in to check on (resident 1). (Staff 1) stated she checked to make sure the hoses were attached, but the she was not familiar with how to read an oxygen tank and wouldn?t know what she was looked for.? 4. The record for staff 1 does not contain documentation of training or instruction in the use and maintenance of resident-specific equipment in regards to oxygen.
Plan of Correction:	Mandatory in-service for all direct care staff scheduled for March 15, 2021 by Seven Hills Hospice on training and instruction in the use and maintenance of resident specific equipment/oxygen.