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, 2021 , May 21, 2021 , June 7, 2021 and June 8, 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 5/20/2021 and concluded on 6/8/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 22. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed three (3) resident records, three (3) staff records, staff schedules, fire drill records, background check review on new staff, health care oversight report, medication management policy, and infection control policy 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 #:	22VAC40-73-100-A
Description:	Based on document review, the facility failed to ensure that their infection control policy was consistent with federal Centers for Disease Control and Prevention (CDC) guidelines. EVIDENCE: 1. The facility's infection control policy lacks CDC recommendations for COVID-19.
Plan of Correction:	The Covid-19 Policy has been added as an addendum to the infection control policy to meet CDC recommendations.
Standard #:	22VAC40-73-100-C-1
Description:	Based on document review, the facility failed to address a required section of the infection control policy. EVIDENCE: 1. Section 100-C-1-a requires procedures for the implementation of infection prevention measures by staff and volunteers to include the use of standard precautions. The facility's infection control plan does not describe what the standard precautions are.
Plan of Correction:	The infection control policy does describe standard precautions. It discusses hand hygiene, use of PP equip, gloves, mask, garbage bags, cough etiquette, sharps safety, which are all examples of standard precautions. The policy is written to follow by number & letter standards for 22VAC 10-73-(2)100-C-1. This policy was accepted in its entirety a year ago when the facility became an LLC & the standard has not changed in the last year.
Standard #:	22VAC40-73-200-C
Description:	Based on staff record review, the facility failed to have a new direct care staff person qualified within two months of employment. EVIDENCE: 1. Staff 1 was hired on 02/01/2021 and began work on 02/05/2021. As of 04/21/2021, when she stopped working, staff 1 had not completed training requirements to provide direct care to residents. The facility identified staff 1 as providing direct care.
Plan of Correction:	Staff was in the process of completing DCS training & was involved in an accident & is no longer employed by the facility.
Standard #:	22VAC40-73-250-C
Description:	Based on staff record review, the facility failed to have a required document in a staff file. EVIDENCE: 1. Staff 1 began work on 2/5/2021 and the criminal history record check was not obtained within 30 days of starting work. It is dated 03/11/2021.
Plan of Correction:	The criminal history form was sent on 2/10/21 w/n 5 days of employment & was not returned until 3/17/ Our facility cannot control the efficiency of VA State Police & pandemic.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to have comprehensive individualized service plans ISP) address some known resident needs. EVIDENCE: 1. The ISP dated 02/06/2021 for resident 1 does not address the need for assistance with medication administration, which was identified on the uniform assessment instrument (UAI) dated 02/06/2021. The accuracy of the need was confirmed on a telephone interview with staff 1 on 05/20/2021 at 4:23 PM. 2. The ISP dated 03/28/2021 for resident 3 does not address the need for assistance with medication administration, which was identified on the uniform assessment instrument (UAI) dated 03/28/2021. The accuracy of the need was confirmed on a telephone interview with staff 1 on 05/20/2021 at 4:23 PM. The UAI dated 03/28/2021 shows resident 3 is disoriented to place and time, and this need is not addressed on the ISP dated 03/28/2021. The accuracy of the need was confirmed on a telephone interview with staff 1 on 05/20/2021 at 4:23 PM.
Plan of Correction:	This information has been added to the ISP as of 6/9/21. This information has been added to the ISP as of 6/9/21.
Standard #:	22VAC40-73-620-B
Description:	Based on document review, the facility failed to obtain a dietitian report that had a required element. EVIDENCE: 1. The Assisted Living Registered Dietitian Report dated 09/11/2019 lacks an evaluation of the adequacy of residents' special diets. The residents are not named, and the special diets are not identified.
Plan of Correction:	The special diets were named & identified however the facility just sent the top sheet showing when the Reg. Dietician did the evaluation. Sheets attached.
Standard #:	22VAC40-73-640-A
Description:	Based on document review, the facility's medication management plan failed to address a requirement. EVIDENCE: 1. 640-A-13 requires that the medication management plan address the person responsible for routinely communicating issues or observations related to medication administration to the prescriber. The facility's plan identifies multiple people, but does not state who (or what job title) is responsible for this task.
Plan of Correction:	The Administrator is responsible for communicating with Wellness Concepts.
Standard #:	22VAC40-73-650-A
Description:	Based on resident record review, the facility failed to ensure that there were valid prescriber orders for medications to be administered. EVIDENCE: 1. The May 2021 medication administration record (MAR) for resident 2 shows the following medications are being administered: metronidazole, sertraline, oxycodone (scheduled), hyoscyamine, and oxycodone (as needed). The record for resident 2 does not have valid orders for these medications.
Plan of Correction:	Wellness Concepts sent us valid orders for all of these medications.
Standard #:	22VAC40-73-650-E
Description:	Based on resident record review, the facility failed to have a signed prescribers order for a medication administered to a resident. EVIDENCE: 1. The order for Nystatin cream for resident 1 has not been signed. The Telephone Prescription Order Form dated 09/10/2020 called in to the pharmacy has not been signed by the prescriber. 2. The order to discontinue Ferrous Sulfate for resident 3 has not been signed. The Telephone Prescription Order form dated 09/03/2020 called in to the pharmacy has not been signed by the prescriber.
Plan of Correction:	Wellness Concepts sent signed orders for the discontinuation of meds.
Standard #:	22VAC40-73-650-F
Description:	Based on resident record review, the facility failed to obtain new orders for medications listed on the hospital discharge summary. EVIDENCE: 1. The hospital discharge summary for resident 2, dated 04/01/2021 shows the following medications should be given: docusate sodium, echinacea, gabapentin, lactobacillus rhamnosus, lysine, mupirocin, naproxen sodium, neomycin-bacitracin-polymyxin ointment, and Vitamin D-3. These medications are not on the medication administration record for May 2021, and there are no orders to discontinue these medications.
Plan of Correction:	Wellness Concepts sent valid orders for these meds they were not discontinued..
Standard #:	22VAC40-73-680-D
Description:	Based on review of resident records, the facility failed to administer medication in accordance with the prescriber's instructions. EVIDENCE: 1. The signed order for resident 1 is for Pericolace 8.6-50 mg two tabs qhs (qhs means daily at bedtime). The medication administration record (MAR) shows this is being administered at 7 AM. 2. The hospital discharge orders dated 04/01/2021 for resident 2 show that gabapentin 100 mg should be given one capsule by mouth each night at bedtime as needed. The May 2021 MAR for resident 2 shows that two 100 mg capsules are being administered three times a day.
Plan of Correction:	Wellness Concepts corrected administration time for Pericolace. Wellness Concepts has sent order for Gabapentin that match May 2021 MAR.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to ensure that some required information was recorded on medication administration records (MAR). EVIDENCE: 1. The May 2021 MAR for resident 3 was lacking diagnoses or specific indications for administering Vitamin D2 and Vitamin D3. 2. The May 2021 MAR for resident 1 was lacking diagnoses or specific conditions for administering Vitamin B-12, Vitamin D2, Xanax, aspirin, fenofibrate, lisinopril, Myrbetriq, and rosuvastatin.
Plan of Correction:	Wellness Concepts corrected the MAR to show diagnosis.
Standard #:	22VAC40-73-690-B
Description:	Based on resident record review, the facility failed to have a licensed health care professional, practicing within the scope of his profession, perform a review every six months of all the medications of the resident. EVIDENCE: 1. The Consultant Pharmacist's Medication Regimen Review shows that resident 2 was not included in the review dated 01/13/2021, and there is no evidence to support that it was done within the past six months.
Plan of Correction:	Wellness Concepts corrected the med review & sent a copy to us.