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: Nov. 9, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/09/2023 10:40AM through 1:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/30/2023 regarding allegations in the areas of: personnel and additional requirements for facilities that care for adults with serious cognitive impairments. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1130-C
Complaint related:	Yes
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.The Document Census Report by Head Count For the Month of October 2023, showed the facility?s census count as follows: 63 on 10/30/2023 and 11/01/2023; 62 on 10/27/2023, 10/28/2023, and 10/29/2023; 61 on 10/09/2023, 10/11/2023, 10/14/2023, 10/15/2023, 10/16/2023, 10/20/2023, 10/21/2023, 10/24/2023, and 10/26/2023; and 60 on 10/22/2023. 2. Based on the census, there should have been 7 direct care staff on duty at all times during the 11PM-7AM shift hours on 10/09/2023, 10/11/2023, 10/14 ? 10/16/2023, 10/20/2023, 10/21/2023, 10/24/2023, 10/26-30/2023 and 11/01/2023. 3. Timesheets for facility staff for the time period 10/8/2023 ? 11/01/2023 showed that on 10/09/2023, 10/11/2023, 10/15/2023, 10/16/2023, 10/26-30/2023 and 11/01/2023 there were only 6 direct care staff on duty during the 11PM ? 7AM shift and on 10/14/2023, 10/20/2023, 10/21/2023, and 10/24/2023 there were only 5 direct care staff on duty during the 11PM ? 7AM shift.
Plan of Correction:	Facility Administrator or designee will ensure that during the night hours, when more than 40 residents are present, at least 4 direct care members plus at least one more direct care staff for every additional 10 residents.
Standard #:	22VAC40-73-1140-B
Complaint related:	Yes
Description:	Based on staff record review and staff interview, the facility failed to ensure that within four months of the starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairment. EVIDENCE: The records for staff person 12, date of hire 06/01/2023, staff person 15, date of hire 04/19/2023, and staff person 9, date of hire 01/11/2023, did not contain documentation that these staff persons had completed at least 10 hours of training in cognitive impairment within four months of their starting date of employment. Interview with staff person 25 confirmed that this is accurate.
Plan of Correction:	All employees will complete dementia training within the first 4 months of employment.
Standard #:	22VAC40-73-260-A
Complaint related:	Yes
Description:	Based on staff record review and staff interview, the facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment. EVIDENCE: During on-site inspection on 11/09/2023, the record for staff person 15, date of hire 04/19/2023 and first day of work 04/26/2023, and the record for staff person 9, date of hire 01/11/2023 and first day of work 01/23/2023, did not contain documentation that either staff person has current certification in first aid. Interview with staff person 25 confirmed that this is accurate.
Plan of Correction:	A first aid class has been scheduled for the two direct care staff members to obtain their first aid certification.