VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Runk & Pratt Adult Daytime Center
1208 Perrowville Road
Forest, VA 24551
(434) 237-2268

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

Inspection Date: Nov. 5, 2021 , Nov. 12, 2021 and Nov. 19, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-61 GENERAL PROVISIONS 22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUNDS 22VAC40-61 EMERGENCY PREPAREDNESS 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 SANCTIONS. 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2(19.2) Criminal Procedures. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

A new facility inspection was conducted on 12/5/2021 from 11:45 to 1:15. Four staff records were reviewed and a physical plant tour was done. The facility requested a review of model forms during the inspection and that was done. The policies were reviewed on 11/12/2021 and 11/18/2021 off site, and the facility was offered an opportunity to provide missing required documents. A final exit interview was conducted by telephone on 11/19/2021.

Violations:

Standard #:	22VAC40-61-300-A
Description:	Based on document review, the medication management plan is lacking some required sections. EVIDENCE: 1. The facility's written medication management plan lacks: methods to ensure that authorizations for the administration of medications are current, methods to secure and maintain supplies of each participant's prescription medications and any over-the-counter drugs and supplements in a timely manner to avoid missed dosages.
Plan of Correction:	The Facilities? medication management plan will include methods to ensure that authorizations for the administration of medications are current, methods to secure and maintain supplies of each participant?s prescription medications and any over the counter drugs and supplements in a timely manner to avoid missed dosages.
Standard #:	22VAC40-61-400
Description:	Based on observation, the facility failed to provide an environment that ensured the safety of the participants. EVIDENCE: 1. The raised border around the "grassy" carpet areas rises approximately 1 inch above the adjacent flooring and is a trip hazard.
Plan of Correction:	The Facility is currently reviewing consultations to the border at the ?grassy? area to enhance safety as the facility is not currently open.
Standard #:	22VAC40-61-430-C-1
Description:	Based on observation, the facility failed to be maintained at an inside temperature between 70?F and 84?F. EVIDENCE: 1. The digital thermometer had fluctuating temperatures averaging approximately 57?F.
Plan of Correction:	The facility will maintain a temperature between 70-84 degrees at all times.
Standard #:	22VAC40-61-520-A-1
Description:	Based on document review, the facility failed to have documentation of initial contact with the local emergency coordinator to determine (i) local disaster risks, (ii) community wide plans to address different disasters and emergency situations, and (iii) assistance, if any, that the local emergency management office will provide to the center in an emergency. EVIDENCE: 1. The plan referred to this document as Attachment 1; however, this was not attached. There was a document labeled EMERGENCY PREPAREDNESS / EVACUATION PLAN, however, it does not identify who signed it, and is lacking information regarding: (i) local disaster risks; (ii) community wide plans to address different disasters and emergency situations; and (iii) assistance, if any, that the local emergency management office will provide to the center in an emergency.
Plan of Correction:	The fire and evacuation plan will reflect the signature of the appropriate fire official.
Standard #:	22VAC40-61-530-A
Description:	Based on document review, the facility failed to have the fire and emergency evacuation plan approved by the appropriate fire official. EVIDENCE: 1. One of the evacuation drawings has some unidentified initials on it; it is not clear whose initials they are. The fire plan itself is interspersed within the Emergency Preparedness plan and there is no documentation to support that this has been approved by the appropriate fire official.
Plan of Correction:	The facility will have the fire and emergency evacuation plan approved by the appropriate fire official.
Standard #:	22VAC40-61-530-B
Description:	Based on document review, the fire and emergency evacuation drawing is missing some required elements. EVIDENCE: 1. The fire and emergency evacuation drawings show the evacuation routes on two separate maps, and both are labeled as primary evacuation routes. Both maps lack: area(s) of refuge and assembly area(s)
Plan of Correction:	The facilities? area of refuge and assembly area will be labeled on the fire and emergency evacuation drawings approved by the appropriate fire marshal.
Standard #:	22VAC40-61-560-A
Description:	Based on document review, the facility lacked a plan for participant emergencies. EVIDENCE: 1. Review of the Emergency Preparedness plan, which at first appeared to incorporate all required emergency plans, lacked the required parts of the participant emergency plan: Procedures for handling medical emergencies, including identifying the staff person responsible for (i) calling the rescue squad, ambulance service, participant's physician, or Poison Control Center and (ii) providing first aid and CPR when indicated; Procedures for handling mental health emergencies such as, but not limited to, catastrophic reaction or the need for a temporary detention order; Procedures for making pertinent medical information and history available to the rescue squad and hospital, including a copy of the current medical administration record, advance directives, and Do Not Resuscitate Orders; Procedures to be followed in the event that a participant is missing, including (i) involvement of center staff, appropriate law-enforcement agency, and others as needed; (ii) areas to be searched; (iii) expectations upon locating the participant such as medical attention; and (iv) documentation of the event; Procedures to be followed in the event of a vehicle emergency to include notifying the center or emergency personnel, telephone numbers for vehicle repair, and options for alternate transportation. Procedures to be followed in the event that a participant's scheduled transportation does not arrive or the participant is stranded at the center shall also be developed. The center shall ensure that these procedures are in place for transportation provided by both the center and contracted services if appropriate; Procedures for notifying the participant's family, and legal representative; and Procedures for notifying the regional licensing office as specified in 22VAC40-61-90.
Plan of Correction:	The facility will implement a plan for participant emergencies to meet the guidelines of VAC40-61-560.