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: July 12, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/12/2022, 11 am to 11:40 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 21 Number of resident records reviewed: 2 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 Susan Mallory, Licensing Inspector at (540) 309-3043 or by email at susan.mallory@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-A
Description:	Based on resident record review and interview, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care (POC) was developed to address the basic needs of the resident that adequately protects his health, safety, and welfare, nor comprehensive individualized service plan (ISP) completed on the day of admission. EVIDENCE: 1. Resident 3 was admitted to the facility on 7/7/2022. The resident record lacked a preliminary POC completed on or within seven days prior to admission, or a comprehensive (ISP) completed on the day of admission. An interview with staff 1 confirmed there was no preliminary POC nor a comprehensive (ISP) that had been completed for the resident. This was noted on 7/1/22022.
Plan of Correction:	Not available online. Contact Inspector for more information.