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: Dec. 14, 2023

Complaint Related: Yes

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 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:

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/14/2023 9am until 12:30pm 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 regarding allegations in the area(s) of: Personal, staffing, resident care and related services. Number of residents present at the facility at the beginning of the inspection: 25 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 7 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Personal, staffing resident care and related services. A violation notice was issued; any violation(s) not related to the (complaint(s)/self-report) 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-120-A
Complaint related:	Yes
Description:	Based on staff record reviews, the facility failed to ensure that all staff received orientation and training that is required within the first seven working days of employment. EVIDENCE: 1. The record for staff person 1, hired on 11/30/2023 did not contain documentation that the employee has completed required orientation and training. 2. The record for staff person 2, hired on 11/25/2023 did not contain documentation that the employee has completed required orientation and training. 3. The record for staff person 3, hired on 11/16/2023 did not contain documentation that the employee has completed required orientation and training. 4. The record for staff person 4, hired on 11/27/2023 did not contain documentation that the employee has completed required orientation and training. 5. The record for staff person 5, hired on 05/23/2023 did not contain documentation that the employee has completed required orientation and training. 6. The record for staff person 6 did not contain documentation that the employee has completed required orientation and training. A date of hire was not located in staff person 6?s record but staff person 6 is noted on the facility employee schedule as working in the facility as early as 11/27/2023. 7. The record for staff person 7, hired on 11/27/2023 did not contain documentation that the employee has completed required orientation and training. 8. In an interview with staff person 9 and collateral witness 1 conducted on 12/14/2023, staff person 9 expressed that these employees have not received orientation and training to the facility.
Plan of Correction:	Staff person 1 has completed required orientation and training. Staff person 2 is no longer employed at facility. Staff person 3 has completed required orientation and training. Staff person 4 is no longer employed at facility Staff person 5 has completed required orientation arid training. Staff person 6 is no longer employed at facility. Staff person 7 is no longer employed at facility. Administrator has corrected and documented staff 1,3,: and 5 with orientation and training. staff 2,4,6 and 7 are no longer employed.
Standard #:	22VAC40-73-250-C
Complaint related:	Yes
Description:	Based on staff records review and staff interviews, the facility failed to ensure that a staff record with all required information was maintained for all employees. EVIDENCE: 1. Staff person 8?s name with a phone number listed below was observed on a board that was hanging on the computer room door. 2. An invitation letter to an RMA class was observed in the record for staff person 1. Staff person 8?s name and the title of ?Administrator in training? for the facility was located at the bottom of the letter. 3. Staff person 8?s name is listed on the facility employee schedule as a person on call. 4. In an interview with staff person 9 and collateral witness 1 conducted on 12/14/2023, staff person 9 expressed that a staff record for staff person 8 has not been developed as of the day of inspection. 5. The records for staff persons 1, 2, 3, 5 and 6 do not have verification of current professional license, certification, registration, or completion of a required approved training course. These employees are listed as working on the November/December 2023 employee schedule in a direct care position.
Plan of Correction:	Administrator no longer employees' staff 8 due to incompetence. Documentation has been cotTected on staff 3 artd 5. Staff 1 has CNA. staff 2 and 6 are no longer ernployed.
Standard #:	22VAC40-73-250-D
Complaint related:	Yes
Description:	Based on staff record review, the facility failed to ensure that risk assessment for tuberculosis was completed by all staff on or within seven days prior to the first day of work. EVIDENCE: 1. The record for staff person 1, hired on 11/30/2023 does not contain documentation that a risk assessment for tuberculosis has been completed. 2. The record for staff person 2, hired on 11/25/2023 does not contain documentation that a risk assessment for tuberculosis has been completed. . 3. The record for staff person 3, hired on 11/16/2023 does not contain documentation that a risk assessment for tuberculosis has been completed. 4. The record for staff person 4, hired on 11/27/2023 does not contain documentation that a risk assessment for tuberculosis has been completed. 5. The record for staff person 6 does not contain documentation that a risk assessment for tuberculosis has been completed. A date of hire was not located in staff person 6?s record but staff person 6 is noted on the facility employee schedule as working in the facility as early as 11/27/2023. 6. The record for staff person 7, hired on 11/27/2023 does not contain documentation that a risk assessment for tuberculosis has been completed.
Plan of Correction:	Staff person 1 has the required document Staff person 2 is no longer employed. Staff person 3 has the required document Staff person 4 is no longer employed. Staff person 5 has the required document. Staff person 6 is no longer employed. Staff person 7 is no longer employed.
Standard #:	22VAC40-73-260-A
Complaint related:	Yes
Description:	Based on staff record review and staff interviews, the facility failed to ensure that at least one staff person was in the building at all times who has current certification in first aid. EVIDENCE: 1. The record for staff persons 1, 2, 3 and 5 did not contain documentation that these employees have current certification in first aid. 2. The employee schedule for December 2023 has staff persons 1 and 5 listed as the only direct care staff in the building on the 6 to 3 shift on 12/02/2023. The employee schedule for December 2023 has staff persons 2 and 3 listed as the only direct care staff in the building on the 11 to 7 shift on 12/01/2023, 12/02/2023 and 12/09/2023. 3. In an interview with staff person 9 and collateral witness 1 conducted on 12/14/2023, staff person 9 expressed that these employees have not received training/certification in first aid.
Plan of Correction:	Administrator has corrected this error by giving staff 1,3, and 5 the required first aid training. staff 2 Is no longer employed. Staff person 1 has a CNA Proper staff will be present at II times. Administrator has corrected error by giving staff required training
Standard #:	22VAC40-73-260-B
Complaint related:	Yes
Description:	Based on staff record review and staff interviews, the facility failed to ensure that at least one staff person was in the building at all times who has current certification in cardiopulmonary resuscitation (CPR). EVIDENCE: 1. The record for staff persons 1, 2, 3 and 5 did not contain documentation that these employees have current certification in CPR. 2. The employee schedule for December 2023 has staff persons 1 and 5 listed as the only direct care staff in the building on the 6 to 3 shift on 12/02/2023. The employee schedule for December 2023 has staff persons 2 and 3 listed as the only direct care staff in the building on the 11 to 7 shift on 12/01/2023, 12/02/2023 and 12/09/2023. 3. In an interview with staff person 9 and collateral witness 1 conducted on 12/14/2023, staff person 9 expressed that these employees have not received training/certification in CPR.
Plan of Correction:	Administrator has corrected: error by giving staff 1,3, and 5 with CPR training. Staff 2 is no longer employed. Proper staff will be present at all times.
Standard #:	22VAC40-73-270-1
Complaint related:	Yes
Description:	Based on staff and resident record review and staff interviews, the facility failed to ensure that all direct care staff were trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. EVIDENCE: 1. The record for resident 1 has documentation in a physician progress noted dated 11/30/2023 under reason for visit that ?pt don?t want to take meds-can be mean?. The progress note also has documentation of an order for ?Seroquel 100mg ? tab bid PRN severe agitation?. 2. The records for staff persons 1, 2, 3, 5 and 6, who are listed on the employee schedule in November and December 2023 in a direct care capacity, do not have documentation that these employees have received training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states 3. In an interview with staff person 9 and collateral witness 1 conducted on 12/14/2023, staff person 9 expressed that resident 1 can be agitated at times and that staff persons 1, 2, 3, 5 and 6 have not received aggressive behavior training.
Plan of Correction:	Staff has recewed training for aggressive behavior and how to de-escalate situations. Staff 1,3, and 5 now have the required training for aggressive behaviors. Staff 2 and 6 are no longer employed.
Standard #:	22VAC40-73-280-E
Complaint related:	Yes
Description:	Based on staff record review and staff interviews, the facility failed to ensure that direct care staff who have not received a completed criminal background check worked under the direct supervision of another employee for whom a background check has been completed. EVIDENCE: 1. The records for staff persons 1, 2, 3 and 5 did not contain documentation that the facility has received a completed criminal background for these employees. 2. The employee schedule for December 2023 has staff persons 1 and 5 listed as the only direct care staff in the building on the 6 to 3 shift on 12/02/2023. The employee schedule for December 2023 has staff persons 2 and 3 listed as the only direct care staff in the building on the 11 to 7 shift on 12/01/2023, 12/02/2023 and 12/09/2023. 3. In an interview with staff person 9 and collateral witness 1 conducted on 12/14/2023, staff person 9 expressed that the facility has not received a completed criminal background check for these employees.
Plan of Correction:	Staff persons 1,3, and 5 have the required background check. Staff 2 is no longer employed. As of present proper staff will be at facility at all times.
Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on resident record review, the facility failed to ensure that individualized service plans (ISP) were updated as needed for a change in resident condition. EVIDENCE: 1. The record for resident 1 has documentation in a physician progress noted dated 11/30/2023 under reason for visit that ?pt don?t want to take meds-can be mean?. The progress note also has documentation of an order for ?Seroquel 100mg ? tab bid PRN severe agitation?. 2. In an interview with staff person 9 and collateral witness 1 conducted on the day of inspection, staff person 9 expressed that resident 1 can be agitated at times. 3. The ISP dated 02/06/2023 in the record for resident 1does not address the residents identified need for assistance with services related to agitation.
Plan of Correction:	Staff has received training for aggressive behavior and how to de-escalate situations. Staff has been trained on aggressive behavior. Administrator has corrected resident 1 's ISP.