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: Jan. 12, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION

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: 01/12/2024 8:15am until 9:30am 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. Number of residents present at the facility at the beginning of the inspection: 23 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of staff records reviewed: 1 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 review, 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 employee schedule for November and December 2023 and January 2024 has staff person 1?s name listed as working several shifts throughout these months. 2. In an interview with staff person 2 conducted on 01/12/2024, staff person 2 expressed that there is no documentation of an orientation and training to the facility for staff person 1.
Plan of Correction:	This employee has CPR/FA and RMA/CNA. As of this day we have corrected the errors and will ensure this doesn't happen again. All of the orientation training has been done and documented.
Standard #:	22VAC40-73-250-C
Complaint related:	Yes
Description:	Based on staff record review and staff interviews, the facility failed to ensure that a staff record with all required information was maintained for all employees. EVIDENCE: 1. The employee schedule for November and December 2023 and January 2024 has staff person 1?s name listed as working in a direct care capacity for several shifts throughout these months. 2. In an interview with staff person 2 conducted on 01/12/2024, staff person 2 expressed that a staff record for staff person 1 had not been developed as of the day of inspection. There was no documentation of staff person 1?s verification of current professional license, certification, registration, or completion of a required approved training course.
Plan of Correction:	The employee is CNA and RMA certified. The documentation has been added to employees chart.
Standard #:	22VAC40-73-250-D
Complaint related:	Yes
Description:	Based on staff record review and staff interview, the facility failed to ensure that a risk assessment for tuberculosis was completed by all staff on or within seven days prior to the first day of work. EVIDENCE: 1. The employee schedule for November and December 2023 and January 2024 has staff person 1?s name listed as working several shifts throughout these months. 2. In an interview with staff person 2 conducted on 01/12/2024, staff person 2 expressed that staff person 1 does not currently have an employee record and that there is no documentation of a screening for tuberculosis for staff person 1.
Plan of Correction:	Staff person 1 has CNA, RMA, CPR and FA located in emp!oyee records. Staff has a employee record and TB screening and will keep this updated.
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. Staff person 1 is noted on the employee schedule as working in a direct care capacity on the 6 to 3 shift on 12/15/2023 and 12/16/2023 and on the 11 to 7 shift on 11/30/2023. The employee schedule shows that staff person 1 was working with other individuals who did not have verification of current certification in first aid for these shifts. 2. In an interview with staff person 2 conducted on 01/12/2024, staff person 2 expressed staff person 1 does not currently have an employee record and that there is no documentation of current certification in first aid for staff person 1.
Plan of Correction:	Staff person 1 has CPR/FA also CNAIRMA. Certification is up to date.
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. Staff person 1 is noted on the employee schedule as working in a direct care capacity on the 6 to 3 shift on 12/15/2023 and 12/16/2023 and on the 11 to 7 shift on 11/30/2023. The employee schedule shows that staff person 1 was working with other individuals who did not have verification of current CPR for these shifts. 2. In an interview with staff person 2 conducted on 01/12/2024, staff person 2 expressed staff person 1 does not currently have an employee record and that there is no documentation of current certification in CPR for staff person 1.
Plan of Correction:	Staff is proper1y staffed with qualified personal. All of the staff has CPR/FA as of now. Staff person 1 is certified with CPR/FA and CNAIRMA.
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. Staff person 1 is noted on the employee schedule as working in a direct care capacity on the 6 to 3 shift on 12/15/2023 and 12/16/2023 and on the 11 to 7 shift on 11/30/2023. The employee schedule shows that staff person 1 was working with other individuals who did not have a completed criminal background check. 2. In an interview with staff person 2 conducted on 01/12/2024, staff person 2 expressed staff person 1 does not currently have an employee record and that there is no documentation of a completed background check for staff person 1.
Plan of Correction:	All staff has the required documentations. staff person 1 has a employee record with required documentation.