VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Barrington at Hioaks
350 Hioaks Road
Richmond, VA 23225
(804) 320-1412

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: Sept. 22, 2023

Complaint Related: Yes

Areas Reviewed:

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Complaint Date and time the licensing inspector was on-site at the facility on the day of the inspection: 9/22/23 10a -11:30 a The Acknowledgement of Inspection form was emailed for each date of the inspection. A complaint was received by VDSS Division of Licensing on 9/18/23 regarding allegations in the areas of: Administration and Administrative Services, Personnel; Staffing And Supervision; Admission, Retention And Discharge of Residents; Resident Care and Related Services; and Additional Requirements For Facilities That Care For Adults With Serious Cognitive Impairments. Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Number of interviews conducted with collateral contacts: 1 Observations by licensing inspector: Memory Care Environment, Staff/Resident Interactions, Resident Care and Services Additional Comments/Discussion: None 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: Admission, Retention and Discharge of Residents; Resident Care And Related Services; and Additional Requirements for Facilities That Care For Adults With Serious Cognitive Impairments. A violation notice was 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 Yvonne Randolph, Licensing Inspector at (804) 662-7454 or by email at yvonne.randolph@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1100-C
Complaint related:	No
Description:	Based on a review of file documentation for one resident, the facility did not document that the order of priority was followed in obtaining written approval for placement in the safe, secure environment. Evidence: 1. The form for Approval for Placement in a Secured Unit was signed by the adult child. 2. The spouse and legal representative/guardian are listed above the adult child on the Approval for Placement in a Special Care Unit. There was no explanation of why written approval was not obtained from each individual higher on the list of priority.
Plan of Correction:	The community will provide a written explanation as to why the signature is not obtained from higher-level representatives/guardian on Approval for Placement forms as needed. All current records will be reviewed to ensure compliance.
Standard #:	22VAC40-73-310-H
Complaint related:	No
Description:	Based on a review of the admission physical examination for one resident, a resident was admitted and retained with a prohibited care need. Evidence: 1. Resident # 1 was admitted to the facility on 9/11/23. 2. The admission physical examination for resident # 1 (dated 8/15/23) documented a prohibited care need ? ?requires continuous licensed nursing care?. When staff #1 was informed that resident #1 was admitted with a prohibited condition, staff #1 indicated she was unaware of the prohibited condition.
Plan of Correction:	Will ensure a complete review of History and physical and UAI by Executive Director and Director of Clinical Service before admission approval. Upon clinical identification, the Community Relations Director will not proceed with admission if the resident has a known prohibited condition. All current records will be reviewed to ensure no further incidents occur.
Standard #:	22VAC40-73-450-A
Complaint related:	Yes
Description:	Based on a review of the individualized service plan (ISP) and an interview with the responsible party, the individualized service plan was not developed in conjunction with the resident and/or the resident?s family, legal representative and was not signed and dated by the licensee, administrator or his designee, and by the resident or his legal representative. Evidence: 1. The responsible party/legal representative for resident # 1 reported during an interview on 9/27/23 that the plan was not shared with her and was developed without her input. 2. The individualized service plan for resident # 1 was not signed by the resident?s responsible party/legal representative.
Plan of Correction:	A collaborative care plan meeting will be conducted with the responsible party and the resident to ensure resident needs are identified and documented. All signatures will be obtained by all parties present during the care plan meeting. All current records will be reviewed to ensure no further incidents occur.
Standard #:	22VAC40-73-460-D
Complaint related:	No
Description:	Based on a review of file documentation for one resident, the facility failed to provide supervision of the resident schedule, care, and activities, including attention to specialized needs, such as prevention of falls. Evidence: 1. Facility documented in the initial progress note and move-in record on 9/11/23 the following diagnosis: (1) frequent falls (R29.6) and (2) Other Slipping, Tripping and Tumbling and Falls. 2. Resident # 1 had a Fall Risk Assessment completed at admission (on 9/11/23) that documented a high fall risk. a. The total assessment score for resident # 1 was 75. b. The risk rating scale indicated a total rating of 45 or above as a high fall risk. 3. Resident # 1 had three documented falls within the first five days of admission.
Plan of Correction:	The community will identify any potential risk to ensure that the resident health and safety needs are met and will set up appropriate safety interventions to minimize further fall risks specific to the resident. All current records will be reviewed to ensure compliance.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on a review of medication administration records (MARs) for one resident, medication was administered without a valid physician order. Evidence: 1. MARs for Resident # 1 for September 2023 documented the administration of Seroquel 25 mg on 9/16/23 at 1200 and 2000. 2. Staff #1 was asked and was unable to provide the physician order for the administration of Seroquel 25. At 1200 and 2000.
Plan of Correction:	The community will ensure all verbal orders will be signed by a physician and placed in the chart within the allotted 14-day timeframe. A licensed nurse will review all new orders in a timely manner.