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: May 28, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

Two Representatives with the Division of Licensing conducted an unannounced, mandated, monitoring inspection on 5/28/2019 from 11:00am to 5:30pm. At the point of entranced the facility Administrator was available and on-site and the facility had 163 residents in care. The Licensing Representatives observed the facility physical plant, observed the medication administration pass, observed residents during meals and engaged in activities, reviewed ten resident and five staff records. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return it to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 10 steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on staff record reviews the facility failed to ensure each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment . Evidence: On 05/28/2019 with two Representatives with the Division of Licensing and staff #1, documentation showed that staff #2 whom was hired on 06/05/2018 and staff #3 whom was hired on 01/22/2019 did not have First Aid certification in the record.
Plan of Correction:	An audit was performed on all direct care staff to ensure that current first aid certifications is in the record of each. All have submitted certifications to obtain complete compliance. Human Resources, Director of Nursing, or designee will ensure that all certifications are current and filed within the community for each direct care staff member. Compliance will also be confirmed during initial orientation.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review the facility failed to ensure the comprehensive individualized service plan contained a description of identified needs. Evidence : On 05/28/2019 with two Representatives with the Division of Licensing and staff #1, documentation showed resident #8's care plan was reviewed on 11/28/2018 by staff #1. The Individualized service plan did not address the need for hospice care in which the resident was admitted to according to facility progress notes after 03/29/2019.
Plan of Correction:	ISP was updated by the Director of Nursing to include all needs and services provided by Hospice to resident #8. Insurance of Compliance- Director of Nursing and or designee will update the Individual Service Plan when a resident begins Hospice.
Standard #:	22VAC40-73-670-1
Description:	The facility failed to ensure that every staff person who administers medication was authorized by ? 54.1-3408 of the Virginia Drug Control Act. Evidence: On 05/28/2019 with two Representatives with the Division of Licensing and staff #1, documentation showed that staff #2 Medication Aide License expired on 04/30/2019.
Plan of Correction:	Human Resources reviewed all licensed staff records to confirm all were not expired. Insurance of Compliance- Human Resources, DON, or designee will keep updated system to ensure all licenses stay current and do not expire.
Standard #:	22VAC40-73-870-A
Description:	Based on observation of the facility physical the facility failed to keep the building maintained in good repair. Evidence: On 05/28/2019 with two Representatives with the Division of Licensing and staff #1, the following areas were found not in good repair: 1-Room #239 carpet was stained and dry wall damage as evidenced by photos taken. 2-The wall outside of the facility secured unit contained two large spots. 3- Room #126 contained a dirty commode and shower. 4-Room #127 was dirty behind the commode and appeared to have feces in the shower. 5-Room #131 shower was dirty from what appeared to be feces.
Plan of Correction:	Areas noted during inspection were corrected immediately. Insurance of Compliance- Maintenance & Housekeeping directors or designee will perform daily rounds to ensure that all areas of building have been cleaned and left in good repair.
Standard #:	22VAC40-73-870-B
Description:	Based on observation of the facility physical plant the facility failed to ensure the facility was free from foul odor. Evidence: On 05/28/2019 with two Representatives with the Division of Licensing and staff #1, while entering room #403 a lingering urine odor was present. Upon further review with the two Licensing Representatives and staff #1 present a urinal was on an end table in the resident's sitting area of the apartment filled with what appeared to be urine as evidenced by photos taken.
Plan of Correction:	Urinal was emptied and cleaned by staff during time of inspection. Insurance of Compliance- Routine rounds by staff will include emptying and cleaning urinals as needed.
Standard #:	22VAC40-73-925-C
Description:	Based on observation of the facility secured unit, the facility failed to ensure resident do not share soap. Evidence: On 05/28/2019 with two Representatives with the Division of Licensing and staff #1, it was observed in the bathroom of room #126 which was shared by two residents there was one open, unlabeled bar of soap on the bathroom sink as well as an unlabeled bar of soap in a unlabeled wash bin in the shared rest room shower as evidenced by photos taken.
Plan of Correction:	Resident's personal hygiene products were labeled and placed in a secured cabinet assigned to the resident to ensure products don't run the risk of being shared. Insurance of Compliance- Director of Nursing and or Designee will complete daily monitoring to ensure that all items remain labeled and secured in assigned resident cabinet.