VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hickory Hill Retirement Community
900 Cary Shop Road
Burkeville, VA 23922
(434) 767-4225

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: July 17, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-80 THE LICENSE.

Comments:

On 07/17/2019 two VDSS inspectors were on site to conduct a follow up monitoring inspection. During the entrance interview the inspectors met with the facility Administrator and explained the purpose of the inspection. A sample of resident records were reviewed for compliance and a noon time medication administration pass was observed. The noncompliance revealed during this inspection is contained within this report. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and returned 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: 1) 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). If you have any questions please feel free to contact me at (804)662-9774 or by e-mail at Angela.r.reaves@dss.virginia.gov if you have any questions. The inspection was conducted between the approximate hours of 10:30a.m and 1:30p.m

Violations:

Standard #:	22VAC40-73-660-A
Description:	Based on observation on 07/17/2019 the facility failed to ensure that all medications were stored in a manner consistent with current standards of practice. Evidence: As evidenced by the photographs taken (1)-On 07/17/2019 the inspector observed that medication prescribed to resident #1 was left unattended on the counter top of the nurses station. (2)- The inspector also observed that a CVS/Pharmacy pill container case that contained four different medications were left unattended on the counter at the nurses station.
Plan of Correction:	FACILITY RESPONSE-"Education concerning medication safety, procurement and containment was conducted with all RMA and LPN staff. They were also reminded at this time that containers such as that found by inspectors are not permitted in our facility at any time. Admission worksheet was then amended to inform family members of our business practice which does not allow the daily dispense containers in our facility. This was also done while inspectors were onsite. The DON will be responsible for implementation and regular monitoring through daily environmental rounds conducted by supervisory nursing staff."
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation and interviews conducted with the facility Administrator on 0717/2019 the facility failed to ensure that the findings of the most recent inspection of the facility was posted. Evidence: Upon entering the facility and based on observation the facility did not have the 03/28/2019 inspection conducted at the facility posted. During interviews the facility Administrator stated that the most recent inspection was not posted and that she did not know that she was suppose to post the report.
Plan of Correction:	FACILITY RESPONSE- "General Procedures and Information for Licensure were printed and reviewed by Administrator and Assistant Administrator. All inspection reports will be posted accordingly in the future."