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: Jan. 7, 2020

Complaint Related: No

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced renewal inspection was conducted at the facility on 01/07/2020 by two VDSS licensing inspectors. At the time of entrance on 01/07/2020, the facility's Assistant Administrator offered 72 residents in care. Based on the census offered and other information discussed during the entrance interview a sampling of ten resident records, four staff and other facility records were reviewed for compliance. The facility reported new and discharged residents since the last on-site inspection as well as new staff hires. Observation of the mid-morning medication administration pass was discussed with the Assistant Administrator throughout the day and with the facility?s Administrator during the exit interview. Resident and staff interviews were conducted and the noon time meal was observed. No obvious physical plant concerns were observed. The noncompliance revealed during this renewal inspection is identified in this report. During the exit interview the facility's Administrator and Assistant Administrator was given an opportunity to submit for the inspectors review documented evidence of compliance. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the Inspector 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 non-compliance 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). Please 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 11:15a.m and 5:36p.m

Violations:

Standard #:	22VAC40-73-40-B-6
Description:	Based on the review of facility records and interviews conducted with the facility Administrator, the facility?s Assistant Administrator and other facility staff on 01/07/2020, the facility failed to exercise general supervision over the affairs of the licensed facility establish policies and procedures concerning its operation in conformance with applicable law, this chapter and the welfare of the residents. Evidence: ? The facility?s medication management plant that was submitted for the inspectors review on 01/07/2020 was not documented to identify methods to ensure that each resident's prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. ? The facility?s electronic medication administration record (EMAR) charting for January 2020 revealed that as of 01/07/2020 resident #3 was not administered 27 dosages of his prescribed medications. ? Facility records submitted for the inspector?s review during the 01/07/2020 renewal inspection, interviews conducted with facility staff on 01/07/2020 and the facility?s subsequent submission of requested documentation revealed that the facility does not have an adequate plan in place to monitor and supervise facility staff responsible for the welfare of the residents and responsible for the resident?s daily medication administration program.
Plan of Correction:	FACILITY RESPONSE- " The facility?s medication management plan has been modified to 1/10/20 Include better methods and additional procedure to ensure residents? medications are filled/refilled in a fashion to avoid missed dosages and/or incorrect documentation. It further addresses the issues which resulted in Resident #3 not having his meds administered properly (due to duplicate orders and meds not available), as well as Resident #6 being out of a particular medication. All staff responsible for medication administration were retrained by the RN and 1/10/20 Assistant Administrator on proper procedure, plus new procedure and verbiage from the updated Med Administration and Management Plan during mandatory training conducted on 1/10/20. This class also addressed proper documentation of blood glucose readings as well as the seriousness of residents not receiving their meds as ordered, and what to do if meds have not come in from pharmacy or VA in a timely fashion. Lists of topics discussed and staff in attendance were sent to inspector via email on 1/13/20."
Standard #:	22VAC40-73-680-D
Description:	Based on observation, the review of facility records and interviews conducted with the facility Administrator, the facility?s Assistant Administrator and facility staff on 01/07/2020, the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: During observation of the mid-morning medication administration pass on 01/07/2020 the inspector observed and the following was revealed: 1-Resident # 6 asked facility staff #1 about a medication she was supposed to have administered to her. In response facility staff #1 stated ?we?re waiting on the pharmacy.? Based on the interview with resident #6, further discussion with staff #1 and the review of the facility?s electronic medication administration record (EMAR) charting for January 2020, it was revealed that two 300 MG capsules of the medication Gabapentin to be administered three times a day was last administered to resident # 6 on 01/04/2020 at 8:30p.m. As of 01/07/2020 the resident was not administered nine dosages of her prescribed medication. 2- The facility?s EMAR charting for January 2020 that was submitted for the inspectors review on 01/07/2020, and the interview with facility staff #1 revealed that resident # 7 is prescribed 1 chewable ACID GONE Hydroxide-Mag Carbonate tablet to be administered three times daily before meals. Observation revealed that the resident was administered the medication after she had finished her lunch time meal on 01/07/2020. Facility staff #1 stated to the inspector that the resident asked her ?Don?t I suppose to get med at noon?.
Plan of Correction:	FACILITY RESPONSE-"The aforementioned training purposed to correct the previous violation also 1/10/20 corrected and addressed this violation. The updated med management plan directs staff how to proceed if med is not available for any reason or physician?s order has expired, cannot be obtained, etc. so that residents do not miss their medications and they are administered according to the timeframe they are prescribed. The corrected Medication Administration and Management Plan with addendum is attached to this submission and as stated therein, will be reviewed at least annually. All RMA?s will be evaluated for competency by an RN (or other licensed professional) annually or more often if necessary. The RN and Assistant Administrator are responsible for oversight of this program. Additionally, HHRC is currently in the process of changing pharmacies as well as 3/01/20 medication administration software, effective 3/01/20. The new pharmacy has an emergency med delivery system, including local back-up pharmacy, to ensure that ALL medications are available and able to be given as prescribed."