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 12, 2021

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:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 5/12/2021 and concluded on 5/24/2021. The Executive Director was contacted to initiate the inspection. The Executive Director reported a current census of 119 residents. The inspector emailed the Executive Director a list of items required to complete the inspection. The inspector reviewed five (5) resident records, five (5) staff records, staff schedules, fire drills, fire and health inspection reports, emergency practice exercises, physician orders and medication administration records, staff qualifications and training, etc. submitted by the facility to determine compliance. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations are documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-450-E
Description:	Based on a review of individualized services plans for five residents during a remote inspection, the individualized service plan for one resident was not signed and dated by the licensee, administrator, or his designee, (i.e., the person who developed the plan). Evidence: The signature page of the individualized service plan for resident # 5 was not completed, there was no facility staff signature.
Plan of Correction:	Resident # 5 ISP includes staff signature. Resubmitted correct ISP for review. Going forward, all ISPs will be reviewed by Director of Clinical Services or designee for proper signature prior to placing in resident's chart. All ISPs to be reviewed for signature and corrected as needed.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of individualized services plans for five residents during a remote inspection. one individualized service plan was not updated to reflect a significant change in the resident?s condition. Evidence: Resident # 5 is prescribed a "puree and NTL" diet and " 1 ensure daily". The individualized service plan for the resident documents only a no added salt diet.
Plan of Correction:	Resident # 5 ISP includes updated diet modifications and staff signature. Resubmitted correct ISP for review. Going forward, all ISPs will be reviewed by Director of Clinical Services or designee for specialty diets/diet modifications prior to placing in resident's chart. Proper notification and signatures will be obtained with any changes.
Standard #:	22VAC40-73-680-H
Description:	Based on a review of the March 2021 electronic and hand signed medication administration records for five residents during a remote inspection, facility staff failed to document on the medication administration record (MAR) all medications administered to one resident. Evidence: 1. The administration of nine medications were not documented on the March 2021 MAR for resident # 3: (1) Crestor on 3/2, 3/27, 3/28; (2) Iron on 3/26/, 3/27, 3/28; (3) Travatan on 3/22, 3/27, 3/28; (4) Trazadone on 3/22, 3/27, 3/28; (5) Vitamin B12 on 3/26/, 3/27, 3/28; (6) Tylenol on 3/23, 3/24, 3/25, 3/26, 3/29, 3/30, 3/31 at 000 and 600 and on 3/27 and 3/28 at 1200 and 1800; (7) Neurontin on 3/23, 3/24, 3/25, 3/29, 3/30, 3/31 at 600 and 3/26, 3/27, 3/28 at 1400 and 3/27, 3/28 at 2200; (8) Pilocarpine on 3/26, 3/27, 3/28 at 900 and 1300 and 3/22, 3/27, 3/28 at 1700 and 2100; (9) Dorzolamide on 3/26, 3/27, 3/28 at 800 and 1300 and 3/27, 3/28 at 1700. 2.The administration of four medications were not documented on the March 2021 MAR for resident # 1 on 3/22/21: Aspirin, Ensure, Ferrous Sulfate and Protonix on 3/13 and 3/26. 3. The administration of seven medications were not documented on the March 2021 MAR for resident # 2 on March 31, 2021: (1) Depakote, (2) Donezil, (3) Malatonin, (4) Seroquel, (5) Namneda in pm, (6) Oxybutynin in pm and (7) Sinemet. 4. The administration of one medication was not documented on the March 2021 MAR for resident # 4 on 3/27 and 3/28 for Oxybutynin Chloride. 5. The administration of six medications were not documented on the March 2021 MAR for resident # 5: (1) Calcium on 3/31; (2) Cholecalciferol on 3/10; (3) Clopidopgrel on 3/10; (4) Docusate Sodium on 3/5 and 3/10; (5) Protonix on 3/5 and 3/10; (6) Tamsulosin on 3/5 and 3/10.
Plan of Correction:	All staff will be given EMAR access for documentation. Director of Clinical Services or designee will monitor MAR documentation daily to ensure proper documentation has been completed on each shift. Any corrections will be made at the time identified.
Standard #:	22VAC40-73-680-I
Description:	Based on a review of the March 2021 electronic and hand signed medication administration records for five residents during a remote inspection, one medication administration record (MAR) did not accurately reflect the name, signature, and/or initials of staff administering medications Evidence: The initials on the hand signed March 2021 MAR and the electronic March 2021 MAR submitted for review had different staff initials for three medications (Pulmicort, Symbicort, Meclizine) administered in the pm on March 2, 2021
Plan of Correction:	Electronic MAR will be utilized to secure signatures of all staff administering medications.