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: Feb. 8, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-90 The Sworn Statement or Affirmation

Comments:

An unannounced renewal inspection was initiated on February 3, 2022 by phone and conducted at the facility on February 8, 2022 by licensing staff from 7:21 a.m. to 8:42 a.m. The Exit call was conducted on February 15, 2022 to conclude the inspection. A tour of the facility was conducted which included the following observations: building and grounds, facility postings, meal observations, and staff interviews. Record reviews of resident records, staff records, healthcare oversight, dietary oversight, pharmacy oversight, staff schedules, fire and health inspections, fire and emergency drills was completed. Non-compliance was found in the areas of Personnel, Resident Care and Related Services, and Emergency Preparedness. Thank you for your cooperation during this inspection. I can be reached at Alex.Poulter@dss.virginia.gov or (804) 662-9771.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on record review and interview with staff, the facility failed to ensure prior to his admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. Resident #3 admitted to the safe, secure environment on 1-08-2020. Resident #3?s ?Assessment of Serious Cognitive Impairment? dated 1-06-2020 by Physician #1 checked ?No? to the question, ?Does the individual named above have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his/her own safety and welfare?? 2. Staff #2 and Staff #3 confirmed during interview that Physician #1 did not assess Resident #3 as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his/her own safety and welfare.
Plan of Correction:	When the Administrator realized that Resident #3?s PCP had made an error completing the form (checking the wrong box) shortly after admission, she contacted the practice and was informed that the MD had just retired. The new MD that took over the practice stated that he would not make the change since he did not know and had never treated the resident. Since the Administrator is not a physician, we knew we had no authority to change it and with it being an admission form, we didn?t know that it was acceptable to complete a new one after the fact. To correct the violation, we asked our facility physician, who now sees this resident, to complete the form -checking the correct box- and have placed in the resident?s chart even though it is post-admission. The Administrator and other admissions staff will be more diligent going forward in checking admission documentation for any errors.
Standard #:	22VAC40-73-1110-A
Description:	Based on record review and interview with staff, the facility failed to ensure prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment (SSE), the licensee, administrator, or designee shall determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident's file. Evidence: 1. The following residents who were admitted to the SSE on the following dates did not have determination and justification by the licensee, administrator, or designee as to whether placement in the special care unit was appropriate: a. Resident #3 admitted 1-08-2020; and b. Resident #4 admitted 12-03-2021. 2. Staff #2 acknowledged during interview that the aforementioned residents? did not have written documentation of the determination and justification for placement in the SSE.
Plan of Correction:	The facility Administrator has edited the department?s Review of Appropriateness of Placement form, creating an `Admission Review of Appropriateness? document to be completed on all residents with a serious cognitive impairment applying for admission to the SSE. This new form showing the Administrator?s determination of appropriate placement was completed for Resident #s 3 and 4 and placed in their file.
Standard #:	22VAC40-73-100-A
Description:	Based on observation, record review, and interview with staff, the facility failed to ensure the assisted living facility implemented their infection control program addressing the surveillance, prevention, and control of disease and infection that is consistent with the federal Centers for Disease Control and Prevention (CDC) guidelines. Evidence: 1. Staff #1?s mask was pulled down below Staff #1?s nose and mouth on 2-08-2022 during inspection while administering medications to residents. 2. Additionally, Staff #1 stated, ?The resident [Resident #1] I was speaking to is hard of hearing? when asked why the staff?s mask was pulled down. 3. The facility?s policy titled ?Pandemic Plan (Including Covid-19 update)? revised 6-04-2020 documented under ?Policy?? ?It is the policy of Hickory Hill RC to effectively respond to any Pandemic Illness and meet the guidelines established by the Centers for Disease Control.? And under ?Procedures?? ?2. Standard precautions will be maintained in all treatment settings. All staff will wear masks at all times while in the facility.? 4. The CDC website updated 2-02-2022 under ?Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic? documented, ?Implement Source Control Measures ?Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person?s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing.? 5. Staff #2 acknowledged during interview that Staff #1 was not following the facility?s policy ?Pandemic Plan (Including Covid-19 update)?.
Plan of Correction:	Staff #1 was re-trained on facility?s IC plan. The resident she was speaking to had just moved in a few days prior and is deaf as well as mute. All staff are now using a dry erase board to better communicate with her without compromising IC protocol.
Standard #:	22VAC40-73-290-A
Description:	Based on record review and interview with staff, the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working each shift. Evidence: 1. The ?Activity Director Schedule? (last updated 11-30-2021) did not document the names of the Activity Director or Activity Assistant for any of the dates. 2. Staff #3 confirmed that the ?Activity Director Schedule? is the written work schedule for the Activities department and stated that ?it remains the same week to week (unless otherwise noted)?. 3. Staff #3 identified Staff #4 as the Activity Director and Staff #5 as the Activity Assistant.
Plan of Correction:	The activity staff names were added to the schedule and forwarded to the LI.
Standard #:	22VAC40-73-550-F
Description:	Based on observation and interview with staff, the facility failed to ensure the rights and responsibilities of residents shall be printed in at least 14-point type and posted conspicuously in a public place in all assisted living facilities. The facility shall also post the name and telephone number of the appropriate regional licensing supervisor of the department. Evidence: 1. The ?Rights and Responsibilities of Residents of Assisted Living Facilities? posted onsite was the 2007 version that contained only 19 rights versus the 2013 version that contains 20 rights as per ? 63.2-1808 of the Code of Virginia. Additionally, the appropriate regional licensing supervisor of the department was not posted at the time of inspection. Photographic evidence was taken during inspection. 2. Staff #2 acknowledged during interview that the information was not up to date with the current version of ?Rights and Responsibilities of Residents of Assisted Living Facilities? (2013) per ? 63.2-1808 of the Code of Virginia and the incorrect regional licensing supervisor?s name was posted.
Plan of Correction:	The latest version of the Resident Rights & Responsibilities document was obtained from the department?s website, including the correct Regional Licensing Supervisor?s name, and was posted immediately. Photo was then submitted to LI. Assistant Administrator will check the website no less than annually to ensure that all forms and postings are the most recent updates.
Standard #:	22VAC40-90-30-C
Description:	Based on record review, the facility failed to ensure that any person did not make a false statement on the sworn statement or affirmation. Evidence: 1. Staff #6?s date of hire was 4-21-2021. Staff #6?s sworn statement dated 4-27-2021 documented ?No? for the question, ?Have you ever been convicted of a law violation(s) but excluding offenses committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth offender law??; however, Staff #6?s ?Virginia Criminal Record? dated 5-05-2021 had a conviction. 2. Staff #2 and Staff #3 acknowledged during interview the form was filled out with a false statement by Staff #6.
Plan of Correction:	Staff #6 was contacted immediately concerning this error. She stated that she really did not understand the question. (The verbiage really is quite difficult to understand for many.) She corrected her answer on the spot and apologized for the error. Note: She did disclose the conviction on her application. HR has been advised to thoroughly explain this particular question on the disclosure statement to all new applicants when they are completing the form going forward.