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 8, 2022 and Aug. 9, 2022

Complaint Related: Yes

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 ACCOMMODATIONS AND RELATED PROVISIONS ? 22VAC40-73 BUILDINGS AND GROUND ? 22VAC40-73 EMERGENCY PREPAREDNESS ? 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ? ARTICLE 1 ? SUBJECTIVITY ? 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS ? 63.2 GENERAL PROVISIONS ? 63.2 PROTECTION OF ADULTS AND REPORTING ? 63.2 LICENSURE AND REGISTRATION PROCEDURES ? 63.2 FACILITIES AND PROGRAMS ? 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES ? 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION ? 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT ? 22VAC40-80 THE LICENSE ? 22VAC40-80 THE LICENSING PROCESS ? 22VAC40-80 COMPLAINT INVESTIGATION ? 22VAC40-80 SANCTIONS

Technical Assistance:

Consultation is recommendation of separating a delegation statement from other forms (i.e. from ISP).

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/08/2022, 10:10 a.m. ? 11:45 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 5/11/2022 regarding allegations in the areas of Administration and Administrative Services and Resident Care and Related Services An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Administration and Administrative Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-80
Complaint related:	Yes
Description:	Based on record review and interview with staff, the facility failed to ensure there was documentation of the resident requesting facility assistance with the management of personal funds via a delegation request signed and dated by the resident. Evidence: 1. Resident #1 admitted 1-01-2017. Resident #1?s file did not contain a delegation statement. 2. Staff #1 stated of the delegation statements, ?That is a part of their care plan [ISP]? and confirmed they do assist with Resident #1?s management of personal funds; however, there was no delegation statement on Resident #1?s ISP dated 3-29-2022 or anywhere in the record.
Plan of Correction:	Not available online. Contact Inspector for more information.