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: Nov. 18, 2019 and Jan. 7, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Responding to a complaint made against the facility regarding resident care, services and supervision two VDSS inspectors were on site at the facility on 11/18/2019 between the approximate hours of 1:15p.m and 4:22p.m and on site on 01/07/2020 during the approximate hours of 11:15a.m and 5:14p.m to investigate the complaint. During both days of the investigation the inspectors reviewed facility records and conducted interviews with facility staff. On 01/28/2020 a telephone interview was conducted with a facility staff person. The information gathered during the investigation could not substantiate the allegations made against the facility. However, the information gathered during the investigation did reveal noncompliance that 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

Violations:

Standard #:	22VAC40-73-210-E
Complaint related:	No
Description:	Based on the review of facility records, interviews conducted with the facility Administrator and Assistant Administrator and other facility staff on 11/18/2019 and 01/07/2020 and 01/28/2020, the facility failed to ensure that training for facility staff were relevant to the population in care and was provided by a qualified individual through in-service training programs or institutes, workshops, classes, or conferences. Evidence: Responding to a complaint that facility staff #s 1 and 2 caused resident #1 to fall from the Hoyer lift; injury occurred, during the resident?s transfer to the Hoyer, the inspectors requested documentation that facility staff had received training on how to use Hoyer lifts. Upon request the facility did not submit for the inspectors review documented evidence that facility staff #s 1 and 2 had Hoyer lift training. Staff #2 stated during the 11/18/2019 on-site interview that he had Hoyer lift training years ago but that he not had any recent Hoyer lift training since being employed with the facility. Documented date of hire for staff #2 is 09/22/2019. Facility staff #1 stated during the 01/28/2020 telephone interview that she had Hoyer lift training in1998 when she worked another facility and that the facility recently offered Hoyer lift training on 0/10/2020. Documented date of hire for staff #1 is 09/28/2003.
Plan of Correction:	FACILITY RESPONSE- "During a mandatory direct care staff meeting on 01/10/2020 in-service training on Hoyer lift was performed by the Healthcare Oversight LPN, and a Team Leader LPN. Two types of lifts were presented for specific training for each. Future training on all special equipment, to include Hoyer lifts will be performed inhouse by nursing professionals for all new direct care staff employed. It will be documented on their orientation checklist and monitored by the Human Resources Manager. Ongoing training will be conducted at least annually."
Standard #:	22VAC40-73-450-D
Complaint related:	No
Description:	Based on the review of facility records, interviews conducted with the facility Administrator and Assistant Administrator and other facility staff on 11/18/2019 and 01/07/2020, the facility failed to ensure that when hospice care is provided to a resident, the services provided by each is included on the individualized service plan. Evidence: A document titled Hospice IDG Comprehensive Assessment and Plan of Care Update Report that was submitted for the inspectors review, identified the start of hospice care service for resident #1 as 05/16/2019. Upon request to review the most recent individualized service plan (ISP) for resident #1, the facility submitted a document titled Level 2 Intensive Assisted Living dated 05/16/2019. The document notes under the heading Planned Activities ? 1.Call hospice with all care concerns and 2. Coordinate care with hospice services.? The individualized service plan does not identify a written description of what services will be provided.
Plan of Correction:	FACILITY RESPONSE- "Hickory Hill began additional ISP training of Registered Medical Aides (RMAs) and all supervisory staff at the beginning of December, introducing new procedures for the inclusion of a hospice face sheet document, describing all services being provided by them in caring for our residents. Hospice companies servicing Hickory Hill residents are aware of the requirement to provide this documentation for all new hospice admissions. The same procedure is in place for all companies providing home health services. All ISPs for residents under hospice care now include the agency?s face sheet with services outlined for each resident under their care. The Individualized Service Plans are developed by the Assistant Administrator and Nursing Team Leaders, as well as regular coordination with hospice agencies to ensure the highest standard of care for our residents is maintained."