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: Sept. 14, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION x 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS x 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS x 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:

Elopement policy specifications regarding resident scenarios

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9-14-2022, 10:00 ? 11:00 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 9-14-2022 regarding allegations in the area of resident care and related services: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 #:	22VAC40-73-1100-C
Description:	Based on record review, the facility failed to document that the order of priority specified in subsection A of this section was followed, and the documentation shall be retained in the resident's file. The order of priority in subsection A is 1. The resident, if capable of making an informed decision; 2. A guardian or other legal representative for the resident if one has been appointed; 3. A relative who is willing? or 4. If the resident is not capable of making an informed decision? an independent physician. Evidence: 1. The legal guardian approved placement prior to placing Resident #1 in the Special Care Unit; however, Resident #1?s ?Approval for Placement in Special Care Unit? document dated 8-19-2022 was blank for the question, ?Explanation of why written approval was not obtained from each individual higher on the list of priority.?
Plan of Correction:	The facility Administrator has amended the Approval For Placement document (that was signed by family prior to placement) with the reason why the first individual of the priority order was not used ? the resident, ?Self?, was unable to give approval due to her cognitive inability to do so. The second person in the priority order is who gave approval.
Standard #:	22VAC40-73-1110-A
Description:	Based on record review, 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, the licensee, administrator, or designee determined 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. Approval for placement documentation was requested of Staff #1 onsite on 9-14-2022. Documentation provided by Staff from Resident #1?s record did not contain a written determination and justification by the licensee, administrator, or designee for Resident #1 to be placed in the safe, secure environment.
Plan of Correction:	The facility Administrator has completed and signed the correct document and placed in the resident?s chart.
Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure the physical examination for the resident by an independent physician contained a description of the person?s reactions to any known allergies. Evidence: 1. Resident #1 admitted 8-17-2022. Resident #1?s ?Report of Resident Physical Examination? dated 7-18-2022 documents the resident is allergic to ?PCN [penicillin] and Quinapril?. The report does not include a description of the person?s reactions to either of these medications.
Plan of Correction:	The expected allergic reactions were immediately added to the resident?s chart by the HO nurse following the exit interview with LI by phone. HO nurse will follow up with MD for confirmation.
Standard #:	22VAC40-73-460-D
Description:	Based on record review and interview with staff, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises. Evidence: 1. A self-reported incident was received from the facility on 8-23-2022 regarding an incident on 8-19-2022 involving Resident #1. The report documented, ?Resident [#1] eloped and was unaccounted for for approximately 2 hours. Resident [#1] was located by staff in the woods behind facility?? 2. Documentation in the record of Resident #1 contains a ?Report of Resident Physical Examination? dated 7-18-2022. The resident?s ?General physical condition including systems review? is documented as, ?Advanced dementia with confusion ? medically stable otherwise?. 3. Staff #1 confirmed during onsite inspection on 9-14-2022 that Resident #1 was located emerging from the woods behind the facility and that the resident was unsupervised during that period of elopement.
Plan of Correction:	Following the elopement, an After-Action meeting was held to investigate and discuss what circumstances allowed the incident to happen. While Resident #1 had not been identified by her physician or family prior to admission as an elopement or wandering risk, she did have advanced dementia and therefore, should have been watched more closely than she was by the staff member assigned to her care. The After-Action meeting determined that 1) The nursing assistant assigned to this resident failed to ensure her whereabouts for 45 minutes 2) The maintenance assistant failed to secure the exterior gate of the courtyard after driving through with the lawnmower. The facility has updated its procedure for all new residents, regardless of cognitive status ? that they shall not only be treated as a wandering risk for the first two weeks, but that 1) the nurse assigned shall document the resident?s exact location in the electronic chart every 20 minutes and 2) immediately before shift change, ?see? the resident and share that location with the oncoming staff member during report. That staff member is to then ?see? the new resident before tending to any others they are assigned to and continue with the 20-minute reporting. This shall continue and be charted for two weeks, unless otherwise directed and documented by the Health Oversight (HO) nurse or an Administrator. Both staff members involved have been counseled and that documentation is located in the personnel record.