VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Inspirit Hilltop Operator LLC
111 Denny Lane
Winchester, VA 22603
(540) 667-5323

Current Inspector: Jill James (540) 418-2631

Inspection Date: March 22, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 63.2 Protection of adults and reporting.

Technical Assistance:

The UAI is to indicate medication administration by lay person to include RMA.

Comments:

A non-mandated complaint inspection was initiated on 03/22/2022 and concluded on 03/02/2022 A complaint was received by the department regarding allegations in the areas of resident care. The licensing inspector conducted an on-site observation at the facility on 03/22/2022. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on a review of residents' records, the facility failed to ensure all assessed needs are included on the Individualized Service Plan. EVIDENCE: 1. The UAI for resident 1 dated 12/15/2021 indicates resident requires physical and mechanical assistance with walking. The Individualized Service Plan (ISP) dated 12/15/2021 indicates resident is unable to to perform this task. 2. The UAI for resident 1 indicates mechanical and physical assistance is required with wheeling. This is not indicated on the ISP. 3. The UAI indicates resident 1 is disoriented to place, time and situation. The ISP indicates resident is disoriented to place and situation. 4. The ISP for resident 1 indicates resident 1 has a wound and a Foley catheter. This is not reflective of resident's current status as per an interview with the Executive Director on 03/22/2022. 5. The hospice plan of care indicates resident 1 is to be turned every 2 hours. This is not indicated on the ISP. 6. The UAI for resident 2 dated 10/06/2021 indicates resident requires mechanical and physical assistance with dressing, toileting, transferring walking and mobility. The ISP dated 07/16/2021 indicates resident is independent in dressing, toileting, transferring, walking and mobility. 7. The UAI for resident 3 dated 09/08/2021 indicates resident has abusive behaviors. The ISP dated 09/08/2021 does not indicate interventions for behaviors. 8. The ISP for resident 3 indicates another resident's name for psychosocial expected goals and time frames.
Plan of Correction:	ISP and UAI for residents 1, 2 and 3 to be updated to reflect current level of care needs and cognition. The Resident Wellness Director and the Resident Care Director will ensure when completing plans and assessments that they match and have the correct name displayed. All care plans will be reviewed by the Executive Director before presenting to resident and family for signature. All current ISPs and UAIs are being reviewed for accuracy.
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on review of residents' records, the facility failed to ensure the Individualized Service Plans are signed and dated by the resident or their legal representative. EVIDENCE: 1. The ISP for resident 1 dated 12/15/2021 does not contain the signature of resident or legal representative. 2. The ISP for resident 2 dated 07/16/2021 does not contain the signature of resident or legal representative. 3. The ISP for resident 3 dated 09/08/2021 does not contain the signature of resident or legal representative.
Plan of Correction:	ISPs and UAIs of resident 1, 2 and 3 will be reviewed by Resident Wellness Director, Resident Care Director, along with ED and signatures will be obtained. The Resident Wellness Director and Resident Care Director will work together to review and ensure that all care plans have signature of resident and POA/family member.
Standard #:	22VAC40-73-650-A
Complaint related:	Yes
Description:	Based on document review and an interview, the facility failed to ensure a valid order was obtained to start a treatment. EVIDENCE: 1. Documentation received from the facility on 03/19/2022 indicates resident A has head lice. 2. Resident A has an order effective 03/15/2022 for Permethrin 5% Cream: Apply topically to scalp, leave on for 6-8 hours and repeat for one application for seven days. 3. The Medication Administration record for resident A indicates treatment was completed on 03/15/2022. 4. The LI and collateral 1 interviewed staff 1 and the Executive Director on 03/22/2022 who stated resident A still had visible lice on 03/17/2022 and a treatment of mayonnaise and tea tree oil was applied to resident's scalp by staff 1 on 03/17/2022. 5. There is no documentation of notification to physician that resident still had active head lice after treatment with Permethrin 5% Cream on 03/15/2022. 6. The record for resident A did not contain a physician's order to treat resident resident's head lice with mayonnaise and tea tree oil.
Plan of Correction:	Resident Wellness Director along with Resident Care Director will ensure that any treatment to be started will have a valid MD order with clear stop and start date. Resident Wellness Director and Resident Care Director will ensure that communication is transmitted to the MD regarding ongoing issues that were not resolved with treatment prescribed by Physician. Training for all Med Techs will be conducted to ensure they are aware to report any issues to supervisor and to never start treatment without orders.