VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hillside Residential Living
403 N. Coalter Street
Staunton, VA 24401
(540) 885-0191

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Aug. 5, 2021

Complaint Related: No

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 63.2 Protection of adults and reporting. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

Discussed posting locations for activity schedules, resident rights and CPR/First Aid staff list due to the configuration of the building.

Comments:

A renewal inspection was initiated on 08/05/2021 and concluded on 09/20/2021. The administrator was contacted by telephone and email to initiate the inspection. The administrator reported that the current census was 48. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. There was a delay between the initiation and documentation response due to Covid. The inspector reviewed 3 resident records, 3 staff records, staffing schedules, outside inspections, emergency drills, menus and activity plans submitted by the facility to ensure documentation was complete. The health inspection application was submitted in a timely manner and paid for but the inspector has not arrived. The inspector conducted the on-site portion of the inspection on 9/20/2021. An exit interview was conducted with the administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance(s) with one applicable standard or law, and the violation was documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Facility staff administering medication failed to consistently follow the medication administration plan as it relates to documentation to ensure accurate counts of schedule II drugs. Based on a review of the count sheet for resident three, the medication administration record (MAR) and the pill pack containing the hydrocodone staff did not consistently document on both the MAR and the count sheet when medication was administered. The count sheet did not match the medication pack or the MAR. This was reconciled during the inspection. (Standard 640-1-8)
Plan of Correction:	The administrator and assistant will review all count sheets against the pill packs and if necessary the MARs to ensure all match. Staff will further be re-in-serviced by the pharmacy nurse on proper documentation as it relates to schedule II medication. The administrator and assistant assume responsibility for correction and future monthly monitoring to maintain compliance.