VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Hillside House Assisted Living Memory Care Community
20501 Earhart Place
Sterling, VA 20165-3581
(703) 404-5186

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: April 14, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: LI entered the facility at 11:15 am on 4/14/2023 and exited at 12:50 pm on 4/14/2023. 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 2/21/2023 and 3/27/2023 regarding allegations in the area(s) of resident care and related services and additional requirements for facilities that care for adults with serious cognitive impairments. Number of residents present at the facility at the beginning of the inspection: 8 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed the door where a resident attempted to exit to inspect the locking mechanisms and security feature. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-reports of non-compliance with standard(s) or law. However, violation(s) not related to the self-reports but identified during the course of the investigation can 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-930-D
Description:	Based upon a review of records and interviews, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, the following shall be met: 1. This inability shall be included in the resident?s individualized service plan. 2. The plan shall specify a minimal frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated resident needs. Evidence:1. LI interviewed the administrator on 4/14/2023. According to the administrator, only Resident #2 ?has the ability to use a call bell pendant.? 2. The Individualized Service Plans (ISPs) provided by the facility for Resident?s #1, #3, and #4 and reviewed by LI on 4/14/2023, did not include the following information: the residents inability to use the signaling device, or a minimal frequency of daily rounds to be made by direct care staff for emergencies or other unanticipated resident needs.
Plan of Correction:	1. An audit of each resident?s individualized service plan will be conducted. Any resident that does not have the ability to use a signaling device will have their Individualized Service Plan (ISP) updated to reflect that inability and a minimum frequency of daily rounds will be specified. 2. The Individualized Service Plans for Resident #1, #3, and #4 have been updated to reflect their inability to use a signaling device and the frequency of daily rounds to be made by direct care staff. 3. The nurse coordinator will educate to ensure that all individualized service plans are updated as needed and for new admissions to reflect the inability/ability to use a signaling device and the frequency of daily rounds. 4. All ISP?s will be reviewed quarterly to ensure that the resident?s ability/inability to use a signaling device is accurately reflected as well as the frequency of daily rounds. All findings will be reported to the Quality Assurance Meeting and followed up on as needed.