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: July 11, 2023

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 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

Technical Assistance:

A completed Renewal Application must be submitted prior to the expiration of the current license. The facility should receive an application in the mail, however if an application has not been received one can be obtained from the DSS web site or by calling the main office at (276) 206-0492.

Comments:

Type of inspection: Renewal 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 8:30 am on 7/11/2023 and exited at 4:20 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 10 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed medication administration. LI observed residents eating breakfast and lunch and engaging in activities. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-1110-B
Description:	Based upon a review of records, the facility failed to ensure that six months after placement of the resident in the safe, secure environment the licensee, administrator, or designee shall perform a review of the appropriateness of each resident in the special care unit. Evidence: 1. During the renewal inspection conducted on 7/11/2023, LI reviewed resident records and observed that the six-month review of appropriateness for continued residence for Resident #3, who was admitted to the safe and secure unit on 11/7/2022, had not been completed. 2. During the renewal inspection conducted on 7/11/2023, LI reviewed resident records and observed that the six-month review of appropriateness for continued residence for Resident #6, who was admitted to the safe and secure unit on 10/20/2022, had not been completed.
Plan of Correction:	An initial chart audit for all residents will be done to determine is any current resident is in their six-month review window. When appropriate the review will be completed. Going forward the Administrator or designee bimonthly audit of resident move-in dates . Every month the Administrator or designee will perform an audit of resident move-in dates and complete a review of appropriateness for any resident with-in the six-month window.
Standard #:	22VAC40-73-260-A
Description:	Based upon a review of documents, the facility failed to ensure that for each direct care staff member who does not have current certification in first aid, shall receive certification in first aid within 60 days of employment. Evidence: 1. During renewal inspection conducted on 7/11/2023, LI reviewed the staff records and did not observe documentation of first aid certification for Staff #2, who was hired as a certified nurse assistant effective 5/8/2023. 2. On 7/14/2023, LI received an email from the administrator confirming that Staff #2 ?is not first aid certified.?
Plan of Correction:	Upon hiring a new direct care staff member, the Clinical Coordinator or designee will keep a record/copy of their first aid certification. If the individual does not have a current certification the Clinical Coordinator will enroll them in a course to be completed before the 60-day deadline.
Standard #:	22VAC40-73-320-A
Description:	Based upon a review of records, the facility failed to ensure the physical that within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such exam shall contain the following information: ? A statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H; ? A statement that specifies whether the individual is considered to be ambulatory or nonambulatory as defined in this chapter; ? A statement that specifies whether the individual is or is not capable of self-administering medications Evidence: 1. During renewal inspection conducted on 7/11/2023 during renewal inspection, LI reviewed resident records and observed that the physician exam report for Residents #1 and #4 did not include the following: ? a statement that the residents did not have any of the conditions prohibited by 22VAC73-310; ? a statement that specified whether the resident is ambulatory or nonambulatory; ? a statement that specifies whether the individual is capable of self-administering medications
Plan of Correction:	Hillside House will use a standard form that will be included in the pre-admission paperwork that is to be filled out by the doctor who is completing the physical exam. This form will prompt the physician to answer questions that will provide all the required information. Proper completion of this form will be confirmed by the Admissions Coordinator and/or the Administrator.