VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Barrington at Hioaks
350 Hioaks Road
Richmond, VA 23225
(804) 320-1412

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: May 22, 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

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/22/23 10 am ? 3:50 pm The Acknowledgement of Inspection form was emailed for each date of the inspection. The licensing inspector completed a tour of the portions of the physical plant that included the building and grounds of the facility. Discussion/Comments: Additional documentation faxed to the inspector on 5/30/23 and 5/31/23 was reviewed for compliance. Number of residents present at the facility at the beginning of the inspection: 139 Number of staff records reviewed: 5 Number of resident records reviewed: 10 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Medication administration and storage, postings, resident-staff interactions Additional Comments/Discussion: Documentation requested was not provided in a reasonable time. An exit meeting was 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 Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by email at yvonne.randolph@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-250-C
Description:	Based on a review of five staff files, one did not have an original criminal record as specified in the Regulation for Background Checks for Assisted Living Facilities. (22 VAC 40- 90) Evidence: A background check was not found from the Virginia State Police for staff # 6.
Plan of Correction:	Human Resource Manager and/or designee will ensure all active staff members have a Virginia State Police background on file and will ensure all background checks are ran. No new employee shall begin work until background check is completed.
Standard #:	22VAC40-73-250-D
Description:	Based on a review of five resident files, each staff person was not evaluated annually for tuberculosis. Evidence: Documentation of an annual tuberculosis screening was not found during the file review for staff # 1, # 2, # 3, # 4 and # 5. The files documented the following screening dates: staff # 1- 2/12/21, staff # 2 -11/29/21, staff # 3 ? 4/5/21, staff # 4 ? 12/3/21, staff # 5 ? 3/1/22.
Plan of Correction:	All employees charts review for list of annual TB assessments outside of compliance. Director of Clinical Services will work with Human Resource Manager to update non-compliant assessments.
Standard #:	22VAC40-73-310-H
Description:	Based on a review of ten resident files, an individual was retained at the facility with a documented prohibited condition or care need. Evidence: The uniform assessment instrument (UAI) for resident # 2 dated 11/15/22 stated that the resident has a prohibited condition.
Plan of Correction:	The Clinical Director or designee will review the residents UAI for accuracy and correct as needed. Resident charts will be audited for prohibited conditions and corrected accordingly. Completed UAIs will be reviewed by the Clinical Director or designee for accuracy and signature attainment.
Standard #:	22VAC40-73-450-B
Description:	Based on a review of ten individualized service plans, there was no documentation to support that eight service plans were developed in conjunction with residents, residents' families, or residents' legal representative. Evidence: Eight service plans (residents # 2, 3, 4, 5, 6, 7, 8, 10) were not signed by the residents, residents' families, or residents' legal representatives. There was a notation that the plans had been emailed to family members and/or legal representatives.
Plan of Correction:	The Clinical Director or designee will review the resident ISP with RP and obtain a signature. Resident charts will be audited and signatures will be obtained as needed. Signatures will be obtained on ISPs within 7 days.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of ten resident files, the individual service plan (ISP) did not address an identified need for five residents based on a fall risk rating. Evidence: The fall risk assessment form identified a rating of 45+ as a high fall risk. Residents # 1, 5, 7, 9, and 10 had a rating of 50-90. The ISPs for the residents did not have a fall risk plan or goal.
Plan of Correction:	The Clinical Director or designee will review the residents ISP to ensure residents at risk for falls have risk identified on ISP. Fall risk ratings will be routinely reviewed and added to ISP as necessary.