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: July 19, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8:45 am to 12 noon 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: 131 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: meals, memory care environment 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 standards or law, and violations 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 violations will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards 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 805-662-7454 or by email at yvonne.randolph@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-440-D
Description:	Based on file reviews, the facility did not ensure that the uniform assessment instrument is completed as required by 22VAC30-110. Evidence: The uniform assessment instruments for residents # 1 and # 2 were not signed by the assessor or administrator.
Plan of Correction:	At the time of review and implementation, the Director of Clinical Services and designee will review and sign each UAI. Each signature will be obtained prior to UAI being placed on resident record.
Standard #:	22VAC40-73-450-E
Description:	Based on file reviews, the facility did not ensure that the individualized service plan shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: The Individualized service plans for residents # 1 and # 2 were not signed or dated by the resident or his legal representative.
Plan of Correction:	Director of Clinical Services or designee will review, sign, and date each ISP at time of review with the resident and/or RP. Each signature and date will be obtained prior to ISP being placed on resident record.
Standard #:	22VAC40-73-450-F
Description:	Based on a documentation review, the facility did not ensure that individualized service plans shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. Resident # 2 was admitted to the facility on 12/7/23. The facility documented a 9.7 % (30 lbs) weight loss for resident # 2 from 12/7/23 to 6/14/24. The individualized service plan does not have a goal for meals/eating. 2. The facility documented a 10% (51.8 lbs) weight loss for resident # 1 between 2/5/24 and 6/14/24. The UAI for resident # 1, updated on 3/20/24, states under functional status for eating that the resident requires ? mechanical & human help?. The Individualized service plan (ISP), updated on 6/27/24, does not address the change in resident?s condition.
Plan of Correction:	Director of Clinical Services or designee will review all active resident weights to identified areas of opportunity for intervention implementation and update ISP accordingly. Director of Clinical Services or designee will monitor obtained weights routinely for significant variances (per policy), reweight will be obtained for verification. Verified significant variances will be addressed timely with new interventions incorporated within the ISP.