VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hills Home for Adults
1443 Commerce Avenue
Chesapeake, VA 23324
(757) 545-8797

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: July 10, 2024 and July 11, 2024

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

22VAC40-73-930 22VAC40-73-940

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: 07/10/2024 from 9:00 am to 12:12 pm and 07/11/2024 from 8:00 am to 9:05 am. 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: 45 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 3 residents. The following were reviewed: resident and staff records, medication carts, call bells, and water temperatures. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-210-F
Description:	Based on record review, the facility failed to ensure staff?s annual training include at least two of the required hours of training focus on infection control and prevention. Evidence: 1. Staff #2 and Staff #4?s 2023 annual training did not include at least two of the required hours of training focusing on infection control and prevention.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. Evidence: 1. Staff #5 was hired on 03/29/2024; however, Staff #5?s initial TB risk assessment was completed 04/25/2024.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-330-A
Description:	Based on record review, the facility failed to ensure a mental health screening be conducted prior to admission if behaviors or patterns of behavior occurred within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual. Evidence: 1. Resident #7 admitted to the facility on 03/27/2024 and did not have a mental health screen completed in their resident record. The hospital discharge paperwork indicates Resident #7 had behavior within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-350-B
Description:	Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and failed to document that this was ascertained and the date the information was obtained. Evidence: 1. Resident #7 (admitted 03/27/2024) did not have a completed sex offender screening in their record.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-A
Description:	Based on record review and interview, the facility failed to complete a resident?s UAI at least annually. Evidence: 1. The last UAI for Resident #1 was completed on 11/04/2022. 1. The last UAI for Resident #5 was completed on 12/15/2022.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-690-E
Description:	Based on record review, the facility failed to ensure the medication review include the items identified in the standard. Evidence: 1. The last medication review was completed on 4/30/2024; however, the review indicates a med room/station inspection to include its general appearance and observations, medication cart review, controlled drugs review, emergency kit review, and refrigerator/freezer review. The report did not include a review of the following: all medications that the resident is taking and medications that he could be taking if needed (PRNs), an examination of the dosage, strength, route, how often, prescribed duration, and when the medication is taken, documentation of actual and consideration of potential interactions of drugs with one another, documentation of actual and consideration of potential interactions of drugs with foods or drinks, documentation of actual and consideration of potential negative effects of drugs resulting from a resident's medical condition other than the one the drug is treating, consideration of whether PRNs, if any, are still needed and if clarification regarding use is necessary, consideration of a gradual dose reduction of antipsychotic medications for those residents with a diagnosis of dementia and no diagnoses of a primary psychiatric disorder, consideration of whether the resident needs additional monitoring or testing, documentation of actual and consideration of potential adverse effects or unwanted side effects of specific medications, identification of that which may be questionable, such as (i) similar medications being taken, (ii) different medications being used to treat the same condition, (iii) what seems an excessive number of medications, and (iv) what seems an exceptionally high drug dosage, and the health care professional shall notify the resident's attending physician of any concerns or problems and document the notification.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to ensure the interior of the building be maintained in good repair and kept clean and free of rubbish. Evidence: 1. Two ceiling tiles outside the Electrical Equipment Room off the dining area were observed with stains.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. There was not a completed criminal history record report for Staff #5 (hired 03/29/2024) in their record. 2. Staff #6 was hired on 12/30/2023; however, the criminal history record report for Staff #6 was completed on 06/05/2024.
Plan of Correction:	Not available online. Contact Inspector for more information.