VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harmony at Independence
2077 South Independence Boulevard
Virginia beach, VA 23453
(757) 802-3665

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

Inspection Date: June 4, 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

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: 06/04/2024 from 8:35 am to 2:45 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: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 4 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 #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff #2 (hire date 01/22/2024) works as direct care staff and does not have documentation of a current certification in first aid in their staff record.
Plan of Correction:	The BOM/designee assigned Staff # 2 to an approved first aid training course to be completed on 6/06/24. Moving forward the BOM and/or designee will ensure that all new employees who do not have certification obtain it within the first 60 days of employment. During the monthly audit of employee files, the First Aid and CPR training on each employee will be validated as current and taught through an approved training provider per the standards.
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 #5 (admitted 04/16/2024) did not have a completed sex offender screening in their record.
Plan of Correction:	Resident # 5 Sex Offender screening completed and filed in their business record by the ED on 6/4/2024. Moving forward the DSM, ED and/or designee will create a pre-admit checklist for admissions files to include verifying that all sex offender screens are completed prior to admission and filed in the resident?s business record.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the comprehensive ISP include a description of current identified needs and written description of what services will be provided to address identified needs. Evidence: 1. Resident #6 had a change to regular liquids and discontinuance of thickened liquids on 03/06/2024; however, the ISP for Resident #6 (dated 02/23/2024) indicates the resident has a mechanical soft with nectar thickened liquids and does not reflect this change.
Plan of Correction:	Resident # 6 ISP updated to reflect diet change from thickened liquids to regular liquids by the HSD on 6/4/2024. Ongoing: The HCD, HSD and/or designee will assure that when physician?s orders are transcribed they are cross-referenced with the resident?s ISP to assure that all information on residents newly identified needs and associated services are reflected on the service plan.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication. Evidence: 1. The following expired medications were observed in the medication carts at the facility: PRN Acetaminophen 500 mg tablets expired 06/03/2024 and PRN Promethazine 25 mg tablets expired 05/22/2024 for Resident #10 and PRN Tramadol 50 mg tablets expired 01/26/2018 for Resident #11.
Plan of Correction:	Expired medications removed from Medication cart for Resident #10 & 11 by the RMA & HCD on 6/04/24. Ongoing: RMAs will be re-educated to monitor medication expiration dates as they are completing the med pass to check for expiration dates, and to remove expired medications. With oversight from the HCD, HSD and/or designee RMAs will do weekly checks of the medication carts to check for expired medications and other proper medication storage practices. The HCD, HSD and/or designee will conduct a monthly audit of all medication carts.