VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harmony on the Peninsula
3540 Victory Boulevard
Yorktown, VA 23693
(757) 447-3544

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: Sept. 26, 2022 and Sept. 27, 2022

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 63.2 LICENSURE AND REGISTRATION PROCEDURES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal Date(s) of inspection the licensing inspector was on-site at the facility: 9/26/22 & 9/27/22 Number of residents present at the facility at the beginning of the inspection: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 6 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 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 Alyshia E. Walker, Licensing Inspector at (757) 670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-200-D
Description:	Based on record review, the facility failed to obtain a copy of the certificate issued or other documentation indicating that a person in a role as a direct care staff had met one of the requirements to work as a direct care staff. Evidence: The staff record for Staff # 5 included a Certified Nurse Aide certificate with an expiration date of 4/30/2022.
Plan of Correction:	The staff record has been updated with a valid CNA certificate. The Business Office Manager will conduct an audit to ensure all current direct care staff certificates meet compliance requirements.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure each direct care staff member maintain a current certification in first aid. Evidence: The staff record for Staff # 4 did not contain a current certification in first aid.
Plan of Correction:	A first aid certification course has been scheduled and will be offered to facility staff. The Business Office Manager will conduct an audit of direct care staff?s first aid certifications to ensure first aid certifications meet compliance.
Standard #:	22VAC40-73-320-A
Description:	Based on record reviewed, the facility failed to ensure a person shall have a physical examination by an independent physician within 30 days preceding admission and include the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form. Evidence: Resident # 7?s admission date was 7/9/2022 and the resident?s record did not contain an initial TB evaluation.
Plan of Correction:	The Health Care Director or designee will conduct an audit of all current residents? TB evaluations by 12-31-22 and ongoing.
Standard #:	22VAC40-73-325-B
Description:	Based on record review, the facility failed to ensure that a fall risk rating was completed at least annually. Evidence: 1. The most recent fall risk rating for Resident # 4 was dated 6/10/2021. 2. The most recent fall risk rating for Resident # 2 was dated 1/2/2020. 3. There was no fall risk rating for Resident # 1 provided at the time of the inspection.
Plan of Correction:	The Health Care Director or designee will conduct an audit of all current residents? fall risk ratings to ensure all current residents have a fall risk rating at least annually by 12-31-22 and ongoing.
Standard #:	22VAC40-73-350-B
Description:	Based on review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. Evidence: 1. Resident # 1 had an admission date of 2/19/2022 however the Sex Offender Screening was dated 2/26/2022. 2. Resident # 7 had an admission date of 7/9/2022 and the record did not contain a Sex Offender Screening.
Plan of Correction:	The Director of Sales and Marketing or designee will conduct an audit of all current residents? sex offender screenings by 12-31-22 and ongoing.
Standard #:	22VAC40-73-440-B
Description:	Based on document review and interview the facility failed to ensure that for private pay individuals, the UAI shall be completed by an assisted living facility staff who has successfully completed state-approved training and the form shall be signed by the administrator or the administrator?s designee. Evidence: Resident # 4?s UAI with assessment date of 5/10/2022 did not contain a signature of the assessor or administrator or administrator?s designee.
Plan of Correction:	The Health Care Director or designee will conduct an audit of all current residents? UAIs to ensure all UAIs are signed by 12-31-22 and ongoing.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview with staff, the facility failed to ensure the comprehensive individualized plan (ISP) included a description of identified needs. Evidence: 1. The Resident # 6 (ISP dated 1/24/2022) and Resident #5 (ISP dated 6/15/2022) have identified allergies which were not documented on their ISPs. 2. Resident #3 is receiving home health services which are not listed on ISP. 3. Resident # 4 is receiving hospice services which are not identified on ISP.
Plan of Correction:	The Health Care Director or designee will conduct an audit to ensure all current residents have a description of identified needs on their ISPs by 12-31-22 and ongoing.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review, the facility failed to have the individualized service plan (ISP) signed by the resident or his legal representative. Evidence: The following resident ISPs did not have a resident or legal representative signature: Resident # 1 (ISP dated 6/19/2022), Resident # 6 (ISP dated 1/24/2022), Resident # 3 (ISP dated 6/17/2022), and Resident # 5 (ISP dated 6/15/2022).
Plan of Correction:	The Health Care Director or designee will conduct an audit to ensure all current residents have a signed ISP by 12-31-22 and ongoing.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed as the condition as the resident changes. Evidence: The record for resident #4 contained an ISP last updated 5/11/2021.
Plan of Correction:	The Health Care Director or designee will conduct an audit to ensure all current residents have an ISP that has been reviewed and updated at least once in 12 months by 12-31-22 and ongoing.
Standard #:	22VAC40-73-550-G
Description:	Based on review of resident?s records, the facility failed to ensure that annual review of resident?s rights and responsibilities occur with each resident or his legal representative. Evidence: 1. Resident #3?s last documented review of Residents Rights was dated 6/9/2021. 2. Resident # 2?s file did not contain documentation that Resident Rights were reviewed.
Plan of Correction:	The Life Enrichment Director or designee will conduct an audit of current residents? documented review of resident?s rights by 12-31-22 and ongoing.
Standard #:	22VAC40-73-580-A
Description:	Based on a review of facility documentation and interview, the facility failed to ensure that it obtained an annual inspection report from the Virginia Department of Health. Evidence: The most current health inspection provided by the facility was dated 7/1/2021.
Plan of Correction:	The facility obtained a health inspection and updated records on 10-11-22.