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. 1, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/1/2023 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 8/30/2023 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 73 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: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on resident record review and interviews with staff, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of one resident. Evidence: A review of the facility?s Resident Incident Log noted two incidents where Resident #3 had falls (8/27/23 and 9/2/23) and was found on the floor. The log further stated that, ?State Notified?. The Regional Licensing Office was not notified of these incidents.
Plan of Correction:	1. Health Care Director reports all incidents and falls in real time to ensure compliance with standard. 2. An in-service will be completed with the Healthcare Director and Department Heads to ensure compliance with the standard. 3. A review of all falls and incidents are reviewed and documented in Stand-Up meeting Monday through Friday to ensure compliance with the standard. 4. Findings will be reported to the Quality Assurance Committee. Any outliers will be addressed as indicated.
Standard #:	22VAC40-73-150-C
Complaint related:	No
Description:	Based on record inspection, record review, and interview, the administration failed to oversee the day-to-day operation of the facility in a manner that ensured care is provided to residents that protects their health, safety, and well-being. Evidence: 1. Facility policy indicates all call bells will be responded to within four minutes of the initial call. The facility failed to implement this policy during multiple instances in the months of August and December 2023. 2. A review of facility documentation for August 25, 2023, through August 31, 2023, confirmed there were over 150 instances in which calls were not responded to within facility established timeframes. 3. A review of facility documentation for December 21, 2023, through December 26, 2023, confirmed there were over 90 instances in which calls were not responded to with facility established timeframes. 4. Facility administration has stated they are aware that some calls for assistance have required an excess of an hour and fifteen minutes for a response from staff. 5. Facility policy states, ?The Healthcare Coordinator and Executive Director will pull time reports weekly to ensure alerts are being answered in a timely manner and to address any issues or problems regarding the response time.?
Plan of Correction:	1. All current staff will be in serviced to standard regarding call bell response times, demonstrations to reset call bell and resident individual pendant. 2. Training will be held by Health Care Director, Maintenance, or designee. All new hires will have training regarding call bell response time, demonstrations to reset call bell and resident individual pendant reset. 3. Health Care Director will audit call bell response times daily Monday through Friday during daily Stand-Up Meeting. Any response times standards will be addressed immediately. 4. Findings will be reported to the Quality Assurance Committee for follow-up as indicated.
Standard #:	22VAC40-73-460-B
Complaint related:	No
Description:	Based on the review of facility records the facility failed to ensure that the facility provided prompt response to the residents? needs as reasonable as possible. Evidence: 1. A review of the call bell log for Resident #1 documented the facility took 46 minutes to respond to a call on 8/25/23, the facility took 40 minutes to respond to a call on 8/26/23, the facility took 2 hours and 40 minutes to respond to a call on 8/27/23, the facility took 48 minutes to respond to a call on 8/28/23, and the facility took 34 minutes to respond to a call on 8/29/23. 2. A review of the call bell log for resident # 2 documented the facility took 1 hour and 15 minutes to respond to a call on 8/25/23, the facility took 1 hour 26 minutes to respond to a call on 8/26/23. 3. On 8/26/23, Resident #2 activated the emergency call system at 3:26 am as the resident had a fall and needed immediate assistance. The resident obtained a laceration to the head and was bleeding onto the floor. After the resident was unable to obtain assistance by staff, the resident called a family member who then called the facility. According to the family member, several calls had to be made to the facility before a staff member could be reached. The family member remained on the phone line while the Staff #2 checked on the resident. Staff #2 verified the resident had fallen and EMS was alerted. The resident was transported to the Emergency Room where they obtained 5 staples to the head. The Progress Note dated 8/26/23 documents the phone call between the RMA and the family member. 4. On 8/27/24 Resident #3 pulled the call bell from the bathroom at 5:28 pm. The facility took 39 minutes to respond to the call. According to the facility?s Resident Incident Log, Resident #3 was found on the floor and the incident was documented on the Resident Incident Log at 6:00 pm. According to the Resident Progress Note, the resident was found on the bathroom floor by an RMA. 5. A review of the facility?s Emergency Call System Policy states, ? 13. All radios are to be answered as promptly as possible.? The policy further states, ?Failure to respond to an alert in a customary period of time (approximately 4 minutes) could result in disciplinary action. 6. A review of the call log from 8/25/23 through 8/31/23 documented 162 times where the facility exceeded 4 minutes in resolving resident calls. There were 40 calls where the facility exceeded 30 minutes to respond to resident calls. 7. On 12/27/2023 during an on-site visit to the facility, Licensing Inspectors interviewed several residents who stated the facility takes an extremely long time to respond to the Emergency Call System and during the overnight shift. There have been several calls where they did not receive any assistance therefore, they do not attempt to activate the system. 8. Staff #1 acknowledged the facility is working on decreasing the facility?s call response times.
Plan of Correction:	1. All current staff will be in serviced to standard regarding call bell response times, demonstrations to reset call bell and resident individual pendant. 2. Training will be held by Health Care Director, Maintenance, or designee. All new hires will have training regarding call bell response time, demonstrations to reset call bell and resident individual pendant reset. 3. Health Care Director will audit call bell response times daily Monday through Friday during daily Stand-Up Meeting. Any response times standards will be addressed immediately. 4. Findings will be reported to the Quality Assurance Committee. Any outliers will be addressed as indicated.