VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harmony at Spring Hill
8350 Mountain Larkspur Drive
Fairfax, VA 22079
(571) 348-4970

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: March 8, 2023 and March 9, 2023

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 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS

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: 3/8/23 (7:48 AM ? 5:50 PM), 3/9/23 (8:20 AM ? 3:15 PM) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of participants present at the facility at the beginning of the inspection: 54 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: eight Number of staff records reviewed: four Number of interviews conducted with participants: five 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 Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure that each staff member annually submits the results of a risk assessment, documenting that the individual is free 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. Evidence: Staff #3?s record was reviewed, during the inspection. The most recent tuberculosis risk assessment, included in Staff #3?s record, was dated 3/23/19.
Plan of Correction:	BOM will complete an audit of all current employees TB risk assessment to ensure assessments meet compliance. The BOM or designee will present findings of the monthly TB risk assessment audit at the QAPI meeting until 6/30/23.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member maintains 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. Each direct care staff member who does not have current certification in first aid of this subsection shall receive certification in first aid within 60 days of employment. Evidence: The record of Staff #4, hired 8/5/20, was reviewed during the inspection. Staff #4?s record contained first aid certification that expired in July 2022.
Plan of Correction:	A first aid certification course has been scheduled and will be offered to facility staff. The BOM will conduct an audit of current direct care staff first aid certifications to ensure first aid certifications meet compliance. In order to ensure future compliance, the BOM or designee will present the findings of the monthly audit of all current direct care staff members? first aid certification statuses at QAPI meeting until 6/30/23.
Standard #:	22VAC40-73-325-C
Description:	Based on record review, the facility failed to document the analysis and circumstances of the fall and interventions initiated to prevent or reduce subsequent falls. Evidence: Resident #5?s record was reviewed during the inspection. Resident notes indicate that Resident #5 was found on the floor on 1/5/23. No documentation was provided, during the inspection, of an analysis of the circumstances of the fall and interventions that were initiated.
Plan of Correction:	The HCD 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. The HCD or designee will present the findings of the monthly audit of all due fall risk ratings at QAPI meeting until 6/30/23.
Standard #:	22VAC40-73-440-L
Description:	Based on record review, the facility failed to ensure that completed UAI (Uniform Assessment Instrument) is maintained in the resident?s record. Evidence: Resident #7?s record was observed during the inspection. Resident #7?s UAI was not included in her resident record. Facility staff reported that a UAI was completed in December 2022, but it was not placed in the resident record. Resident #8?s record was observed during the inspection. The UAI, included in Resident #8?s record was completed in 2020. Facility staff reported that a UAI was updated in March 2022, but it was not placed in the resident record.
Plan of Correction:	The HCD or designee will conduct an audit of all current residents UAI?s to ensure all UAI?s are current and meets compliance. In order to ensure future compliance, the HCD or designee will present the findings of the monthly audit of all due UAIs at QAPI meeting until 6/30/23.
Standard #:	22VAC40-73-450-E
Description:	Based on record review, the facility failed to ensure that the individualized service plan (ISP) is signed and dated by the licensee, administrator, or their designee, (i.e., the person who has developed the plan), and by the resident or his/her legal representative. Evidence: Resident #6?s ISP, dated 2/26/23, was observed during the inspection. The ISP was not signed by the resident or his legal representative. Resident #7?s ISP, dated 2/27/23, was observed during the inspection. The ISP was not signed by the resident or her legal representative.
Plan of Correction:	The HCD or designee will conduct an audit of all current ISP?s to ensure all ISP?s are signed by the resident or legal representative. In order to ensure future compliance, the HCD or designee will present the findings of the monthly audit of all due ISPs at QAPI meeting until 6/30/23.
Standard #:	22VAC40-73-640-A
Description:	Based on record review, the facility failed to implement the medication management plan. Evidence: Resident #8?s record was observed during the inspection. Resident #8?s record contained an order, dated 10/26/20, that states that the resident may administer her own meds and that her husband is helping. The record of Resident #8?s husband, Resident #9, did not contain documentation that he is a licensed health care professional or a registered medication aide. Resident #8?s record included documentation about her dementia diagnosis. The facility?s medication management plan indicated that residents would be evaluated on their ability to self-administer medication at least annually. No self-administration evaluation, was observed in Resident 8?s record during the inspection. Resident #8 was not listed as being included in the self-administration evaluations, that are conducted as part of the facility?s health care oversight on: 3/2/23, 6/4/22, or 3/29/22.
Plan of Correction:	HCD will complete an audit of residents self-administering medications to ensure the self-administration evaluation is completed and meets compliance.
Standard #:	22VAC40-73-660-A
Description:	Based on observation, the facility failed to ensure that a medicine cabinet, container or compartment is used for the storage of medications and that the storage area remains locked. Evidence: A medication tablet was observed on the floor, next to the memory care wellness office, shortly after 9:40 AM on 3/8/23. During the observed medication pass in memory care on 3/8/23, the medication cart was left unlocked and the keys were left at the medication cart. The staff member had left the cart to pass medication, and the other staff member was serving meals.
Plan of Correction:	Staff members will be reeducated on the importance and safety of securing medication carts properly via in-service.
Standard #:	22VAC40-73-680-D
Description:	Based on record review, the facility failed to ensure that medications are administered in accordance with the physician?s or other prescriber?sinstructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Resident #2?s MAR (medication administration record) was reviewed during the inspection. Resident #2?s MAR stated that her Carbidopa-Levodopa was not administered during the 8 AM and 2 PM medication administrations on 2/15/23. The MAR noted on the 8 AM administration that a refill was requested. The MAR noted on the 2 PM administration that the medication was pending delivery. Resident #10?s MAR was reviewed during the inspection. Resident #10?s MAR noted that her Famotidine was not administered during the noon administrations on 2/11/23 and 2/12/23. The MAR noted that the medication was not administered on those dates as they were waiting for a new prescription.
Plan of Correction:	Med techs and LPN?s will be reeducated to ensure that medications are administered in accordance with the physician?s instructions and consistent with the standards of practice outlines in the current medication aid curriculum approved by the Virginia Board of Nursing. HCD or designee will present the findings of a weekly MAR review at QAPI meeting until 6/30/23 to ensure ongoing compliance with the components of this plan of corrections.
Standard #:	22VAC40-73-860-I
Description:	Based on observation and record review, the facility failed to ensure that cleaning supplies and other hazardous materials are stored in a locked area. Evidence: Polident denture cleaning tablets were observed, to be unlocked and unattended, in the bathroom of Resident #7 on the memory care unit.
Plan of Correction:	In-service will be conducted to re-educate staff on ensuring that cleaning supplies and other hazardous materials are stored in a locked area. HCD or designee will present the findings of room rounds at QAPI meeting until 6/30/30.