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: June 7, 2024

Complaint Related: Yes

Areas Reviewed:

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Technical Assistance:

N/A

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/07/2024: 9:15 AM to 10:45 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 06/06/2024 regarding allegations in the areas of: Resident Care and Related Services and Resident Accommodations and Related Provisions. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services and Resident Accommodations and Related Services. A violation notice was issued; any violation(s) not related to the self-report 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 Amanda Velasco, Licensing Inspector at (703) 397 4587 or by email at Amanda.Velasco@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-D
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure that the individualized service plan (ISP) included services provided by Hospice. Evidence: 1. Resident 1 was admitted to hospice on 05/29/2024. 2. Resident 1?s ISP was completed on 01/30/2024. 3. Resident 1?s hospice plan including what services or interventions hospice will be provided was not added to the Resident?s ISP as of 06/06/2024.
Plan of Correction:	Community will complete an audit of all residents? charts to ensure that residents? plans of care are timely updated with hospice care information. Care team will be reeducated on the importance of proper and timely documentation.
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure the ISP is signed and dated by the licensee, administrator, or his designee and by the resident or his legal representative. Evidence: 1. Resident 1?s ISP was updated on 01/30/2024 and signed by a facility representative on 02/01/2024. 2. Resident 1?s ISP was not signed by the resident or the legal representative.
Plan of Correction:	Community will complete an audit of all residents? charts to ensure that each resident? plan of care is timely updated, signed by resident, the family responsible party and the community representative. Community team will be reeducated on the importance of meeting with resident, family representative, agreeing on planned care and signing the ISP.
Standard #:	22VAC40-73-720-B
Complaint related:	No
Description:	Based on staff interview and resident record review, the facility failed to implement a system that ensure all staff are aware of residents who have a valid DNR order. Evidence: 1. The most recent Do Not Resuscitate (DNR) order for Resident 1, signed 05/20/2024, was found in the resident chart behind the resident?s face sheet. 2. During an interview with Staff 3, Staff 3 said that DNR orders are kept in the chart as the first page for staff members to reference on the front page. 3. Staff 3 also said that resident charts also have a sticker identifying the status on the chart. 4. Staff 3 confirmed this chart did not have a sticker and added that to the chart at time of interview. 5. Staff 4, over the phone, reiterated that they are supposed to be kept in the front page, but also included staff can check the electronic resident record to reference. 6. Staff 1 stated that they were not able to locate the DNR orders during an incident that occurred on 06/06/2024, while Staff 5 believes that the residents hospice team may have moved the residents? DNR order. 7. Both Staff 1 and 5 confirmed the DNR was not in the correct location according to the system the facility has in place.
Plan of Correction:	Community care team will complete an audit of all residents with DNR orders. Community will implement a consistent documentation and a filing system that will allow easy access to DNR information. Updated list of residents with DNR orders will be communicated to the team. List of residents with DNR order will be ready and within team members? reach when needed.
Standard #:	22VAC40-73-720-C
Complaint related:	No
Description:	Based on staff interview, the facility failed to ensure that the Do Not Resuscitate (DNR) DNR order was readily available to other authorized persons, such as emergency medical technicians (EMT?s) when necessary. Evidence: 1. On 06/07/2024, an initial incident report was submitted to Licensing inspector stating, ?Resident noted unresponsive in the dining room.? 2. The actions taken in response to the incident include ?Resident assessed, 911/EMS alerted, POA and NP made aware. Resident transported to [Hospital Name] for evaluation and treatment. 3. Resident 1?s business record contained DNR orders signed by physician and legal representative dated 12/28/2023 and 01/29/2024 and Resident 1?s medical record contained an updated physician order for DNR signed by both the physician and legal representative on 05/18/2024. 4. Staff 1?s written statement from 06/06/2024 confirmed that lifesaving measures were performed in the following text: ?Within 2 mins the emergency medical team arrived. Asking if he was DNR we said he was not. They questioned us why we did not start CPR and Haja explained we were instructed to wait until help arrived. Emergency services arrived asked for DNR status we provided that we do not have a DNR for this resident. They proceeded with life saving measures. As they performed those measures Fairfax County Police came and observed. Once resident stable they transported to [Name of Hospital.? 5. On 06/22/2024, a full incident report was submitted to the Licensing Inspector that included an update that stated ? Resident admitted to [Hospital Name] ICU. RP notified community on 6/11/24 that the resident expired in the hospital, no further paperwork provided. RP/NP notified.? 6. Written statements from Staff 1, 2, and 6 regarding an incident on 06/06/2024 for Resident 1 confirm that DNR orders were not available to EMT?s. 7. Staff 1?s written statement, dated 06/06/2024, included the following regarding Resident 1?s DNR order: ?As [Staff 6] as speaking with 911 and reviewing [Resident 1?s] chart for a DNR. Looking and unable to find one stating that the family has not sent bac.? 8. Staff 6, in a handwritten statement give to Staff 1 on 06/06/2024, stated ?Writer called 911 at 9:28 am. 911 asked about the resident code status. Writer respond [Resident 1] is DNR.? 9. Staff 2 sent an emailed statement to Staff 1 regarding the incident that occurred on 06/06/2024 which included the following regarding Resident 1?s DNR: ?I asked if [Resident 1] had a DNR and it was not signed by the family.? 10. Staff 1 confirmed that the DNR orders were found in Resident 1?s medical chart after the resident was transported to the hospital.
Plan of Correction:	List of residents with DNR will be readily available to the team and all other residents? care providers upon request. Care team will be reeducated on Code status and medical emergency response.
Standard #:	63.2-1808-A-6
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that each resident is afforded the opportunity to participate in the planning of his program of care and medical treatment at the facility and the right to refuse treatment. Evidence: 1. Resident 1 has an active Do Not Resuscitate (DNR) order signed on 05/18/2024. 2. In an emergency incident that occurred on 06/06/2024, life saving measures were performed on Resident 1 by EMS due to the facility failing to locate the DNR order during the incident. 3. Staff 1 confirmed that the facility did not initiate lifesaving procedures; however, EMT?s provided life saving measures because a DNR could not be located. 4. Resident 1 was stabilized and transported to the hospital where the resident remained until passing on 06/11/2024.
Plan of Correction:	Community will reeducate the team on resident?s right to participate in care planning. Updated list of residents with DNR order will be communicated to the team, residents with DNR list will be available when needed.