Harmony at Spring Hill
8350 Mountain Larkspur Drive
Fairfax, VA 22079
(571) 348-4970
Current Inspector: Amanda Velasco (703) 397-4587
Inspection Date: July 10, 2024
Complaint Related: Yes
- Areas Reviewed:
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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 BUILDINGS AND GROUND
22VAC40-73 EMERGENCY PREPAREDNESS
ARTICLE 1 ? SUBJECTIVITY
63.2- (1) GENERAL PROVISIONS
22VAC40-80 COMPLAINT INVESTIGATION
- Technical Assistance:
-
Annual Training, Oxygen Orders
- Comments:
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Type of inspection: Complaint
A complaint was received by VDSS Division of Licensing on 06/27/2024 regarding allegations in the area(s) of: resident care & related services and resident accommodations and related provisions.
Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection:
07/10/2024 1:35 PM to Approximately 4:00 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: 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: 1
Number of staff records reviewed: 3
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 3
Observations by licensing inspector: Activities.
Additional Comments/Discussion: N/A
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 #: 22VAC40-73-1130-C Complaint related: No Description: Based on facility document review and staff interview, the facility failed to ensure that when 23 to 32 residents are present, at least three (3) direct care staff members are always awake and on duty.
Evidence:
1. On the date of inspection, the census for the Special Care Unit was 24, with 23 residents on site and one (1) resident on leave.
2. Staff 1 confirmed that from June 16th to June 23rd, 2024, there were 24 residents in the unit. After June 23rd, the census remained at 23.
3. The June 2024 staff scheduled revealed that on June 18, 2024, and June 19, 2024, there was only one (1) direct care staff scheduled in the Special Care Unit from 3:00 PM to 4:30 PM.
4. In an interview with the LI on 07/10/2024, Staff 2 stated that on these days, a direct care staff from Assisted Living was pulled to support from 3:00 PM to 4:30 PM when an additional direct care staff would arrive.
5. The June 2024 staff scheduled revealed that on the following dates, there was only two (2) direct care staff scheduled from 4:30 PM to 11:00 PM for the Special Care Unit.
a. June 18, 2024
b. June 26, 2024
c. June 19, 2024
6. In an interview with the LI on 07/10/2024, Staff 2 stated that on these dates, there was a floating medication aide that supported the Assisted Living and Memory Care unit.
7. The June 2024 staff scheduled revealed that on the following dates, there was only two (2) direct care staff scheduled on the 11:00 PM to 7:00 AM shift for the Special Care Unit.
a. June 16, 2024
b. June 18, 2024
c. June 19, 2024
d. June 21, 2024
e. June 22, 2024
f. June 23, 2024
g. June 25, 2024
h. June 26, 2024
i. June 28, 2024
j. June 29, 2024
8. In an interview with the LI on 07/10/2024, Staff 2 stated that on June 25, 2024, and June 25, 2024, the gap in direct care was filled by a memory care medication aide.
9. The June 2024 staff scheduled revealed that on June 20, 2024, and June 22, 2024, there was only (2) direct care staff scheduled on the Special care unit for the 3:00 PM to 11:00 PM shift.
10. During the preliminary exit meeting with the LI on 07/10/2024, Staff 1 and 9 reviewed the staff ratios for Special Care Units with the LI for the facility. Staff 1 and 9 stated that they always had two (2) staff in the building and were not aware that they had met the range for needing three (3) staff.Plan of Correction: Community has adjusted the team members? schedules, to reflect 3 team members are awake and on duty
Standard #: 22VAC40-73-325-B Complaint related: No Description: Based on resident record review and staff interview, the facility failed to ensure that a fall risk rating was completed upon admission, annually, and after a fall.
Evidence:
1. Resident 1?s progress notes document an incident on 06/19/2024 at 7:05 AM completed by Staff 2.
2. The progress notes state ?Resident observed on the floor in her apartment next to the bed during morning rounds. The CNA and I got her back in the bed, provided care and made her comfortable. NP notified, DON notified, left voicemail for daughter [NAME] around 6:40 AM.?
3. A fall risk rating was not completed for Resident 1 after the incident. The date of the last fall risk rating provided by Staff 2 was 03/03/2023.
4. Staff 2 stated it was not completed due to Resident 1?s hospital visit on 06/23/2024 and would be completed upon return.Plan of Correction: Community will reassess all residents and will complete fall risk assessment for residents upon admission, annually or after fall.
Standard #: 22VAC40-73-930-D Complaint related: No Description: Based on facility document review and staff interview, the facility failed to ensure that for each resident with the inability to use a signaling device, rounds were documented and included the name of the resident, the date and time of the rounds, and the staff member who made the rounds.
Evidence:
1. Resident 1 resided in the Special Care Unit of the facility.
2. Resident 1?s record contains an individualized service plan (ISP), dated 02/28/2024, that stated the following under the Emergency Response Category ?Resident is unable to utilize the emergency response system; may have frequent monitoring in place. Anytime during shift as needed.?
3. Resident 1?s ISP, dated 02/28/2024, stated the following under the Functional Status Check category ?2 Hour Rounds- Monitor for emergencies or other unanticipated resident needs.?
4. Staff 2 stated that the facility was completing two-hour rounds on all residents in the Special Care Unit.
5. Staff 2 stated there was no documentation of rounds being completed in the Special Care Unit, but they were in progress of implementing a system for documentation.Plan of Correction: Community will assess residents? ability to use signaling devices. Rounds will be conducted frequently and documented to reflect residents? names, date and times rounds were completed.
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.