VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harmony at Harbour View
5871 Harbour View Boulevard
Suffolk, VA 23435
(757) 214-6279

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: March 2, 2021 and March 3, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on March 2, 2021 and concluded on March 3, 2021. A complaint was received by the department regarding allegations in the areas of Special Care Unit requirements. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Executive Director a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-1180-B
Complaint related:	Yes
Description:	Based on observation and discussion, the facility failed to ensure ordinary materials that may be harmful to a resident are inaccessible to the resident except under staff supervision. Evidence: 1. During a virtual tour of the Special Care Unit ?Harmony Square? on 03-02-2021, bathrooms in H-111 and H-112 had unlocked drawers with mouthwash, toothpaste, and shampoo. 2. Staff #1 confirmed Resident #5 has a history of attempting to access materials that may be harmful. 3. ?End of Shift? report notes documented for Resident #5: a. 02-02-21 11 p.m. ? 7 a.m., ?[Resident #5]? walking hall?going into residents rooms during the night?? b. 02-19-21 3 p.m. ? 11 p.m., ?[Resident #5] ?in the dinning room while kitchen staff was cleaning up they came and got us said [Resident #5] was trying to drink the solution that they mop with.? 4. Staff #1 acknowledged the broken locks in resident bathrooms and aforementioned information.
Plan of Correction:	What Has Been Done to Correct? A training was completed with the dining team to reiterate safety and the oversite of harmful materials. Locks were repaired in bathrooms where toiletries are stored. Auto locking mechanism installed on kitchen door. How Will Recurrence Be Prevented? Random audits are being completed and results reported to the Executive Director. Person Responsible: ED/Harmony Square Coordinator/Designee
Standard #:	22VAC40-73-450-A
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) included the resident?s identified need, date identified, and expected outcome date. Evidence: 1. Resident #1?s current Uniform Assessment Instrument (UAI) dated 11-05-2020 documented need for mechanical assistance with stairclimbing, and mechanical assistance and supervision with mobility. Additionally, fall risk rating dated 10-01-2020 documented resident is a high risk for falls. 2. Resident #1?s current ISP dated 02-04-2021 did not document the type of mechanical device needed for stairclimbing and mobility, nor a high risk for falls. Additionally, the dates identified and expected outcome dates were not documented for toileting and transferring. 3. Resident #3?s current UAI dated 04-14-2020 documented need for human help, physical assistance with transferring and stairclimbing. 4. Resident #3?s current ISP dated 07-07-2030 did not document assistance needed for transferring or stairclimbing. 5. Staff #1 and staff #2 acknowledged resident #1 and resident #3?s aforementioned needs and dates were not identified on the ISP.
Plan of Correction:	What Has Been Done to Correct? The UAI and ISP of resident #1 and #3 were corrected. How Will Recurrence Be Prevented? The UAI/ISP will be reviewed for accuracy to ensure the resident?s identified needs are addressed including the date identified and expected outcome date. Person Responsible: ED/Designee
Standard #:	22VAC40-73-570-C
Complaint related:	No
Description:	Based on record review and discussion, the facility released information regarding the resident?s personal affairs without the written permission of the resident or his legal representative. Evidence: 1. Resident #1 went on LOA on 02-07-2021. Resident?s responsible party was given Resident #4?s Acetaminophen 500 mg, Vitamin D3 1,000U, Hyoscyamine .0125mg, and Prochlorperazine 10mg. 2. Neither Resident #4 or his legal representative gave permission nor was facility aware Resident #1 had Resident #4 medications until later notified. 3. Staff #1 confirmed during discussion the aforementioned information.
Plan of Correction:	What Has Been Done to Correct? The healthcare director completed a training on the leave of absence protocol with mediation administration staff regarding verifying all documentation prior to release. How Will Recurrence Be Prevented? Leave of absence documentation will be reviewed for accuracy. Person Responsible: Healthcare Director/Designee
Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to implement its written plan for medication management ensuring each resident's medications are refilled in a timely manner. The plan was implemented and revised 02/2018. Evidence: 1. Resident #1?s January 2021 and February 2021 Medication Administration Record (MAR) documented staff did not administer Memantine 28mg on 01-22-2021, and Mirtazapine 30mg on 02-15-2021. The documented reasons Memantine was not administered was ?med was order?; and Mirtazapine was ?out of meds?. 2. Resident #2?s February 2021 MAR documented staff did not administer Sertraline 50mg on 02-01-2021, 02-02-2021, or 02-08-2021. The documented reason for Sertraline 50mg not administered was ?on order, awaiting pharmacy?. 3. Resident #3?s January 2021 and February 2021 documented staff did not administer Buspirone 10mg on 01-31-21 or 02-01-2021, and Escitalopram 20mg or Mirtazapine 15mg on 01-31-2021, 02-01-2021, 02-05-21, nor 02-07-21. The documented reason for January 2021 medications was ?not available? and ?on order? for the February 2021 medications. 4. Staff #1 and staff #2 acknowledged facility did not implement its plan/policy for medication management to ensure medications were refilled in a timely manner to avoid missed dosages.
Plan of Correction:	What Has Been Done to Correct? A reconciliation of resident #1, 2, and 3?s mediation was completed to ensure availability of all medications. How Will Recurrence Be Prevented? The health care director completed a training with the medication administration staff on following all directives of the physician order and Harmony medication reordering process. Person Responsible: Healthcare Director/Designee