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: July 9, 2021 , July 20, 2021 , Aug. 25, 2021 and Aug. 27, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A non-mandated self-report inspection was initiated on 7-9-21 and concluded on 8-27-21. A self-reported incident was received by the department regarding allegations in the areas of resident care and related services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on 8-26-21. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-460-D
Description:	Based record review and staff interview, the facility failed to ensure it provided supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises. Evidence: 1. On 7-6-21, the licensing inspector received an initial incident report documenting resident #1 was ?located in adjacent neighborhood?. 2. Resident #1?s individualized service plan (ISP)s dated 5-27-21 and 7-11-21 documented resident?s need for placement on the facility?s safe, secure unit (Memory neighborhood) for ?safety and constant supervision?. Resident #1?s ISP date 7-11-21 documented resident?s exit seeking behavior need on 6-1-21. Resident #1?s nurse?s notes also documented resident?s exit seeking behaviors: (a) 5-30-21 note at 9:53 p.m., resident forced emergency door open and exiting building to courtyard; (b) 6-4-21 note at 7:35 p.m., resident attempted to exit unit three times on 7-3; (c) 6-22-21 note at 10:56 a.m., resident still trying to leave community with belongings; (d) 6-23-21 note at 6:13 p.m., resident forced exit door to courtyard open, staff coaxed resident back into building; (e) 6-26-21 note at 6:06 p.m. resident forcibly opened exit door to courtyard and resident coaxed back into building; (f) on 6-29-21 note at 11:06 a.m. resident attempted to open back door into courtyard, resident was coaxed back inside; (g) on 7-2-21 note at 4:22 p.m., resident found in dining room had removed screws from the window frame, was removing the screen to attempt to climb out, resident coaxed back inside and (h) on 7-4-21 note at 8:23 a.m., resident got out the side door and into the courtyard. Resident went out of the gate and left the property. 3. The local police was called by facility staff to assist in locating resident #1. Local authorities located the resident in the driveway of a residential neighborhood approximately 1.06 miles from the facility. On 8-27-21, collateral interview and police report confirmed the location of the resident at an address in the local community. 4. Observation of the area confirmed the highway from the facility to the neighborhood is a four lane highway with divided median and a speed limit noted 45 mph at 5:59 a.m. 5. Interviews with staff #2 and #3 confirmed resident #1 left the facility around 3 or 4:00 a.m. on the morning of July 4, 2021 and was located by local authorities in the community. 6. On 8-26-21 and 8-27-21, staff #1 acknowledged resident #1 exited the safe, secure unit and was located in a neighborhood in the community.
Plan of Correction:	What Has Been Done to Correct? Resident #1 was discharged from the community. How Will Recurrence Be Prevented? A review during the assessment process will be completed to identify wandering behavior and implement appropriate interventions. Person Responsible: HCD, or Designee