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 7, 2024

Complaint Related: Yes

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 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 03/07/24 from 9:11 am to 3:25 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 02/15/24 regarding allegations in the area of: Staffing and Supervision, and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 84 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: An observation of the medication storage area was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: A violation notice was issued; any violation(s) not related to the complaint 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.

Violations:

Standard #:	22VAC40-73-280-B
Complaint related:	No
Description:	Based on staff interview it was determined that the facility failed to maintain a written plan that specifies the number of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care. This plan shall be directly related to actual resident acuity levels and individualized care needs. Evidence: 1. The facility?s written plan that specifies the number of direct care staff required to meet the day to day, routine direct care needs of the residents in care was requested on 03/07/24 and was not provided. 2. Staff #3 acknowledged the facility did not have a written plan that specifies the direct care staff required to meet the day to day, routine direct care needs of the residents.
Plan of Correction:	The appropriate number of direct care staff members will be scheduled for all three shifts. Staff at the community shall meet the requirements per DSS guidelines. HCD or designee will review staffing needs on a weekly basis to ensure adequate staffing. Staffing sheets posted for each shift to allow employee to report to their duty station in a timely manner. HCD or designee shall review the payroll system to ensure ongoing compliance and present findings monthly at QAPI until 06.01.24.
Standard #:	22VAC40-73-680-C
Complaint related:	Yes
Description:	Based on the record review it was determined that the facility failed to ensure medications shall be administered not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: 1. The facility?s medication management plan dated 02/2018 documents ?medications should be given within 1 hour on either side of the specified times.? 2. Resident?s #1 medication administration record (MAR) for March 2024 documents a scheduled time of 7:00 am to take the medication, Levothyroxine. The facility?s ?Orders Charted Report? documents the resident was administered the medication more than one hour after the scheduled time on the following dates and times: 03/02/24 @ 9:48am; 03/03/24 @ 8:26 am; 03/04/24 @ 8:05am; 03/05/24 @ 8:54 am; 03/07/24 @ 9:47 am; 3. Resident?s #1 medication administration record (MAR) for March 2024 documents a scheduled time of 8:00 am to take the medications, Midodrine, Sertaline, Vitamin B-12, Vitamin D3, and Xarelto. The facility?s ?Orders Charted Report? documents the resident was administered the medication more than one hour after the scheduled time on the following dates and times: 03/02/24 @ 9:48 am; 03/07/24 @ 9:47 am. 4. Resident?s #3 medication administration record (MAR) for March 2024 documents a scheduled time of 8:00am and 6:00 pm to take the medication, Quetiapine Fumarate and a scheduled time of 8:00 am and 8:00pm to take the medications, Carbidopa-Levodopa, Latanoprost eye drops, Oyster Shell Calcium, Preservision, Systane eye drops, and Dorzolamide eye drops. The facility?s ?Orders Charted Report? documents the resident was administered the medication more than one hour after the scheduled time on the following dates and times: 03/01/24 @ 10:00 pm, and 10:13 pm; 03/02/24 @ 10:12 am; 8:09pm; 9:43 pm; 03/04/24 @ 9:47 pm;
Plan of Correction:	All medication aides and licensed nurses will be educated by the HCD/HSD on the procedure for documenting the specific reason a medication was documented as late. This information will be reviewed by the HCD/HSD on a weekly basis to determine if changes need to be made for specific residents, or if the staff assignments need to be revised to complete the medication pass in a timely manner. The HCD/HSD will review the administration of medication policy with all medication aides and licensed nurses every six months. The Pharmacy Manual will also be reviewed in relation to the procedure for ordering medications. The HCD/HSD will complete a medication pass audit on all medication aides and licensed nurses once every six months, or more often if deemed necessary based on the results of the audit.