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: May 7, 2024

Complaint Related: No

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 ARTICLE 1 ? SUBJECTIVITY 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 05/07/24 from 9:07 am to 4:36 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 04/03/2024 regarding allegations in the area of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 85 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: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation of the facility?s medication cart was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on the onsite observation, record review, and staff interview the facility failed to implement a written plan for medication management to include: methods to ensure that each resident?s prescription medications and any over the counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages, and a plan for proper disposal of medication. Evidence: 1. The record for resident #1 contains the following physician orders: A physician order dated 02/06/24 for Estradiol ?apply pea sized amount around the uretha nightly;? A physician order dated 04/05/24 for Imodium, ?take 1 tablet by mouth 3 times a day PRN Diarrhea.? During the medication cart observation, the medications, Estradiol and Imodium, prescribed for resident #1 was not located on the cart. 2. Staff #1 confirmed resident?s #1 Estradiol and Imodium medications were not located on the facility?s medication carts.
Plan of Correction:	HCD/designee will ensure disposal of unused, unneeded or expired medications will be mixed in an undesirable substance prior to storing in a non-descript container or securely stored in a sealed container prior to turning them over to a disposal company. HCD/Designee will run report on a monthly basis to review with Primary Care Physician to discontinue PRN?s not used in the last 90 days. HCD/HSD will complete MAR to cart audits quarterly to assure medications ordered are physically present in the community. Initial MAR to cart audit will be complete before June 15, 2024.
Standard #:	22VAC40-73-680-D
Description:	Based on the record review the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. The record for resident #1 contains a medication error report that documents on the day of 03/31/24, the resident reported not receiving, Levothyroxine for the am dose and the? resident was given an Keflex that was discharged but still in the resident?s medication cart and slot.? 2. The record for resident #1 contains the following: a physician order dated 03/13/24 for Levothyroxine, ?Take 1 tablet by mouth every day;? a physician order dated 03/01/24 for Keflex ?take four times a day for 10 days." 3. Resident?s #1 medication administration record (MAR) includes a note for the date of 03/31/24 ?Levothyroxine, not available, will order, patient unable to make medication.? 4. During an interview with resident #1, resident #1 confirmed that on the day of 03/31/24, the resident received a dose of Keflex, and the resident did not receive a dose of Levothyroxine as prescribed.
Plan of Correction:	HCD/designee will provide re-education to RMAs based on the standard training curriculum to include proper documentation of medication administration, resident refusals, medications wasted, medication inventory and counting, dating medications when opened, and dates of expiration. HCD/designee will also provide re-education on physician orders, proper filing of orders within the wellness record, proper turnover and shift change reporting including information relevant to changes in resident medication orders, and the review of all discharge papers by the HCD/designee. New physician orders will be reviewed and signed off by HCD/designee. Medication time adjustments will be made as needed and per resident request.