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: June 11, 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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS

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 06/11/24 at 9:48 am to 3:25 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: 88 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Lunch was observed. The following were reviewed: staffing schedule, emergency preparedness drills, and medication carts. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-200-C
Description:	Based on the onsite staff record review it was determined that the facility failed to ensure direct care staff shall meet one of the requirements in this subsection. If the staff does not meet the requirement at the time of employment, he shall successfully meet one of the requirements in this subsection within two months of employment. Evidence: 1. The record for staff #1, hire date 03/12/24, did not contain documentation of staff #1 meeting one of the direct care staff qualifications. 2. The record for staff #1 and the facility?s staff record list, documents staff #1 position as a ?personal care aide.? Staff # 1?s record did not contain a personal care aide certification. 3. Staff # 8 was unable to provide documentation to demonstrate staff #1 meets the requirements for direct care staff.
Plan of Correction:	The business office manager or designee will perform an audit of employee files by 7/1/2024 to validate the certifications of all current employees. The business office manager or designee will collect all required certifications for employees during the hiring process. The ED or designee will validate that new employee files contain all required certifications through 12/31/2024. Date to be corrected: 7/1/2024 (audit); 12/31/2024 (monitoring)
Standard #:	22VAC40-73-250-D
Description:	Based on the record review the facility failed to ensure each staff person on or within 7 days prior to the first day of work at the facility prior to coming in contact with residents shall submit the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. Evidence: 1. The record for staff #1, hire date of 3/12/24, did not contain a risk assessment for TB completed on or within 30 days prior to the first day of work. 2. The record for staff #5, hire date of 3/15/24, did not contain a risk assessment for TB completed on or within 30 days prior to the first day of work. 2. Staff #8 confirmed the record for staff #1 and staff #5 did not contain a risk assessment for TB completed on or within 30 days prior to the first day of work for staff #1 and staff #5.
Plan of Correction:	The business office manager or designee will perform an audit of employee files by 7/1/2024 to validate that the required initial TB risk assessment is no more than 30 days prior to the employee?s date of hire. The business office manager or designee will collect required TB risk assessments dated within the required timeframe during the hiring process. The ED or designee will validate that the new employee files contain a properly dated TB risk assessment through 12/31/2024. Date to be corrected: 7/1/2024 (audit); 12/31/2024 (monitoring
Standard #:	22VAC40-73-260-A
Description:	Based on the record review and staff interview it was determined that the facility failed to ensure each direct care staff member shall maintain current certification in first aid. Evidence: 1. The record for staff # 2, hire date 10/29/22, does not contain a current certification in first aid. 2. The record for staff # 5, hire date 03/15/24, did not contain documentation of a certification in first aid. 3. Staff #8 acknowledged the records for staff #2 and staff #5 did not contain documentation of a current certification in first aid.
Plan of Correction:	The business office manager or designee will perform an audit of employee files by 7/1/2024 to validate that proof of required, current first aid and CPR training is present. Employees who are found to not have the required training will receive such training. Training will be repeated as required by the certifying agency/organization. The business office manager or designee will collect proof of required, current first aid and CPR training during the hiring process. The ED or designee will validate that the new employee files contain proof of required, current first aid and CPR training through 12/31/2024. Date to be corrected: 7/1/2024 (audit), 12/31/2024 (monitoring) Next Class scheduled: June 26, 2024 10am and 1pm
Standard #:	22VAC40-73-450-A
Description:	Based on the record review the facility failed to ensure on or within 7 days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Exception: A Preliminary plan of care is not necessary if a comprehensive individualized service plan (ISP) is developed, in conformance with this section, on the day of admission. Evidence: 1. The record for resident #1, admission date of 5/20/24 does not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission. 2. The record for resident #3, admission date 5/15/24, does not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission. 3. Staff #8 confirmed the records for resident #1 and resident #3, did not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission.
Plan of Correction:	The Health Care Director or designee will complete and finalize the ISP on the day the resident moves in or within 7 days prior. The HCD will provide ISP training, including the required timeframes for completion to all employees who develop plans of care by 7/1/2024. Date to be corrected: 7/1/2024
Standard #:	22VAC40-73-990-B
Description:	Based on the record review it was determined that the facility failed to ensure the procedures in the plan for resident emergencies required in subsection A of this section shall be reviewed by the facility at least every six months with all staff. Documentation of the review shall be signed and dated by each staff person. Evidence: 1. The record for staff #2, hire date 10/29/22, did not include evidence staff #2 reviewed the facility?s written plan for resident emergencies at least once every six months. 2. The record for staff #3, hire date 8/17/15, did not include evidence staff #3 reviewed the facility?s written plan for resident emergencies at least once every six months. 3. The record for staff #4, hire date 4/04/23, did not include evidence staff #4 reviewed the facility?s written plan for resident emergencies at least once every six months. 4. Staff #8 acknowledged the facility did not have evidence of staff #3, staff #2, staff #3, and staff #4 reviewing the facility?s written plan for resident emergencies at least once every six months.
Plan of Correction:	The administrator will assure that there is a written plan for medical emergencies in place that includes all requirements as outlined in 22VAC40-73-990. The plan will be reviewed with all employees every six months and documentation of training will be retained at the community. Additionally, every six months all employees on duty will participate in an exercise in which they carry out procedures for responding to medical emergencies based on the plan, and documentation of this training will be retained at the community. A copy of the medical emergency plan will be available in the community for staff, residents, families and legal representatives to review. Date to be corrected: 07.01.24(audit) monitoring 12.31.24