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: Aug. 12, 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 8/12/24 at 9:11 am to 3:10 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 8/01/24 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: A review of the facility?s staffing schedule and medication carts 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 allegation?s area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services 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. 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 #:	22VAC40-73-450-A
Complaint related:	Yes
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 08/09/24, 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. The ISP in the record for resident #1 is dated as completed on 8/11/24. 2.The record for resident #2, admission date 8/05/24, 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 The ISP in the record for resident #2 is dated as completed on 8/11/24.
Plan of Correction:	The HCD/HSD will ensure that a preliminary plan of care is completed on or within 7 days of admission or that an ISP is completed on the day of admission. The HCD/HSD/ED or designee will review the records of all new admissions prior to move-in to assure compliance.
Standard #:	22VAC40-73-930-D
Complaint related:	No
Description:	Based on the record review the facility failed to ensure for each resident with an inability to use the signaling device the following shall be met: once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum direct care staff shall make rounds no less than every two hours; the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. Evidence: 1.The record for resident #2 contains an ISP dated 8/11/24 that documents the following: `due to physical or serious cognitive impairment resident cannot utilize call bell system; staff will perform every 2-hour checks from time resident goes to bed to waking up and about any time resident is in room resting as needed.? 2.The facility?s round logs did not include documentation 2-hour rounds were completed for resident #2 on the dates of 8/11/24 to 8/12/24 during the 11pm to 7am shift.
Plan of Correction:	A new rounding log was implemented. The HSD/ED will schedule training for all direct care staff to review use of the log and reinforce the importance of signing after completing two-hour rounds. The HSD/HCD/Executive Director or designee will audit the log daily to check for accuracy. Audits will continue for 4 months to monitor compliance.