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: Oct. 2, 2024 and Oct. 29, 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 10/02/24 at 9:45 am to 2:15 pm and 10/29/24 at 9:33 am to 3:50 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 9/23/2024 regarding allegations in the area(s) of: Personnel, Resident Care and Related Services, and the Safe Secure Environment 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: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 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 #:	22VAC40-73-200-D
Complaint related:	No
Description:	Based on the record review the facility failed to ensure the facility shall obtain a copy of the certificate issued or other documentation indicating that the person has met one of the requirements of subsection C of this section, which shall be part of the staff member?s record in accordance with 22VAC40-73-250. Evidence: 1. During the onsite inspection on 10/02/24, the record for staff #2, hire date of 12/28/22, contains personal data information that documents staff #2 is employed as a personal care aide. The facility?s staff roster documents staff #2 as a personal care aide. During the Licensing Inspector review on 10/02/24, the record for staff #2 did not contain a personal care aide certificate or documentation of staff #2 meeting the qualifications as a direct care staff. 2. During the onsite inspection on 10/02/24, staff #5 reviewed the record for staff #2 and was not able to provide documentation of staff #2 qualifications as a personal care aide or direct care staff.
Plan of Correction:	The Executive Director or designee will ensure documentation of staff qualifications is on file in staff records. The ED or designee will audit staff records to ensure compliance.
Standard #:	22VAC40-73-210-B
Complaint related:	Yes
Description:	Based on the record review the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. Evidence: 1. The record for staff #2, hire date of 12/28/22, did not contain at least 18 hours of annual training during the timeframe of 12/28/22 through 10/02/24. 2. The record for staff #2 documented 3 hours of training after the employment date of 12/28/22. 3. Staff #5 reviewed the record for staff #2 and was not able to provide documentation staff #2 completed at least 18 hours of annual training.
Plan of Correction:	The Executive Director or designee will ensure that all staff must meet the training requirements to include the number of hours and special training annually.
Standard #:	22VAC40-73-210-F
Complaint related:	Yes
Description:	Based on the record review the facility failed to ensure at least two of the required hours of training shall focus on infection control and prevention. Evidence: 1. The record for staff #2, hire date of 12/28/22, did not contain documentation of completion of at least two hours of training focusing on infection control during the timeframe of 12/28/22 through 10/02/24.
Plan of Correction:	The Executive Director or designee will ensure that all staff will have 2 hours of infection control with the training year and 1 hour of infection control training will be scheduled at least twice per year.
Standard #:	22VAC40-73-250-D
Complaint related:	No
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 8/19/24, did not contain a risk assessment for TB completed on or within 30 days prior to the first day of work. 2. Staff #5 reviewed the record for staff #1 and was not able to provide documentation of a risk assessment for TB completed on or 30 days prior to staff #1?s first day of work.
Plan of Correction:	Executive Director or designee will review all staff records for current documentation of TB Assessment Screening.
Standard #:	22VAC40-73-260-A
Complaint related:	No
Description:	Based on the record review the facility failed to ensure each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment. Evidence: 1. The record for staff #2, hire date of 12/28/22, did not contain documentation of a certification in first aid. 2. During the onsite inspection on 10/02/24, Staff #5 reviewed the record for staff #2 and was not able to provide documentation of certification in first aid for staff #2.
Plan of Correction:	The Executive Director or designee will review all staff records to ensure first aid certification documentation is in each staff record
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative. Evidence: 1. Resident?s #1 ISP dated 5/28/24 does not include the signature and date the resident or the legal representative.
Plan of Correction:	HCD or designee will ensure all individualized service plans are signed by responsible participants. Will obtain copies of email correspondences to verify ISP forms are sent to responsible participants.
Standard #:	22VAC40-73-930-D
Complaint related:	Yes
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: a minimal frequency of daily rounds to be made; 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 #1 contains an ISP dated 5/28/24 that documents the following: ?2-hour rounds monitor for emergencies or other unanticipated needs.? The facility?s round logs did not include documentation 2-hour rounds were completed for resident #1 on the dates of 9/01/24 and 09/06/24. 2. The record for resident #2, contains an ISP dated 8/19/24 that documents the following: ?resident #2 will be checked on every 2 hours? The facility?s round logs did not include documentation 2-hour rounds were completed for resident #1 on the dates of 9/01/24 and 09/06/24.
Plan of Correction:	Executive Director or designee will perform daily audits of 2 hour round sheets to ensure rounds are being done as scheduled.