VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harmony at Spring Hill
8350 Mountain Larkspur Drive
Fairfax, VA 22079
(571) 348-4970

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: May 15, 2019 and May 16, 2019

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 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.

Comments:

An unannounced renewal inspection was conducted on 5/15/19 and 5/16/19. At the time of entrance, 38 residents were in care. Meals, medication administration and activities were observed. Building and grounds were inspected and records were reviewed. The sample size consisted of eight resident records and four staff records. Violations were discussed and an exit meeting was held. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1100-C
Description:	Based on record review, the facility failed to ensure that the order of priority is documented, on the written approval for placement in the special care unit. Evidence: Resident #3 was admitted to the special care unit on 4/11/19. The approval form, dated 4/8/19, was signed by a physician. No information was documented, on the approval form, to explain why the physician signed the form instead of a relative or legal representative.
Plan of Correction:	The Healthcare Coordinator will obtain signatures from family or legal representative regarding approval for placement in a special care unit within 30 days. A random review for appropriate placement in a special care unit will take place by HCC or designee. To prevent this from happening in the future, facility staff will be trained on obtaining proper approval from family or legal representative for placement on special care unit.
Standard #:	22VAC40-73-1110-B
Description:	Based on record review, the facility failed to ensure that a review of continued appropriateness was completed, six months after a resident's placement in the special care unit. Evidence: Resident #4 was placed in the special care unit in October 2018. No review of continued appropriateness was found in the resident record. Resident #5 was placed in the special care unit in April 2018. No review of continued appropriateness was found in the resident record.
Plan of Correction:	Executive Director conducted the review for appropriateness for continued placement on a memory care unit with POA for identified residents and obtained signatures. HCC and ED will audit all resident charts for missing documentation on review for continuous placement. HCC or designee will perform a random audit of charts on a monthly basis.
Standard #:	22VAC40-73-1140-B
Description:	Based on record review, the facility failed to ensure that direct care staff, in the special care unit, attend at least 10 hours of training in cognitive impairment within four months of their start date. Evidence: The record for Staff #4, hired 10/10/18, was reviewed during the inspection. Staff #4, a certified nurse assistant on the special care unit, had not completed the required 10 hours of cognitive impairment training, at the time of the inspection.
Plan of Correction:	Identified staff member will complete required training hours for cognitive impairment by 7/15/19. The Business Office Manager will audit all employee files for required training hours by 7/15/19. All staff members with insufficient hours will obtain training by 7/15/19. BOM will conduct a monthly review of employee training.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member maintains current certification in first aid. Each direct care staff member who does not have current certification in first aid, shall receive certification in first aid within 60 days of employment. Evidence: The record of Staff #4, hired 10/10/18, was reviewed during the inspection. No documentation was provided, during the inspection, to indicate that Staff #4 has current first aid certification.
Plan of Correction:	Identified staff member will obtain first aid certification by 6/30/2019. The Business Office Manager will audit all direct care staff files by 7/15/2019. All direct care staff needing first aid training will be certified by 7/31/19. Business office manager will perform a random audit for first aid certification on a monthly basis.
Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure that physical examination report includes all of the required information. Evidence: The physical examination form for Resident #2, dated 12/12/18, does not include the resident's reactions to known allergens. The physical examination form for Resident #8, dated 3/14/19, does not include the resident's reactions to known allergens.
Plan of Correction:	Identified resident's health record was updated with allergic reactions to known allergens. The Executive Director and Healthcare Coordinator will audit current resident files and review health records for new admissions to ensure that all required documentation is present. HCC will review random charts on a monthly basis for any notation of resident allergies.
Standard #:	22VAC40-73-320-B
Description:	Based on record review, the facility failed to ensure that a risk assessment for tuberculosis is completed annually, for each resident. Evidence: The last documented tuberculosis risk assessment, in the record for Resident #4, was dated 4/12/18. The last documented tuberculosis risk assessment, in the record for Resident #5, was dated 4/15/18.
Plan of Correction:	Missing TB screening for identified residents have been obtained from physician. The Healthcare Coordinator will audit all charts for annual TB screening and initiate quarterly chart review to address any discrepancies.
Standard #:	22VAC40-73-410-A
Description:	Based on record review, the facility failed to ensure that documentation of an orientation, for new residents, are kept in the resident record. Evidence: No orientation document was found in the records of Residents #2, 3, 7, and 8.
Plan of Correction:	Missing orientation checklist for residents identified were obtained. The ED and HCC will audit all resident files to address any missing orientation documentation. HCC will randomly audit charts for proof of resident orientation on a monthly basis.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure that the individualized service plan (ISP) is based upon the Uniform Assessment Instrument (UAI). Evidence: The UAI for Resident #1, dated 10/2/18, states that the resident needs mechanical and physical assistance for dressing and toileting. The UAI also states that the resident needs no assistance for transferring. The ISP for Resident #1, dated 10/2/18, indicates that the resident needs only physical assistance for dressing, supervision for toileting and mechanical assistance for transferring. The UAI for Resident #3, dated 4/9/19, states that the resident needs supervision for stairclimbing and transferring. The ISP for Resident #3, dated 4/11/19, states that the resident needs physical and mechanical assistance for stairclimbing and needs no assistance for transferring. The UAI for Resident #6, dated 11/26/18, states that the resident needs assistance for medication administration. The ISP for Resident #6, dated 11/26/18, states that the resident does not need assistance for medication administration. The UAI for Resident #8, dated 4/30/19, states that the resident needs only mechanical assistance for transferring and mobility. The ISP for Resident #8, dated 4/1/19, states that the resident needs physical assistance for transferring. The ISP also states that the resident needs supervision and mechanical assistance for mobility.
Plan of Correction:	UAI and ISP discrepancies for identified residents have been corrected. The Executive Director and Healthcare Coordinator will audit all resident charts and ensure that all UAIs and ISPs are complete and consistent. The plan will support the principles of individuality, personal dignity, freedom of choice and home-like environment and shall include other formal and informal supports that describes what services will be provided to address identified needs, and if applicable, other services and who will provide them. Executive Director or designee will randomly review UAI and ISP for discrepancies on a monthly basis.
Standard #:	22VAC40-73-450-D
Description:	Based on record review, the facility failed to ensure that hospice services are included on the individualized service plan (ISP). Evidence: The record for Resident #4 contained an order for hospice services, dated 11/16/18. Hospice services were not indicated on the resident's ISP, dated 9/18/18.
Plan of Correction:	Hospice care services for identified resident have been updated on her ISP. The Executive Director and Healthcare Coordinator will review all charts with third party services, add proper services to ISP and obtain family signature. HCC will update once and audit for new admissions.
Standard #:	22VAC40-73-450-E
Description:	Based on record review, the facility failed to ensure that the individualized service plan (ISP) is signed and dated by the administrator and by the resident or his/her legal representative. Evidence: The ISP for Resident #1, dated 10/2/18, was not signed by the administrator or the resident. The ISP for Resident #5, dated 2/15/19, was not signed by the resident or her legal representative. The ISP for Resident #8, dated 4/15/19, was not signed by the resident or his legal representative.
Plan of Correction:	Missing signatures for identified residents have been obtained. The Executive Director and Healthcare Coordinator will ensure that required signatures for ISPs are obtained within 72 hours of admission. HCC/ED will conduct an in-service to all clinical staff regarding signing ISP and obtaining resident/POA signature. ED or designee will do a random review of ISP signatures.
Standard #:	22VAC40-73-650-B
Description:	Based on record review, the facility failed to ensure that physician orders identify the diagnosis or condition for administering each drug. Evidence: Resident #1's orders for Seroquel, Bactrim DS, and Vitamin D did not contain a diagnosis or condition for their administration.
Plan of Correction:	The Healthcare Coordinator obtained missing diagnosis for identified resident. ED and HCC will audit all charts for Physician Orders and ensure that correct diagnosis is indicated. Accurate diagnosis will be obtained on admission, with new orders and quarterly with physician order sheet (POS) review.
Standard #:	22VAC40-73-650-C
Description:	Based on record review, the facility failed to ensure that physician's or other prescriber's oral orders are signed within 14 days. Evidence: Resident #2's record was reviewed during the inspection. The record contained oral orders from: 1/27/19, 1/30/19, and 1/31/19. The orders were unsigned, at the time of the inspection.
Plan of Correction:	The Healthcare Coordinator will In-Service staff by 6/30/19 in regards to obtaining MD signature on all orders within 14 days. HCC will check new orders daily and update with MD signatures obtained for unsigned orders. HCC or designee will check new orders daily and request physician signatures.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation, the facility failed to ensure that the medication storage area is locked. Evidence: During the inspection, the third floor medication room was observed to be unlocked and unattended. Several medications were observed in the room's refrigerator.
Plan of Correction:	HCC will In-Service staff in regards to secure storage of Medication (Locked Doors). Medication room doors were changed on 5/21/19, a sign in/out key log is in place for 30 days. Executive Director (ED), Healthcare Coordinator (HCC) or designee will make daily rounds to ensure medication room doors are locked.
Standard #:	22VAC40-73-680-M
Description:	Based on observation and interview, the facility failed to ensure that medications ordered for PRN administration are available and properly stored at the facility. Evidence: PRN Lorazepam, ordered 3/30/18 for Resident #4, was not present at the time of the medication cart inspection on 5/16/19. The medication cart contained a package of Lorazepam that expired on 5/15/19. Facility staff confirmed that no other Lorazepam was present for Resident #4, at the time of the medication cart inspection.
Plan of Correction:	The HCC obtained an order to discontinue PRN medication for identified resident, as she had not used it for more than 30 days. The Healthcare Coordinator will audit all medication carts for PRN medications. The Healthcare Coordinator will In-Service staff (LPN, RMA) within 30 days on medication availability. HCC or designee will review PRN medications every 30 days.
Standard #:	22VAC40-73-720-A
Description:	Based on record review, the facility failed to ensure that Do Not Resuscitate (DNR) Orders are included in the individualized service plan (ISP). Evidence: The DNR order for Resident #8, dated 3/14/19, is not included in the resident's ISP, dated 4/1/19.
Plan of Correction:	The missing code status was updated on identified resident's ISP. HCC and ED will audit all resident's ISP, HCC and ED will audit all resident's charts for appropriate code status. HCC or designee will perform a random audit on resident files for a code status on a monthly basis.
Standard #:	22VAC40-73-860-I
Description:	Based on observation, the facility failed to ensure that cleaning supplies and other hazardous materials are kept in a locked area. Evidence: Scrubbing Bubbles bathroom cleaner was found unlocked and unattended in the bathroom of Resident #5, of the special care unit. The record, for Resident #5, contains an Assessment of Serious Cognitive Impairment form, dated 10/17/18. The assessment stated that Resident #5 is unable to recognize danger or protect her own safety and welfare.
Plan of Correction:	Hazardous material was immediately removed from resident's apartment. The Harmony Square Director (HSD) will do daily room sweeps twice a day (Sign-Off Sheet) to ensure storage bins are locked and no chemicals and hazardous materials are present. Staff In-Service will be conducted by HCC, HSD and Maintenance Director. ED will review importance of safe storage handling of chemicals at monthly all staff meetings.