VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harmony at Chantilly
2980 Centreville Road
Herndon, VA 20171
(703) 994-4561

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: May 24, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced focused monitoring inspection was conducted on 5/24/19 (8:00 AM - 11:23 AM) to follow-up on high-risk violations that were cited on 3/21/19. Medication administration was observed and records were reviewed. Building and grounds were inspected. 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 #:	22VAC40-73-1090-A
Description:	Based on record review, the facility failed to have each resident assessed by an independent clinical psychologist, as having a serious cognitive impairment with an inability to recognize danger or protect his own safety and welfare, prior to their admission to the safe, secure environment. Evidence: The record for Resident #2, admitted 3/15/19, was observed during the inspection. The resident record contained an Assessment of Serious Cognitive Impairment form, dated 3/14/19. The assessment form stated that Resident #2 is able to recognize danger and protect her own safety/welfare.
Plan of Correction:	The resident physically moved out on 5/31. The physician contacted to clarify the conflict information in the Assessment of Serious Cognitive Impairment form on 6/15. All current Harmony Square resident's assessment of Serious Cognitive Impairment will be reviewed to make sure information is clear and correct. To ensure ongoing compliance, HCC or designee will audit the new resident's assessment documents to make sure information completion and correctness before the move-in.
Standard #:	22VAC40-73-680-D
Description:	Based on observation and documentation, the facility failed to ensure that medications are administered in accordance with the physician's instructions. Evidence: The morning medication administration, for Resident #1, was observed during the inspection. The resident's medication was placed in a pill cup and the medication packages were returned to the medication cart. Furosemide 40mg, was among the pills that were placed in the resident's pill cup. Before the medication was administered, the licensing inspector asked about Resident #1's Furosemide. Resident #1's medication administration record (MAR) called for the resident to receive one 20mg tablet of Furosemide. The physician's order, dated 5/6/19, called for Resident #1 to receive one 20mg tablet of Furosemide during the morning medication administration.
Plan of Correction:	The medication order confirmed with physician on 5/24. The MAR record is correct. Pharmacy contacted to pack and deliver the right dose (20mg) on 5/24. All current resident June POS's will be reviewed and signed by 6/30/2019. HCC and designee will complete reconciliation to ensure medications are being administered as ordered. The HCC and/or designee will re-educate all medication staff on review of medications administered to ensure the dose administered is the dose ordered. This will also be reviewed during medication pass observations and medication cart audits as further reinforcement.