VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harmony on the Peninsula
3540 Victory Boulevard
Yorktown, VA 23693
(757) 447-3544

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: June 17, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced complaint inspection was conducted by the Licensing Inspector from the Eastern Regional Office on 06-17-2019 from 9:31 AM to 3:49 PM. The complaint was alleging concerns regarding PRN medications. There were 90 residents in care at the time of the inspection. A medication pass observation was conducted. 4 resident records and 2 staff records were reviewed. Interviews were also conducted with staff and residents. The facility received violations "under" Personnel and Resident Care and Related Services. Based on the findings during this inspection, the complaint was found to be not valid. The Administrator was not present during this inspection. The areas of noncompliance were discussed with the Director of Clinical Services to include wounds and physician's orders. Please complete the -Plan of Correction- for each violation cited on the violation notice and return it to me within 10 calendar days from today, on 07-18-2019. You will need to specify how the violation will be or has been corrected. Just writing the word corrected is not acceptable. Your plan of correction must include: 1. steps to correct the noncompliance 2. measures to prevent reoccurrences 3. person(s) responsible for implementing and monitoring each step of the corrective measures and / or the preventative measure.

Violations:

Standard #:	22VAC40-73-260-A
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure each direct care staff member maintained current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. During staff #3?s record review with staff #1, staff #3 was hired as a Registered Medication Aid on 02-22-2017. The first aid certification on file was dated with an expiration date of 02-21-2019. Staff #1 was unable to locate a current first aid certification on file for staff #3. 2. During interview, staff #1 acknowledged staff #3 was not currently certified in first aid.
Plan of Correction:	The Healthcare Coordinator scheduled staff #3 for first aid. Business Office Manager will develop spreadsheet that includes employee?s expiration dates of First Aid. Executive Director/Designee will audit the spreadsheet monthly for continued compliance.
Standard #:	22VAC40-73-660-B
Complaint related:	No
Description:	Based on observation, record review, and interview, the facility failed to ensure a resident was permitted to keep their own medication in an out-of-sight place in their room if the Uniform Assessment Instrument (UAI) has indicated that the resident is capable of self-administering medication. Evidence: 1. During the morning medication pass observation with staff #2, a tube of antibiotic ointment and a bottle of cough suppressant was observed in resident #3?s medicine cabinet; and a tube of antibiotic ointment, a bottle of Peroxide, and First Aid antiseptic were observed on resident #4?s kitchen table. 2. During resident record review with staff #1, resident #3?s current UAI dated 10-15-2018, and resident #4?s current UAI dated 07-14-2018 documented medications are to be administered by professional nursing staff. In addition, both residents did not have a physician?s order on file indicating the residents could self-administer the aforementioned medications. 3. During interview, staff #1 acknowledged resident #3 and resident #4?s UAI?s were not permitted to keep medications in their room based on the aforementioned UAI?s.
Plan of Correction:	The Healthcare Coordinator removed items from the rooms of Residents #3 and #4. Both residents and legal representatives (if applicable) have received letters that address the findings in the resident rooms and the protocol for self-administration of medication and storage. The Executive Director will send a notification to the remainder of the residents and POA?s will receive letters addressing medications in resident rooms. The Executive Director/Designee will train housekeeping and nursing staff to the medication storage policy. Both housekeeping and nursing staff will complete room inspections throughout the community during their duties. In the event an undocumented item is discovered in a resident room, staff will notify the shift supervisor. The shift supervisor will ensure we are in compliance with the medication storage policy.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on observation, record review, and interview, the facility failed to ensure medications are administered in accordance with the physician's or other prescriber's instructions. Evidence: 1. During the morning medication pass observation, resident #4?s June 2019 Medication Administration Record (MAR) documented to instill ? ribbon of Erythromycin 0.5% into the resident?s right eye for infection. At 10:10 AM staff #2 was observed administering the Erythromycin 5% eye ointment to resident #4?s left eye. 2. During interview, staff #2 reviewed the June 2019 MAR again and stated the Erythromycin 0.5% eye ointment was administered into resident #4?s left eye. 3. During resident #4?s record review with staff #1, the current physician?s orders on file dated 06-04-2019 documented ?Erythromycin 0.5% eye ointment- Instill ? ribbon into right eye four times a day for infection.? 4. During interview, staff #1 and staff #2 acknowledged resident #4?s Erythromycin 0.5% eye ointment was not administered in accordance with the physician's instructions.
Plan of Correction:	Healthcare Coordinator reviewed the medication administration policy with staff #2. The healthcare coordinator/designee will complete a medication observations with staff #2 monthly for three months beginning in July 2019. Executive Director will monitor documentation to ensure information is correct.