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: July 18, 2019 , July 19, 2019 and July 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:

Monitoring inspections were conducted on 7/18/19, 7/19/19, and 7/24/19. Facility documents and resident 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 #:	22VAC40-73-1130-A
Description:	Based on documentation, the facility failed to ensure that when 20 or fewer residents are present, at least two direct care staff members are awake and on duty at all times in each special care unit. For every additional 10 residents, or portion thereof, at least one more direct care staff member shall be awake and on duty in the unit. The requirements in subsections A and B of this section are independent of 22 VAC 40-73-280 D and 22 VAC 40-73-1020 A. Evidence: The facility's daily staffing sheets were reviewed during the inspection. Only one staff member was listed during the night shift, in the special care unit, on the following dates: 7/6/19, 7/13/19, and 7/14/19.
Plan of Correction:	The Executive Director or designee will reeducate nursing leadership responsible for the clinical staff schedule creation and maintenance on the required staffing ratios for both memory care and assisted living. The posted schedule will reflect and mirror the daily assignment sheets. The posted schedule will indicate that the community has at least 2 direct care staff in the secure unit at all times, when 20 or fewer residents are present, and at least one more direct care staff member for every additional 10 residents, or portion thereof, who shall be responsible for the care and supervision of the residents. Additionally, the schedule will reflect adequate staffing to cover break times. The Healthcare coordinator or designee will review staff schedules daily at Standup to ensure sufficient staffing.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation, the facility failed to ensure that the medication storage area is locked. Evidence: During a walkthrough on 7/18/19, the third floor medication cart was observed to be unlocked and unattended.
Plan of Correction:	The Healthcare coordinator (HCC) provided individual coaching with the Medtech on duty and re-educated all Medtechs and nurses regarding keeping the medication carts and medication room secured at all times. The Executive Director and HCC will make random cart audits to ensure they are locked on daily basis and ongoing.