VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harris Manor 2
15609 Kellers Mill Road
Dewitt, VA 23840
(804) 283-2111

Current Inspector: Belinda Dyson (804) 662-9780

Inspection Date: Aug. 15, 2019

Complaint Related: No

Areas Reviewed:

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 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

An unannounced renewal inspection was conducted on 8/15/19 by 2 licensing inspectors from approximately 10:50 a.m. - 12:15 p.m. There is currently 1 resident in care; the resident attends day support. A tour of the facility was completed. A sample of 1 resident record and 3 staff records were reviewed. Facility documentation, staff schedule, activity and menu calendars were reviewed. Medication administration records (MAR) and physician orders were reviewed. The fist aid kit supplies and emergency food/water supplies were checked. Staff interview was conducted. An exit meeting was held. Violations were cited during this inspection. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the Inspector within 10 days. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Please contact me by e-mail at T.Lesley@dss.virginia.gov if further assistance is needed.

Violations:

Standard #:	22VAC40-73-440-L
Description:	Based on review of resident records, facility documentation and interview with staff, the facility failed to ensure that a completed annual Uniform Assessment Instrument (UAI) be maintained in the resident's record. Evidence: 1) At the time of inspection, there was not a current, annual UAI available for review in resident #1 record; the most current UAI available in the record was dated 7/10/18. 2) At the time of inspection, the facility manager contacted a district 19 community service board case manager via telephone regarding the receipt of the annual UAI for resident #1. The case manager confirmed that the UAI was completed on 7/26/19, however a copy had not been sent to the facility.
Plan of Correction:	The Administrator will contact the appropriate agency to obtain a copy of the completed UAI and place in the resident records. The Administrator will ensure that all completed UAI's be obtained from the assessor and placed in the resident record.
Standard #:	22VAC40-73-990-B
Description:	Based on review of facility documentation and interview with staff, the facility failed to review the plan for resident emergencies with staff, at least every six months. Evidence: 1) At the time of inspection, there was no record of review available to confirm that the procedures in the plan for resident emergencies were reviewed with staff within the last 6 months. 2) The facility manager confirmed during interview that the procedures in the plan for resident emergencies had not been reviewed with staff, as she thought this was covered under the review of emergency preparedness and response plan.
Plan of Correction:	The Administrator will implement a new form to document the review of practice plan for resident emergencies with staff. The Administrator will review records quarterly to ensure all plans are reviewed and records are up to date.