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: Sept. 17, 2019 and Sept. 18, 2019

Complaint Related: No

Areas Reviewed:

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

Comments:

A Representative with the Division of Licensing conducted an unannounced, mandated, monitoring inspection on 09/17/2019 from approximately 11:49 am to 4:38pm and concluded the Inspection on 09/18/2019 from approximately 10:45am to 6:10pm. At the point of entrance, the facility Administrator was available and on-site for the entire Inspection. During the Inspection the facility had 90 residents in care. The facility fire alarm was engaged and the Licensing Inspector was able to observe the facility fire evacuation plan. The Licensing Representative observed the facility physical plant, reviewed criminal background checks for all new hires since the last Inspection, reviewed 10 resident and 5 staff records, reviewed the facility medication administration pass, observed residents engaged during meals and activities, observed the facility first aid kit and the facility emergency food supply. 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 it to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance 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 preventative measures. Please contact the facility Licensing Inspector Kimberly Rodriguez at 804-396-5696 or by email at Kimberly.rodriguez@dss.virginia.gov for any additional questions or concerns.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on staff record review the facility failed to ensure each staff person required to be evaluated annually submitted the results of a risk assessment, documenting the individual is free of tuberculosis in a communicable form as evidenced by the completing of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: On 09/17/2019 documentation showed that staff #5 was hired on 02/14/2018. While reviewing staff # 5's record documentation showed that staff #5's last Tuberculosis screening was completed on 02/05/2018.
Plan of Correction:	What Has Been Done to Correct: Staff #5 obtained TB screening. An audit of TB risk assessmentshave been completed. How Will Reoccurrence Be Prevented: Upon hire, all employees will present a risk assessment. An alert file will be maintained to ensure annual assessment. Person Responsible: Business Office Manager/designee
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review the facility failed to ensure the comprehensive individualized service plan included a description of identified needs based on the UAI. Evidence: On 09/18/2019 with A Representative with the Division of Licensing documentation showed resident #1 required supervision with dressing as evidenced by the Uniform Assessment instrument that was last reviewed for resident #1 on 03/20/2019, however the need was not addressed on resident #1?s Individualized Service Plan that was completed on 03/20/2019 by the facility.
Plan of Correction:	What has been Done to Correct: Resident #1 UAI and ISP were updated on day of inspection. How Will Reoccurrence Be Prevented: Upon completion of UAI?s for residents, ISP?s will be created that identify needs of residents as indicated on UAI. Person Responsible: Healthcare Coordinator/designee
Standard #:	22VAC40-73-550-G
Description:	Based on staff record review, the facility failed to ensure the rights and responsibilities of resident in assisted living facilities were reviewed annually with each staff person. Evidence #1: On 09/17/2019 while reviewing staff records, the record for staff #5 did not contain an annual review of residents rights. Evidence#2: Documentation showed that staff #4 who was hired on 08/11/2017 last reviewed the resident rights on 02/09/2018.
Plan of Correction:	What Has Been Done to Correct: Signatures obtained from staff #4 and staff #5. How Will Reoccurrence Be Prevented: An audit ofemployee review of residents rights and responsibilities havebeen completed.Upon hire, an initial rights and responsibilities will be signed byeach employee and reviewed annually. Person Responsible: Business Office Manager/designee
Standard #:	22VAC40-73-660-A-7
Description:	Based on observation of the facility medication administration pass, the facility failed to ensure single use and dedicated medical supplies and equipment were appropriately labeled and stored. Evidence: During the facility medication administration pass with staff #1 and staff #2, once staff #2 completed the medication administration pass for resident # 11, resident #11 pulled open a kitchen drawer which contained multiple individual Lancets and a Glucometer. Based on staff #7 statements resident #11 did not have an order to self-administer and the Lancets and Glucometer should have been labeled and stored appropriately with the facility.
Plan of Correction:	What Has Been Done to Correct: Medical supplies and equipment were removed from resident #11 room on day of inspection. Medication storage policy reviewed in writing with POA and resident. How Will Reoccurrence Be Prevented: Frequent room inspections by housekeeping and clinical staff will be conducted throughout the facility to ensure medication/supplies are not in resident rooms. Person Responsible: Healthcare Coordinator and Designated person in charge.
Standard #:	22VAC40-73-970-A
Description:	Based on facility documentation the facility failed to ensure the fire and emergency evacuation drill frequency and participation was in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). Evidence #1: On 09/17/2019 facility documentation showed the past three fire drills were conducted on 08/22/2019 at 7:30am, 08/05/2019 at 3:00pm and 06/25/2019 at 2:45pm. The facility did not complete a fire drill during the month of July, 2019. Evidence #2: On 09/17/2019 facility documentation showed the past three fire drills were conducted on 08/22/2019 at 7:30am, 08/05/2019 at 3:00pm and 06/25/2019 at 2:45pm. The facility did not complete a fire drill on the facility 11:00pm to 7:00am shift.
Plan of Correction:	What Has Been Done to Correct: Staff educated on requirements for monthly fire evacuation drills. How Will Reoccurrence Be Prevented: Fire drills and emergency evacuation plans will be scheduled per alternating shift monthly, conducted, and documented according to code and regulations. Person responsible: Maintenance Director/designee