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: Nov. 5, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE.

Technical Assistance:

Documentation was discussed with the provider.

Comments:

An unannounced monitoring inspection was conducted on 11/5/19 (8:20 AM - 6:10 PM). At the time of entrance, 49 residents were in care. Meals, medication administration, and activities were observed. Building and grounds were inspected and records were reviewed. The sample size consisted of eight resident records and four staff records. 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 #:	22VAC40-73-1110-A
Description:	Based on record review, the facility failed to ensure that, prior to admitting a resident with serious cognitive impairment; the licensee, administrator, or designee determines whether placement in the special care unit is appropriate. The determination and justification for the decision shall be retained in the resident's file. Evidence: The record for Resident #6 was reviewed during the inspection. The record indicated that Resident #6 was admitted into the special care unit on 2/13/19. The record contained an administrator determination, dated 4/10/19.
Plan of Correction:	Resident #6?s H&P states that Resident is appropriate for a Specialized Memory Care Unit. The Administrator will determine whether placement in the Memory Care Neighborhood is appropriate and will sign and date the acknowledgement prior to move in. The Healthcare Director and Executive Director audited files of other residents in the Memory Care Neighborhood to verify form reviews and signatures were completed within the appropriate timeframe prior to move in. No issues were found. The Healthcare Director or designee will audit files monthly after initial move-in to confirm the acknowledgements are signed and dated appropriately.
Standard #:	22VAC40-73-1110-B
Description:	Based on record review, the facility failed to ensure that the administrator or designee performed a review of the appropriateness of each resident's continued residence in the special care unit, six months after the resident's placement. Evidence: The record for Resident #6 was reviewed during the inspection. The record indicated that Resident #6 was admitted, to the special care unit, on 2/13/19. The most recent review of continued appropriateness, found in the record, was completed on 5/10/19. No documentation was provided, during the inspection, to indicate that the resident had a review of continued appropriateness in August 2019.
Plan of Correction:	Resident #6?s reassessment was conducted four (4) months too soon. The Executive Director and Healthcare Director will conduct cognitive reassessments six (6) months after date of admission. The acknowledgement of Continued Appropriateness for the Memory Care Neighborhood will be signed and dated accordingly after the first six (6) months of admission. The Executive Director or Healthcare Director is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-210-B
Description:	Based on record review, the facility failed to ensure that direct care staff attend at least 18 hours of training annually. EXCEPTION: Direct care staff who are licensed health care professionals or certified nurse aides shall attend at least 12 hours of annual training. Evidence: The record of Staff #1, hired 1/9/17, was reviewed during the inspection. The record for Staff #1, a certified nurse aide, contained seven hours of annual training within the review period (1/9/18 - 1/9/19).
Plan of Correction:	Staff #1, hired 1/9/2017, will complete five (5) hours of required approved training by 12/04/2019. The Healthcare Director, (HCD), Executive Director, (ED), and Business Office Manager, (BOM), or designated Coordinator will perform monthly audits of employee files, to verify that Direct Care Staff have at least 12 hours of annual training. The Executive Director, (ED), or designated Coordinator is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-250-C
Description:	Based on record review, the facility failed to ensure that the required personal and social data are included in the staff record. Evidence: The record of Staff #3 was reviewed during the inspection. The record for Staff #3, hired 5/16/18, did not contain a copy of the staff member's job description. The record of Staff #4 was reviewed during the inspection. The record for Staff #4, hired 3/29/19, did not contain documentation that the staff member completed orientation training.
Plan of Correction:	Staff #3, hired 5/16/18, reviewed job duties and signed Job Description on 11/15/2019. The Executive Director and Business Office Manager will perform monthly audits of employee files, to verify that all staff members have signed Job Descriptions in the personnel files. The Executive Director or designated Coordinator is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. Staff #4, hired 3/29/19, was reoriented and signed the Record of Initial Staff Training on 11/6/2019. The Executive Director, (ED), and Business Office Manager, (BOM), will perform monthly audits of employee files, to verify that all staff members have signed Records of Initial Staff Training in the personnel files.
Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure that each staff member submits the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: The record for Staff #4 was reviewed during the inspection. No documentation was provided, to indicate that Staff #4 provided the results of a tuberculosis risk assessment within the past year. There was a risk assessment in Staff #4's record, dated 8/28/19, but it did not include the findings from the risk assessment.
Plan of Correction:	Staff #4, assessed for TB on 8/28/2019, was reassessed on 11/06/2019 by the Healthcare Director, with no findings and the form was completed. The Executive Director and Business Office Manager will perform monthly audits of employee files, to verify that all staff members have completed TB Risk Assessment Forms in the personnel files.
Standard #:	22VAC40-73-680-D
Description:	Based on record review, the facility failed to ensure that medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Resident #3 receives Lisinopril and Amlodipine Besylate daily for hypertension. Resident #3's record contained an order, dated 9/17/19, that calls for the resident's blood pressure medications to be held when the resident's systolic blood pressure (SBP) is less than 90 or the diastolic blood pressure (DBP) is less than 60. Resident #3's medication administration record (MAR) states that Lisinopril and Amlodipine were administered on 10/3/19 (DBP= 54) and 10/5/19 (DBP= 51). The MAR for Resident #7 was reviewed. Resident #7 has her blood sugar (BS) checked four times per day, and the MAR calls for her to receive Novolog units (U) based on a sliding scale. Resident #7's MAR included the following sliding scale for Novolog administration: 1U (BS= 150 - 199), 2U (BS= 200 - 249), 3U (BS= 250 - 299), 4U (BS= 300 - 349), and 5U (BS= 350 - 400). The MAR included the following administration of Novolog for Resident #7: zero units (BS= 184) on 10/1/19 at 8 AM, 3U (BS= 240) on 10/3/19 at 8 PM, 3U (BS= 318) on 10/6/19 at 5:30 PM, 2U (BS= 300) on 10/6/19 at 8PM, 3U (BS= 245) on 10/14/19 at 8PM, 4U (BS= 388) on 10/15/19 at 5:30 PM, 4U (BS= 400) on 10/16/19 at 5:30 PM, 3U (BS= 244) on 10/18/19 at 5:30 PM, 4U (BS= 363) on 10/20/19 at noon, 4U (BS= 350) on 10/20/19 at 5:30 PM, 4U (BS= 400) on 10/20/19 at 8 PM, 4U (BS= 400) on 10/31/19 at 8 PM, and 2U (BS= 256) on 11/2/19 at 8 PM.
Plan of Correction:	Resident #3 has a physician signed order for Lisinopril and Amlodipine Besylate, (with parameters respectively), in the medical chart, prescribed by the Hospice provider. Resident #3?s Hospice provider was notified. There were no adverse effects from the medication administration outside of ordered parameters. The Healthcare Director and Executive Director performed an audit to confirm that there are current orders for parameters in resident charts, for those requiring parameters. No issues were identified. Staff were re-educated and corrective disciplinary action was taken. The Healthcare Director will verify the orders for medication parameters upon admission, and will verify new orders for parameters due to change in condition and will confirm the orders are accurately implemented. The Healthcare Director or designee will audit parameter orders monthly for three months to confirm the orders are complete and signed and will report the results to the leadership team. During and at the end of the 3 months, the leadership team will evaluate the results of the audits and determine if additional focus or action is warranted. The Executive Director or designated Coordinator is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. Resident #7 has a physician signed orders for blood sugar checks four (4) times per day, with Novolog units based on a sliding scale, with specific parameters in place. Resident #7?s physician was notified of the medication administered outside of ordered parameters. There were no adverse effects from the medication administration. Staff were re-educated and corrective disciplinary action was taken. The Healthcare Director and Executive Director performed an audit to confirm that there are current orders for parameters in resident charts, for those requiring parameters. No issues were identified. Staff were re-educated on checking parameters, and correctly reading and dialing the doses on the insulin pens. The Healthcare Director will verify the orders for medication parameters upon admission, and will verify new orders for parameters due to change in condition and will confirm the orders are accurately implemented. The Healthcare Director or designee will audit parameter orders monthly for three months to confirm the orders are complete and signed and will report the results to the leadership team. During and at the end of the 3 months, the leadership team will evaluate the results of the audits and determine if additional focus or action is warranted. The Executive Director or designated Coordinator is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-860-I
Description:	Based on observation and record review, the facility failed to ensure that cleaning supplies and other hazardous materials are kept in a locked area. Evidence: Nail polish remover was found unlocked and unattended in the bathroom of Resident #5, of the special care unit. Air freshener spray was found unlocked and unattended in the bedroom of Resident #6, of the special care unit. The records of Residents #5 and #6 contained assessments stating that the residents were unable to recognize danger or protect their own safety and welfare.
Plan of Correction:	Rooms of Resident #5 and Resident #6 were immediately cleared of any potentially hazardous substances. The Healthcare Director, Executive Director and Harmony Square Director checked the rooms of other residents to confirm that no potentially hazardous substances were present. No issues were identified. Staff were re-educated and notifications were sent to family members regarding appropriate toiletries and room accessories. The Healthcare Director, Executive Director and designees will conduct frequent room audits to verify that no potentially hazardous substances are present.