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: Dec. 23, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced focused monitoring inspection was conducted on 12/23/19 to follow-up on a high-risk violation that was cited on 10/10/19. Medication administration was observed and records were reviewed. 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 #:	22VAC40-73-100-A
Description:	Based on interview and observation, the facility failed to implement the infection control program Evidence: Facility staff was observed leaving Resident #3?s room with Resident #2?s glucometer. Facility staff reported Resident #3?s blood sugar was checked using Resident #2?s glucometer, as Resident #3's glucometer was not present. The facility?s infection control plan calls for residents to have their own glucometers, single use safety lancets and testing supplies.
Plan of Correction:	Health Care Director inserviced staff that day on location of facility supply glucometers for these events and infection control policy related to diabetic management.
Standard #:	22VAC40-73-680-D
Description:	Based on documentation, the facility failed to ensure that medication is administered in accordance with the physician?s instructions. Evidence: The December medication administration record (MAR) and treatment administration record (TAR) for Resident #1 was reviewed. Resident #1's record contained an order, dated 12/16/19, for the resident to receive Miralax daily. Resident #1's MAR indicated that the resident did not receive Miralax on 12/22/19. The MAR for Resident #2 was reviewed. Resident #2 has his blood sugar (BS) checked before his Humalog is administered, and the MAR calls for him to receive Humalog units (U) based on a sliding scale. Resident #1?s MAR included the following sliding scale for Humalog administration: 2U (BS= 151 ? 200), 4U (BS= 201 - 250), 6U (BS= 251 ? 300), 8U (BS= 301 ? 350), 10U (BS= 351 ? 400), 12U (BS > 401). The MAR included the following administration of Humalog for Resident #2: Zero units (BS= 193) on 12/1/19 at 5 PM 6U (BS= 240) on 12/7/19 at 5 PM 2U (BS= 130) on 12/8/19 at 7 AM 2U (BS= 127) on 12/10/19 at 7 AM
Plan of Correction:	Health Care Director inserviced staff that day on ACCUFLO. Health Care Director will review each residents sliding scale with their MD. Regional Clinical Nurse will provide additional training to staff.