VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harmony at Harbour View
5871 Harbour View Boulevard
Suffolk, VA 23435
(757) 214-6279

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Aug. 25, 2020 and Aug. 26, 2020

Complaint Related: No

Areas Reviewed:

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 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 08-25-2020 and concluded on 08-26-2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 48. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, criminal background checks and sworn disclosures of newly hired staff, staff schedules, healthcare oversight, fire drills, and the fire and health inspection reports. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-210-F
Description:	Based on record review and interview, the facility failed to ensure at least two of the required annual hours of training for direct care staff focused on infection control and prevention. Evidence: 1. Staff #1 provided documentation of staff #2 and staff #3?s annual training hours. The staff did not have the required annual two hours of infection control and prevention training: A. Staff #2 (date of hire 01-31-2019) had one hour of infection control and prevention training, dated 02-28-2019, during the annual training review period of 01-31-2019 through 01-31-2020. B. Staff #3 (date of hire 02-28-2017) did not have any documentation of infection control and prevention during the annual training review period of 02-28-2019 through 02-28-2020. 2. Staff #1 could not provide documentation of additional infection control and prevention training hours for staff #2 and staff #3 during their aforementioned annual review period. 3. Staff #1 acknowledged staff #2 and staff #3 did not have the required annual 2 hours of infection control and prevention training.
Plan of Correction:	What Has Been Done to Correct? Staff #1 and #3 have completed infection control training How Will Recurrence Be Prevented? Review of infection training will be completed multiple times annually to insure all staff receive required trainings Person Responsible: BOM, ED
Standard #:	22VAC40-73-440-H
Description:	Based on record review and interview, the facility failed to update the resident's Uniform Assessment instrument (UAI) when there was a significant change in the resident's condition. Evidence: 1. Resident #1?s current Individualized Service Plan dated 07-16-2020 documented the need for physical and mechanical assistance with bathing and eating/feeding. A. Bathing- Mechanical and Physical Assistance (Date identified: 01-13-2019): resident will need ?staff, hospice aide assistance with showers twice a week and as needed, she will need grab bars, shower bench, and assistance with washing body, drying off, and getting dressed.? B. Eating/Feeding- Two Handled Cup (Date identified: 05-11-2020) ?Staff will ensure resident is using two handled cup during meals to ensure she can drink independently without assistance;? Weighted Utensils (Date identified: 05-11-2020) ?Staff will ensure resident is using weighted utensils during meals to ensure she can eat independently without assistance;? Eating/Feeding (Date identified: 11-09-2019) ?Resident will need staff assistance with feeding meals.? 2. Resident #1?s current UAI dated 11-27-2019 documented the need for physical assistance only with bathing and eating/feeding. The UAI was not updated to reflect the resident?s need for physical and mechanical assistance with bathing and eating/feeding. 3. Staff #1 could not provide documentation of an updated UAI and acknowledged the UAI was not updated to reflect the resident?s change in condition for bathing and eating/feeding.
Plan of Correction:	What Has Been Done to Correct? Res. #1 UAI/ISP has been updated How Will Recurrence Be Prevented? During the ISP the UAI will also be also reviewed the ISP and UAI for each resident reflect the same information. Person Responsible: HCD/ ED
Standard #:	22VAC40-73-490-A-2
Description:	Based on record review and interview, the facility failed to ensure the healthcare oversight was provided at least every three months for residents who meet the criteria for assisted living care. Evidence: 1. Resident #1?s current Uniform Assessment Instrument (UAI) dated 11-29-2019, resident #2?s current UAI dated 05-19-2020, and resident #3?s current UAI dated 02-06-2020 documented the residents meet the criteria for assisted living level of care. 2. Staff #1 stated the healthcare oversight was provided by a licensed healthcare professional who is not employed full time at the facility. 3. Staff #1 provided a copy of the facility?s most current healthcare oversight dated 04-08-2020 with a review period of 11-01-2019 to 04-08-2020. The healthcare oversight provided prior to the current oversight was dated 11-04-2019. 4. Staff #1 could not provide documentation of a healthcare oversight being provided in February 2020. 5. Staff #1 acknowledged the facility did not have a health care oversight provided at least every three months.
Plan of Correction:	What Has Been Done to Correct? The Health Care Oversite completed in July was late How Will Recurrence Be Prevented? An alert will be set to ensure the healthcare oversight is completed timely. Person Responsible: HCD or ED
Standard #:	22VAC40-73-650-C
Description:	Based on record review and interview, the facility failed to ensure the physician?s oral orders are reviewed and signed by the physician within 14 days. Evidence: 1. Resident #2 physician?s telephone order dated 07-28-2020 documented ?Keflex 500mg- Take 1 tab PO TID x 7 days; Warm Compress- Do warm compress every shift x 7 days; Put Bacitracin ointment on hand over stitches BID. The order was not reviewed and signed by the physician within 14 days and was not signed as of 08-25-2020. 2. Staff #1 acknowledged resident #2?s aforementioned physician?s telephone order was not reviewed and signed by the physician within the 14 days.
Plan of Correction:	What Has Been Done to Correct? Physician?s signature was obtained for resident #2 verbal order How Will Recurrence Be Prevented? A copy of verbal physician?s order with physician?s signature prior to filing in the resident?s record. Person Responsible: HCD or Designee