VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Harmony Collection @ Hanover Assisted Living and Memory Care
8227 Meadowbridge Road
Mechanicsville, VA 23116
(804) 212-2110

Current Inspector: Tamara Watkins (804) 662-7422

Inspection Date: March 1, 2022

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 32.1 Reported by persons other than physicians 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. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Comments:

A unannounced renewal inspection was conducted on this date from 12:30 pm- 5:30 pm. At the time of the inspection there were 81 (53 AL/-34/MC)residents in care. Five (5) resident and five (5) staff files were reviewed as well as other required documentation. All new personnel records were reviewed since the last inspection for criminal history record reports and all were in compliance. Medication administration documentation, activities and meals were observed. Building and grounds were inspected. An exit meeting was held with the Administrator. This inspection determined there were no violations with applicable standards or law. A violation notice was issued. Areas of non-compliance are identified in the Violation Notice. The facility has 5 calendar days from receipt of the inspection reports to complete a plan of correction, sign the inspection report and return them to the licensing office. A copy of the inspection reports shall be retained and posted at the facility. Results of the inspection are subject to public disclosure and will be posted on the VDSS website within 15 calendar days, regardless of whether the plan or correction is completed. The plan of correction shall include the following: (1) Step(s) the facility will take to correct the violations cited; (2) Measures that will be put in place to prevent recurrence of each violation; (3) Person(s) responsible for implementation and monitoring of preventive measures; and (4) Date by which each violation will be corrected.

Violations:

Standard #:	22VAC40-73-260-A
Description:	A review of staff files found that the facility failed to obtain current certification in first aid for direct care staff within 60 days of employment. Evidence: Staff #3 was employed on 7/19/2021 however, on the day of this inspection the facility was unable to produce documentation of first aid certification.
Plan of Correction:	The staff member was able to produce first aid certification, immediately. The facility will offer first aid certification within 60 days of hire. Person Responsible: ED/Designee by 4-1-22
Standard #:	22VAC40-73-325-B
Description:	A review of resident files found that upon completion of a fall risk assessment the facility failed to identify interventions that would be initiated to prevent or reduce risk of subsequent falls. Evidence: Resident #4 had documented falls on 12/28/21; 1/31/2022; 2/3/2022. On the current ISP dated 12/20/21 the fall prevention goal states "personalize her interventions" with no methods or actions to be taken to prevent or reduce risk of subsequent falls.
Plan of Correction:	The Harmony Square Director immediately updated intervention on resident #4 ISP to be more specific. The facility will implement an intervention form to monitor methods utilized to reduce risk of subsequent falls. Person Responsible: Health Care Director/Designee by 4-1-22
Standard #:	22VAC40-73-450-F
Description:	Upon a review of the resident files the facility failed to update the ISP to indicate there was a change in the resident's condition. Evidence: The ISP for resident #1 was not updated to reflect a change in the resident's diet. The ISP dated 12/13/2021 states the resident is on a regular diet and is "independent with meals and does not require assistance". A physican order dated 2/16/22 states "cut food into bite sized pieces". The change was not recorded on the service plan.
Plan of Correction:	The Harmony Square Director corrected ISP immediately on resident #1 to reflect current diet order. A random audit will be completed on ISP's to ensure diet orders have been updated along with quarterly review by Dietician. Person Responsible: Health Care Director/Designee 4-1-2022
Standard #:	22VAC40-73-560-A
Description:	The facility failed to establish procedures to ensure that all required documents are dated. Evidence: A review of resident records found that a physician order for resident #1 regarding a change in diet was not signed; an approval for placement in the special care unit for resident #2 was not dated; and a current ISP for resident #2 was signed but not dated.
Plan of Correction:	The Health Care Director updated the diet order for resident #1 to include physician signature the ISP and approval for placement for resident #2 were updated to include date. An audit was completed on the file for resident #1. New orders will be reviewed for completion prior to filing. Approval for placement forms and ISP's will be reviewed for completion prior to filing. Person Responsible: ED/Designee 4-1-22
Standard #:	22VAC40-73-720-A
Description:	A review of the resident files found that the facility failed to ensure that a written DNR order was included in the individualized service plan. Evidence: Resident #1 who has a DNR order on file has a goal on the ISP (12/13/2021) that states full code.
Plan of Correction:	The Harmony Square Director corrected code status for resident #1 immediately. The ISP will be updated on receipt of a code change. Person Responsible: Health Care Director/Designee 4-1-22
Standard #:	22VAC40-73-730-C
Description:	The facility failed to ensure that information regarding an advance directive (DNR order) is readily available to other authorized persons, staff, emergency medical technicians (EMT's) when necessary. Evidence: The sticker on the file reviewed for resident #1 that is readily available to staff, EMT's etc. said full code. However, the Advance Directive dated 4/11/2014 includes a DNR.
Plan of Correction:	The Harmony Square Director corrected code status immediately updated the sticker to reflect code status. The alert sticker will be updated on the receipt of a code change. Person Responsible: Health Care Director/Designee 4-1-22