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: Aug. 26, 2022 and Sept. 8, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/26/22 (8:36 AM ? 12:27 PM), 9/8/22 (3:15 PM ? 4:13 PM). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov

Violations:

Standard #:	22VAC40-73-560-E
Description:	Based on record review and interview, the facility failed to ensure that the resident record is kept current and retained at the facility. Evidence: Resident #1?s record was observed during the inspection. Resident #1?s Uniform Assessment Instrument (UAI), dated 8/8/22, states that the resident needs his medications administered/monitored by nursing staff. Resident #1?s August MAR indicated that he self-administered his medications on 8/16/22 and 8/17/22. Resident #1?s ISP, dated 8/22/22, states that he does not need assistance with medication administration. The MAR indicated that facility staff members began administering Resident #1?s medication on 8/24/22. No documentation was provided, during the inspection, to detail Resident #1?s admission to the facility, his medication administration from 8/18/22 until 8/24/22, or information to explain the changes to his medication administration status. Facility staff confirmed that Resident #1 did not have any progress notes to clarify the missing information.
Plan of Correction:	HCD reviewed and audited the resident's chart. Resident's UAI has been corrected and filed in resident's chart. HCD will ensure that the resident record is kept current and retained at the facility. HCD or designee will make sure the implementation and ongoing compliance with the component of this plan of correction.
Standard #:	22VAC40-73-680-B
Description:	Based on observation, the facility failed to ensure that medications remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. Evidence: The morning medication administration, for Resident #1, was observed during the inspection. Resident #1?s medications were removed from a pill box and placed into a pill cup. Before the medication was administered, the licensing inspector asked about the number ofpills that were going to be administered to the resident. Only 10 pills were present in the pillbox, but the MAR called for Resident #1 to receive 11 different medications during the 8 AM medication administration.
Plan of Correction:	HCD will ensure that medications remain in pharmacy issued container, with the prescription label or direction label attached, until adminitered to the resident. Resident's medication were reordered and packaged in appropriate packaging with approperiate pharmacy label. All resident's medication were audited to ensure medications are in approperiate packaging with pharmacy label. HCD or designee with ensure the implementation and ongoing compliance with the components of this plan of correction.
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 outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Resident #1?s August MAR (medication administration record) was reviewed during the inspection. Resident #1 receives Hydralazine three times per day. Resident #1?s Hydralazine order, dated 7/29/22, states that the medication should be held if the resident?s systolic blood pressure is less than 150. The MAR indicates that Resident #1?s Hydralazine was administered on 8/25/22 (8 AM administration) when the resident?s systolic blood pressure was 141.
Plan of Correction:	Responses on the enclosed plan of correction do not constitute an admission of agreement of the truth of the facts alleged or the conclusion set forth in the regulatory report. The responses are prepared solely as a matter of compliance with law. Med techs and LPNs will be reeducated to ensure that medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlines in the current medicaiton aide curriculum approved by the virginia board of nursing. HCD or designee with perform weekly checks to ensure the accuracy and ongoing compliance wiht the components of this plan of correction. Executive Director, or designee is responisble for confirming the implementation and ongoing compliance.