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. 13, 2022 and Dec. 14, 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 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 22VAC40-80 THE LICENSING PROCESS

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: 12/13/22 (8:15 AM - 6:45 PM), 12/14/22 (7:45 AM - 4:50 PM) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with participants: 5 Additional Comments/Discussion: 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. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1100-C
Description:	Based on record review, the facility failed to ensure that the order of priority is followed and documented, prior to placing a resident in the safe, secure environment. Evidence: Resident #1?s record was reviewed during the inspection. Resident #1 was placed in the safe, secure environment on 11/29/22. Resident #1?s approval form, dated 11/22/22, was signed by a physician. No documentation, was included in Resident #1?s record, to explain why written approval was not obtained from any individual higher on the list of priority.
Plan of Correction:	All new admission paperwork will be reviewed by administrator or designee prior to admission to ensure compliance with this standard.
Standard #:	22VAC40-73-1110-A
Description:	Based on record review, the facility failed to ensure that the record of each resident admitted into the safe, secure environment, includes documentation of a decision by the administrator/designee determining that the resident?s placement in the special care unit is appropriate. Evidence: Resident #8?s record was reviewed during the inspection. Resident #8 was admitted to the facility on 10/30/22. Resident #8?s record did not contain documentationof a decision by the administrator/designee indicating the resident?s placement in the special care unit was appropriate.
Plan of Correction:	All new admission paperwork will be reviewed by administrator or designee prior to admission to ensure compliance with this standard.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member maintains current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Each direct care staff member who does not have current certification in first aid of this subsection shall receive certification in first aid within 60 days of employment. Evidence: The records for Staff #2 (hired 12/7/18) and Staff #3 (hired 7/29/22) were reviewed during the inspection. No documentation was provided, during the inspection to confirm that Staff #2 or #3 have current first aid certification.
Plan of Correction:	Operations Specialist had already scheduled a CPR class prior to the inspection. This was communicated during the inspection that a class was scheduled for 12/19/22. HCD or designee will maintain the CPR/FA schedule to ensure there are no lapses as it pertains to our staff.
Standard #:	22VAC40-73-320-B
Description:	Based on record review, the facility failed to ensure that a risk assessment is completed annually on each resident, 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 records of Residents #2, #4, #5, and #6 included documentation of tuberculosis risk assessments that were completed on 11/3/21. The risk assessments were more than a year old, at the time of the inspection.
Plan of Correction:	HCD or designee will audit all resident records to ensure all TB risk assessments are current. Administrator, HCD or designee will maintain the risk screenings schedule to ensure there are no lapses and compliance is maintained.
Standard #:	22VAC40-73-390-A
Description:	Based on record review, the facility failed to ensure that the resident agreement was singed by the administrator or licensee. Evidence: Resident #8?s record was reviewed during the inspection. Resident #8?s resident agreement was not signed by the administrator or licensee.
Plan of Correction:	This admission paperwork was completed prior to current administrator or HCD coming to the facility. Administrator or designee will review each admission moving forward to ensure paperwork is signed properly by all parties.
Standard #:	22VAC40-73-440-L
Description:	Based on record review, the facility failed to ensure that the completed Uniform Assessment Instrument (UAI) is maintained in the resident record. Evidence: The records for Residents #1 and #8 were reviewed during the inspection. Completed UAIs were not present in the records of Residents #1 or #8, at the time of the record review.
Plan of Correction:	HCD will print all UAI's at the time of completion and place in the resident record. Administrator or designee will audit all resident records to ensure compliance with this standard.
Standard #:	22VAC40-73-450-E
Description:	Based on record review, the facility failed to ensure that the individualized service plan is signed by the administrator/designee and the resident, or their legal representative. Evidence: The most recent service plans, for Residents #2-6, were not signed by the residents or their legal representatives.
Plan of Correction:	HCD will be in serviced on this standard. HCD or designee will ensure Administrator reviews every ISP that is completed to ensure there is an Administrator signature and a signature from the resident and/or legal representative.
Standard #:	22VAC40-73-470-A
Description:	Based on record review, the facility failed to ensure that the health care service needs of residents are met. Evidence: Resident #8?s record was reviewed during the inspection. Resident #8 went to the hospital on 12/2/22, after a fall. The hospital summary indicated that the resident suffered from a head injury and hematoma, and that a follow-up visit with Resident #8?s physician should take place in 3 days (12/5/22). Facility documentation indicates that the physician saw Resident #8 on 12/9/22. No documentation was provided, during the inspection, to indicate that the facility attempted to have Resident #8 seen by her physician within three days of her hospital visit. The most recent progress note, included in the resident record, was about the resident?s fall and transport to the hospital.
Plan of Correction:	HCD will review all hospital paperwork to ensure facility is following all discharge instructions. Ops specialist will ensure HCD has appropriate systems in place to ensure compliance with this standard.
Standard #:	22VAC40-73-560-E
Description:	Based on observation, the facility failed to ensure that resident records are kept current, retained at the facility, and kept in a locked area. Evidence: Shortly after 8:45 AM, the second floor wellness station was left unlocked and unsupervised. Records for Resident #10 and #11 were accessible in the wellness station. Progress notes, for Resident #9, were observed. The most recent note, dated 10/22/22, stated that the resident was on contact isolation after testing positive for COVID-19. The resident?s status was listed as moved out, but there were no notes about when the resident moved out or his condition at that time. No additional documentation about Resident #9 was provided, during the inspection.
Plan of Correction:	All staff will be in-serviced on this standard as it pertains to keeping resident records current, keeping records in a locked location, and all resident paperwork will be handled properly to ensure confidentiality. HCD, administrator or designee will conduct routine rounds to ensure compliance.
Standard #:	22VAC40-73-650-A
Description:	Based on observation and documentation, the facility failed to ensure that no medication is started, changed, or discontinued by the facility without a valid order from a physician or prescriber. Evidence: Medication administration was observed for Resident #12 during the inspection. Resident #12 received Sodium Bicarbonate 650mg (2 tabs) and Hydralazine 50mg, during the medication pass. Resident #12?s record did not contain physician?s orders for those medications and doses, at the time of the medication administration. The MAR indicated that both medication doses began in July 2022.
Plan of Correction:	Healthcare Director will in-service all medication aides and LPN's as it pertains to this standard. The day of inspection, Operations Specialist called the pharmacy and had the order faxed over while the inspector was still conducting the inspection. Staff have been made aware that no orders are to be approved in the EMAR system without an order to reference it to.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation, the facility failed to ensure that the medication storage area remains locked. Evidence: Shortly after 8:45 AM, the second floor wellness station was left unlocked and unsupervised. Two plastic storage totes of medication were located in the nursing station.
Plan of Correction:	All care staff will be in-serviced on this standard. Signage will be placed on the nurse's station doors reminding them of this standard. HCD, Administrator or designee will conduct daily rounds to ensure compliance to this standard.
Standard #:	22VAC40-73-660-B
Description:	Based on observation and record review, the facility failed to limit medication storage to an out-of-sight place in the rooms of residents whose UAIs have indicated that they are capable of self-administering medication. Medications and dietary supplements shall be stored so that they are not accessible to other residents. Evidence: Tumeric, Mucinex DM, CoQ10, and Fish oil gummies were observed on the counter in Resident #13. Resident #13?s UAI, dated 12/9/21, states that the resident needs her medication to be administered by professional nursing staff. Resident #13?s ISP, dated 12/9/21, states that the resident requires facility staff to administer medications and treatments. Resident #13?s record did contain an order for her to keep certain medication at her bedside, but none of the observed medications/supplements were included in the order.
Plan of Correction:	Ops Specialist will in-service staff and residents on this standard. Routine rounding will be performed by administrator, HCD or designee to ensure compliance and the safety of all residents.
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 instruction and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Resident #13?s December MAR was observed during the inspection. Resident #13?s MAR calls for her insulin to be administered per the following sliding scale: 1U (BS: 200-250), 2U (BS: 251-300), 3U (301-350), and 4U (BS: 351-400). Resident #13?s MAR states she was administered 3 units of insulin on 12/10/22 (noon administration) when her blood sugar reading was 300. Resident #13?s MAR also states she was administered 0 units of insulin on 12/11/22 (8 AM administration) when her blood sugar reading was 240.
Plan of Correction:	All medication Aides and LPN's that administer medications will be in serviced to ensure compliance with the standards of practice that is approved by the Virginia Board of Nursing as it pertains to this standard. HCD or designee will perform med pass reviews with each medication aide that worked the day of inspection to ensure compliance and understanding of standard 22VAC40-73-680-D
Standard #:	22VAC40-73-680-M
Description:	Based on observation, the facility failed to ensure that PRN medications are available and properly stored at the facility. Evidence: PRN Senna and Miralax, ordered for Resident #13, were not present during the medication cart inspection. Facility staff confirmed that they were not present, at the time of the medication cart inspection.
Plan of Correction:	HCD or designee will audit all medication carts weekly to ensure all PRN meds are in the medication cart and available to our residents. All audit findings will be handed to the administrator for review. Medication Aides and LPN's will be in-serviced on this standard.
Standard #:	22VAC40-73-990-C
Description:	Based on documentation, the facility failed to ensure that all staff that are currently on duty, on each shift, participate in an exercise in which the procedures for resident emergencies are practiced. The exercise shall be conducted at least once every six months. Evidence: Documentation was requested of the exercise where the procedures for resident emergencies are practiced. Facility staff did not provide documentation of an exercise in which the procedures for resident emergencies were practiced, within the past six months.
Plan of Correction:	Staff will be trained as it pertains to this standard. HCD, administrator or designee will manage the staff training schedule to ensure there are no lapses and that compliance is maintained.