VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harmony at Independence
2077 South Independence Boulevard
Virginia beach, VA 23453
(757) 802-3665

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: June 21, 2023

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

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: 06/21/2023 from 8:35am to 3:37pm 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: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 An exit meeting will be conducted to review the inspection findings. 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. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1140-B
Description:	Based on record review, the facility failed to ensure within four months of the starting date of employment in the safe, secure environment, direct care staff attend at least 10 hours of training in cognitive impairment that meets the requirements of subsection C of this section. Evidence: 1. Staff #1 (hire date 1/5/23) works as direct care staff; however, Staff #1 participated in 1.25 hours of training in cognitive impairment within four months of their hire date. 2. Staff #3 (hire date 7/19/22) works as direct care staff; however, Staff #3 participated in 6.5 hours of training in cognitive impairment within four months of their hire date.
Plan of Correction:	Staff #1 & 3 educated on the importance of attending all mandatory training. Cognitive Impairment Training Courses assigned by the BOM/designee to staff #1 & 3 to meet hours required. This will be completed by 7/30/23. Moving forward the BOM/designee will create a tickler monthly auditing all employee training hours to include Cognitive Impairment Training Courses to ensure each employee is within standard.
Standard #:	22VAC40-73-210-B
Description:	Based on record review, the facility failed to ensure all direct care staff attend at least 18 hours of training annually with the exception of direct care staff who are licensed health care professionals or certified nurse aides attend at least 12 hours of annual training. Training also should include at least two of the required hours on infection control and prevention and when adults with mental impairments reside in the facility, at least four of the required hours on topics related to residents' impairments. Evidence: 1. Staff #5 (hire date 10/3/2019) works as an RMA/CNA; however, from 10/2021-10/2022, Staff #5 completed 2.25 hours of annual training.
Plan of Correction:	Staff #5 educated on the importance of attending all mandatory training. Training Courses assigned by the BOM/designee to staff #5 to meet hours required. This will be completed by 7/30/23. Moving forward the BOM/designee will create a tickler monthly auditing all employee training hours to ensure each employee is within standard.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure each direct care staff member maintain 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. Evidence: 1. Staff #1 (hire date 1/5/23) and Staff #3 (hire date 7/19/22) works as direct care staff and do not have documentation of a current certification in first aid in their staff record.
Plan of Correction:	The BOM/designee assigned Staff # 1 & 3 to a first aid training to be completed by 7/30/23. Moving forward the BOM/designee will create a tickler monthly auditing all employees? files to ensure each employee is within standard.
Standard #:	22VAC40-73-325-B
Description:	Based on record review, the facility failed to ensure a fall risk rating is completed at least annually. Evidence: 1. Upon review of the resident?s record, the last annual fall risk rating for the Resident #2 was completed on 9/17/2021. 2. Upon review of the resident?s record, the last annual fall risk rating for the Resident #3 was completed on 2/25/2020.
Plan of Correction:	Resident #2 & 3 Annual Fall Risk completed and updated by the HCD/HSD on 6/28/23. Moving forward a chart audit tool including Fall Risk Assessments to be completed on all current and new residents and placed in each resident?s medical chart with due dates. This tool will be audited quarterly by the HCD/HSD and/or designee.
Standard #:	22VAC40-73-550-G
Description:	Based on record review, the facility failed to annually review the rights and responsibilities of residents with each resident, or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person. Evidence: 1. The following resident records did not include a current written acknowledgement of having been so informed of the review of the rights and responsibilities of residents within the last year: Resident #2, Resident #3, and Resident #4.
Plan of Correction:	Residents # 2, 3, & 4 review of resident?s rights with written acknowledgement to be reviewed and updated with resident and legal representative by the ED by 7/10/23. Moving forward the BOM and/or designee will create a tickler audit with due dates for renewal of resident rights evidenced by a written acknowledgement on all residents.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication. Evidence: 1. The following expired medications were observed in the medication carts at the facility: PRN Acetaminophen 325 mg tablets expired 05/21/2023 for Resident #11 and PRN Benzonatate 100 mg capsules expired 06/15/2023 for Resident #12.
Plan of Correction:	Expired medications removed from Medication cart for Resident #11 & 12 by the HCD on 6/21/23. Moving forward, a weekly med cart audit for expired medications will be conducted by the HCD/HSD and/or designee.
Standard #:	22VAC40-73-700-2
Description:	Based on observation, the facility failed to post "No Smoking-Oxygen in Use" signs and enforce the smoking prohibition in any room of a building where oxygen is in use. Evidence: 1. During a tour of the facility, Resident #2 and Resident #10 were noted to have an oxygen concentrator in their apartment; however, there is not a ?No Smoking-Oxygen in Use? sign posted outside their apartment.
Plan of Correction:	?No Smoking-Oxygen in Use? sign placed outside of resident #2 & 10 apartment doors by the HSD on 6/21/23. Moving forward the HCD/HSD and/or designee will conduct a weekly audit on all residents on oxygen to ensure signs are posted outside of their apartment doors.
Standard #:	22VAC40-73-970-A
Description:	Based on record review and interview, the facility failed to ensure fire and emergency evacuation drill frequency and participation be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month. Evidence: 1. Staff #6 could provide evidence of the fire and emergency evacuation drill conducted on 5/23/23; however, there was no documentation of previous drills conducted over the past 3 months.
Plan of Correction:	The MD and/or designee will ensure a record of monthly fire and emergency evacuation drills are kept in a binder located in their office.