VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harbourway Assisted Living
1217 Alliance Drive
Va beach, VA 23454
(757) 716-2150

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Aug. 17, 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 ARTICLE 1 ? SUBJECTIVITY 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 08/17/2023 from 8:16 am to 4:55 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: 63 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: emergency preparedness drills, medication carts, fire inspection report, health inspection report, staffing schedule, and first aid kits. The water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on the record review and staff interview the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. The record for resident #3 contains a hospital discharge summary dated 11/28/22 documenting the resident was admitted to the hospital the dates of 11/25/22-11/28/22. The resident?s record contains a hospital discharge summary dated 03/28/23 documenting an ER visit on 03/28/23 for ?laceration of scalp and a closed head injury.? The facility did not notify the regional licensing office of the resident?s hospital admission from 11/25/22-11/28/22 and the resident?s ER visit on 03/28/23. 2. The record for resident #4 contains a hospital discharge summary dated 03/07/23 documenting a hospital admission the dates of 03/05/23-03/07/23 for a diagnosis of Sepsis. The facility did not notify the regional licensing office of the resident?s hospital admission for the dates of 03/05/23-03/07/23.
Plan of Correction:	Step 1: To prevent the deficiency from reoccurring, the Unit Manager and/or Nurse Educator/Infection Preventionist will focus on education for the nursing staff responsible for incident reporting. We will reinforce the importance of timely reporting and adherence to our existing incident reporting policy. We will conduct refresher training sessions to ensure that all nursing staff are aware of their responsibilities and are equipped with the knowledge to report incidents promptly. Step 2: The facility will monitor corrective actions by conducting audits over the next 90 days. Audits will be performed by an internal quality assurance team, and they will review a sample size of 15% of resident records on a weekly basis. The findings of these audits will be reported to and reviewed by the quality assurance and performance improvement committee. Any instances of non-compliance will be addressed through immediate retraining and corrective action. Step 3: The corrective actions will be completed by September 30, 2023. This timeframe allows for ample time to conduct the necessary audits, provide education and training to the staff, and ensure that the changes are effectively implemented 9/30/2023
Standard #:	22VAC40-73-260-C
Description:	Based on observation and staff interviewed, the facility failed to ensure the posted listing of staff certifications in first aid or cardiopulmonary resuscitation (CPR) or both was kept up to date. Evidence: 1. The First Aid and CPR list posted in the facility included staff who are no longer employed with the facility. 2. Staff #5 acknowledged the First Aid and CPR posting was not up to date.
Plan of Correction:	Step 1: To correct the alleged deficiency related to staff certifications, we will promptly update the posted listing of staff certifications in first aid and CPR. We will remove the names of staff who are no longer employed with the facility from the list. This update will be completed within the next 48 hours to ensure accuracy. Step 2: To prevent the deficiency from reoccurring, we will implement a systematic change by enhancing education and accountability among our staff responsible for maintaining certifications. We will conduct training sessions for relevant staff members, emphasizing the importance of keeping certifications current and the process for updating the posted list. This training will be incorporated into our regular staff development program. Step 3: The facility will monitor corrective actions by conducting audits over the next 90 days. The CPR/First Aid list will be reviewed by Human Resources no less than twice a month to ensure all staff are in compliance. The updated report will be sent to the Administrator and Unit Manager. Any discrepancies will result in immediate corrective action and additional training. Step 4: The corrective actions will be completed by September 15, 2023. This timeframe allows for the swift update of the posted list, thorough staff education, and comprehensive auditing to ensure ongoing compliance.
Standard #:	22VAC40-73-490-A-2
Description:	Based on the record review the facility failed to ensure for residents who meet the criteria for assisted living care, if the facility employs a licensed health care professional who is on site on a full-time basis, a licensed health care professional practicing within the scope of his profession, shall provide health care oversight at least every six month. Evidence: 1. The facility record contains documentation of a health care oversight dated 07/18/23. There was no evidence of a health care oversight completed at least six months prior to the date of 07/18/23.
Plan of Correction:	Step 1: To prevent the recurrence of this deficiency, the Healthcare Administrator will have an assessment form created into the current EMR that will automatically schedule the healthcare oversight for each resident. This form will serve as the individual assessment for each resident?s record that will contain recommendations that will be given to the Harbourway Administrator and/or Unit Manager Step 2: The facility will monitor corrective actions through an audit process over the next 120 days. Our quality assurance team will conduct monthly audits of resident records, specifically focusing on health care oversight documentation. Audit findings will be reported to the Administrator and management team. Any deviations from the policy will result in immediate corrective action and re-education. Step 3: The corrective actions will be completed by September 30, 2023. This timeline allows for the creation and implementation of the health care oversight form.