VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harmony at Chantilly
2980 Centreville Road
Herndon, VA 20171
(703) 994-4561

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Feb. 12, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS

Technical Assistance:

Documentation was discussed with the provider.

Comments:

An unannounced complaint inspection was conducted on 2/12/24 in response to a complaint that was received by the licensing office on 2/1/24 regarding: Administration and Administrative Services; and Admission, Retention, and Discharge of Residents 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. 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 #:	22VAC40-73-50-B
Complaint related:	Yes
Description:	Based on documentation, the facility failed to ensure that the written acknowledgment of the receipt of the disclosure by the resident, or his legal representative, is retained in the resident's record. Evidence: Resident #1's admission documents were reviewed during the inspection. No written acknowledgment, of the receipt of the disclosure document, was present in Resident #1's record.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-310-B
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure that individuals are not admitted before a determination has been made that the facility can meet the individual's needs. The facility shall make the determination based upon the following information at a minimum: 1. The completed UAI 2. The physical examination report 3. A documented interview between the administrator (or his designee) and the individual (or his legal representative). Evidence: Resident #1's record was observed during the inspection. Resident #1's record contained a respite agreement for a period from April 28, 2023 through June 9, 2023. No UAI or physical examination was observed in the record for Resident #1. Facility staff confirmed that the UAI and the physical examination were not present in the record for Resident #1.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-560-E
Complaint related:	No
Description:	Based on record review, the facility failed to ensure that resident records are kept current and retained at the facility. Evidence: Resident #1's record was observed during the inspection. Resident #1's record indicated that he was a respite resident and that the respite period began on 4/28/23. The record contained a note, dated 4/29/23, stating that the resident may have went back home and that facility staff will call to follow up with him. Resident #1's status was listed as "moved out" and the record included a move out inspection form, dated 5/31/23. No documentation was present about the resident's activity after 4/29/23, or the details of his discharge before the scheduled respite end date of 6/9/23.
Plan of Correction:	Not available online. Contact Inspector for more information.