VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harmony on the Peninsula
3540 Victory Boulevard
Yorktown, VA 23693
(757) 447-3544

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: Sept. 1, 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 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: 9/1/2023, 9/19/2023 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed:6 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 3 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 Alyshia E. Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-350-B
Description:	Based on review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. Evidence: Resident # 1 had an admission date of 12/30/22 and the resident?s record did not contain a Sex Offender Screening until 9/1/23.
Plan of Correction:	1. Resident #1?s record #1 has a current Sex Offender Screening. 2. A 100% audit was completed on all current residents? Sex Offender Screenings to ensure compliance with standard. 3. Director of Sales was in-serviced on the standard. 4. The Executive Director or designee will audit admission charts on all new residents to ensure a current a current Sex Offender Screening was completed.
Standard #:	22VAC40-73-430-H-1
Description:	Based on review of resident record, the facility failed to ensure that a discharge statement included all the required information listed in the standards to be provided to the resident and as appropriate, his legal representative and designated contact person at the time of discharge. Evidence: Resident # 6?s Discharge Notification and statement dated 7/5/23 was blank in 7 out of 8 areas.
Plan of Correction:	1. All areas of Resident #6?s Discharge Notification and Statement was updated for compliance. 2. An in-service will be completed with the Healthcare Director and Harmony Square Director on the standard. 3. All current Discharge Notification and Statements will be reviewed by Executive Director/designee to ensure compliance. 4. Standard will be reviewed in QAPI.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of resident records the facility failed to ensure that each resident's individualized service plan (ISP) contained a description of all needs/services identified. Evidence: 1. Resident #5?s ISP dated 4/1/23 states the resident?s food should be cut into bite size pieces, however the Physician?s orders dated 8/10/23 states the resident is on a mechanical soft diet. 2. Resident #2 has a Do Not Resuscitate Order dated 7/11/23 however the ISP dated 1/4/23 states the resident is a Full Code.
Plan of Correction:	1. Resident #5 and Resident #2s ISP were updated. 2. Administrative staff will be in-serviced on 22VAC40-73-450-F. 3. A 100% audit will be completed ISP?s on current residents to ensure compliance. 4. Administrator/Designee will monitor ISPs to ensure individualized service plans be reviewed and updated at At least every 12 months. Any trends will be reported to QAPI.
Standard #:	22VAC40-73-610-B
Description:	Based on observations made during the tour of the facility on 9/1/2023, the facility failed to have the menu for the current week posted. Evidence: During the on-site inspection on 9/1/23, the daily posted menus for breakfast and lunch were dated for 8/31/23. There was no weekly menu posted.
Plan of Correction:	1. The menus state the current day of the week and meal. 2. Administrative staff was in-serviced on 22VAC40-73-610-B. 3. The menus were updated to include month/day/year. 4. Administrator/Designee will monitor menus to ensure that they include month/day/year not just the day of week. Any trends will be reported to QAPI.
Standard #:	22VAC40-73-640-A
Description:	Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes. Evidence: A review of the Controlled Medication Count Record for the medication cart #2 for the month of August 2023, showed staff failed to ensure counts of all control medications were documented on 26 of the shifts for the month. On Medication cart # 4, staff failed to ensure count of all control medications were documents on 55 shifts for the month.
Plan of Correction:	1. Resident #2 and Resident #4?s-controlled medications were counted and documented per the standard. 2.A cart audit was completed on all medication carts to ensure compliance with control medication documentation. 3. All RMAs/LPNs will be in-serviced on the standard to ensure compliance. 4. Health Care Director and Harmony Square Director will complete chart audits weekly to ensure continued compliance with standard. Any trends will be reported to QAPI.
Standard #:	22VAC40-73-640-D
Description:	Based on observation and staff interviewed, the facility failed to ensure the pharmacy reference book, drug guide, or medication handbook was no more than two years old as reference for staff who administer medications. Evidence: 1. The pharmacy drug guide on-site on 9/1/23 was dated 2015. confirmed the facility did not have a drug guide that is no more than two years old. 2. Staff #3 acknowledged the facility did not have pharmacy reference books which were dated within the required timeframes.
Plan of Correction:	1. Facility will purchase copies of a current pharmacy reference book. 2. Healthcare Director and Harmony Square Director were in-serviced on the standard. 3. RMAs and LPNs were in-serviced on the location on the current pharmacy reference book and standard. 4. Standard will be reviewed in QAPI.
Standard #:	22VAC40-73-680-C
Description:	Based on records reviewed, the facility failed to ensure medication be administered no earlier than one hour before and not later than one hour after the facility?s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: 1. A review of the August 2023 Medication Administration Record (MAR) for Resident #4 documented the resident was to receive Dutasteride 0.5 mg, Melatonin 5 mg, Quetiapine Fumarate 50 mg on 8/26/23 at 7:00 pm. Those medications were not administered until 8/26/23 at 10:22 pm. Resident #4 was due to receive Buspirone HCL 10 mg and Quetiapine Fumarate 50 mg on 8/28/23 at 12:00 pm. Those medications were not administered until 2:06 pm. Resident #4 was due to receive Buspirone HCL 10mg and Clonazepam 1 mg on 8/30/23 at 4:00 pm. Those medications were not administered until 8/30/23 at 5:58 pm. 2. A review of the August 2023 MAR for Resident # 3 documented the resident was to receive Acetaminophen 325 mg, Memantine HCL 10 mg, and Quetiapine Fumarate 25 mg on 8/31/23 at 5:00 pm. Those medications were not administered until 8/31/23 at 7:08 pm.
Plan of Correction:	1. Healthcare Director or designee will review medication administration times and MARs to ensure that enough time is permitted to administer medications not earlier than one hour before and one hour after the facilities standard dosing schedule. 2. Healthcare Director will re-educate all RMAs and LPNs on adherence to the Rights of Medication Administration. 3. Resident Care Director or designee will conduct a random medication pass audit a minimum of 2 times per month to ensure ongoing compliance and provide any necessary coaching on medication administration concerns. 4. Any trends will be reported to QAPI.
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the first aid kits were checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. Evidence: On 9/1/23 during the inspection of the First-Aid kit for the vehicle, the contained ointment which had an expiration date of 3/2023.
Plan of Correction:	1. Ointment in vehicle first aid kit was updated. 2. All first aid kits were audited by Health Care Director to ensure compliance. 3. All staff will be in-serviced on the standard to ensure compliance. 4. Health Care Director/designee will audit the first aid kits monthly. Any trends will be reported to QAPI.