VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harmony at Harbour View
5871 Harbour View Boulevard
Suffolk, VA 23435
(757) 214-6279

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Feb. 6, 2024 , Feb. 14, 2024 and March 7, 2024

Complaint Related: Yes

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 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 02/06/24 from 9:21 am to 4:30 pm; 02/14/24 from 9:27 am to 2:00pm; 03/07/24 from 9:11 am to 3:25 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint received by VDSS Division of Licensing on 01/24/2024 regarding allegations in the area of: Personnel, Staffing and Supervision, and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 84 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: 7 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 6 Observations by licensing inspector: Observation of the facility?s medication carts, and medication storage areas were observed. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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.

Violations:

Standard #:	22VAC40-73-40-A
Complaint related:	Yes
Description:	Based on video footage, and documentation gathered during the investigation it was determined that the facility failed to ensure compliance with the facility?s own policies and procedures. Evidence: 1. During an incident with resident #2 on 10/09/23, staff #4 and staff #9 did not follow the facility?s procedure for resident emergencies for when a resident is unresponsive or unconscious. 2. The facility?s resident emergency plan includes the following: If a resident is unresponsive or unconscious ?once CPR has started, do not stop until EMS are present and take over;? ?stay with the resident, if alone use alternate communication systems to call for help (radio, pull cord, resident phone). ? 3. Staff #4 and Staff #9 left resident #2 alone in resident?s #2 room while resident #2 was unresponsive and unconscious. 4. Staff #4 stopped 3 times while providing CPR to resident #2 and EMS was not present to take over.
Plan of Correction:	All staff members will be in serviced on Harmony Senior Services policy and procedure related to plan for resident emergencies and Emergency Medical Action Plan
Standard #:	22VAC40-73-200-C
Complaint related:	No
Description:	Based on the staff record review it was determined that the facility failed to ensure direct care staff shall meet one of the requirements in this subsection. If the staff does not meet the requirement at the time of employment, he shall successfully meet one of the requirements in this subsection within two months of employment. Evidence: 1. The record for staff #7, hire date 07/05/23, did not contain documentation of staff #7 meeting one of the direct care staff qualifications. 2. Staff # 8 could not provide documentation to demonstrate the personal care aide training completed by staff #7 was approved by Virginia Department of Medical Assistance Services or Virginia Department of Social Services.
Plan of Correction:	Business Office Manager, Healthcare Director will have tickler system in place to check licenses monthly to ensure licenses are current. We are checking month prior and reminding employees.
Standard #:	22VAC40-73-250-D
Complaint related:	No
Description:	Based on the record review it was determined that the facility failed to ensure each staff person on or within 7 days prior to the first day of work at the facility prior to coming in contact with residents shall submit the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. Evidence: 1. The record for staff #7, hire date 07/05/23, did not contain a risk assessment for TB. 2. The record for staff #10, hire date 04/04/23, did not contain a risk assessment for TB. 3. Staff #2 risk assessment for TB is dated 02/20/23. The staff record did not contain an annual risk assessment for TB completed after 02/20/23. 4.Staff #4 risk assessment for TB is dated 01/27/23. The staff record did not contain an annual risk assessment for TB completed after 01/27/23. Staff #8 4. Staff #8 acknowledged the records for staff #7 and staff #10 did not contain a risk assessment for TB. 5. Staff #8 acknowledged the records for staff #2 and staff #4 did not contain an annual risk assessment for TB.
Plan of Correction:	Business office Manager or designee will ensure all new staff will not have a TB result older than 30 days from date of hire. BOM or designee will check all employee files for compliance
Standard #:	22VAC40-73-260-A
Complaint related:	Yes
Description:	Based on the record review and staff interview it was determined that the facility failed to ensure each direct care staff member shall maintain current certification in first aid. Evidence: 1. The record for staff # 4, hire date 10/29/22, contains a first aid certification with an expiration date of 01/2024. 2. The record for staff # 6, hire date (03/28/23) and last day of work date (11/03/23) did not contain documentation of a certification in first aid. 3. The record for staff #7, hire date 07/05/23, did not contain documentation of a current certification in first aide. 4. Staff #8 acknowledged the records for staff #4, staff #6 and staff #7 did not contain documentation of a current certification in first aid.
Plan of Correction:	All active employee records will be checked for First Aid and CPR certification. Employees that have not received training will receive formal training. Staff will receive training annually. Records will be reviewed by HR or designee monthly.
Standard #:	22VAC40-73-260-C
Complaint related:	Yes
Description:	Based on observation it was determined that the facility failed to ensure a listing of all staff who have current certification in first aid or CPR, in conformance with subsections A and B of this section, shall be posted in the facility so that the information is readily available to all staff at all times. The listing must indicate by staff person whether the certification is in first aid or CPR or both and must be kept up to date. Evidence: 1. During observation on 02/06/24 and 02/14/24, the First Aid and CPR list posted in the facility was dated 01/20/23. The First Aid and CPR posting was not current and kept up to date as it included employees who no longer work at the facility.
Plan of Correction:	The business office manager or designee will perform an employee audit by 06.01.24 to stay current on the employee?s certifications. The business office manager or designee will audit employee certifications to verify continued compliance.
Standard #:	22VAC40-73-325-B
Complaint related:	Yes
Description:	Based on a review of documentation it was determined that the facility failed to ensure the fall risk rating should be updated after a fall. Evidence: 1. Resident #2 had a fall on 09/22/23 while at the facility. 2. Resident?s #2 record did not include a fall risk rating completed after the resident?s fall on 09/22/23.
Plan of Correction:	ED, HCD/HSD or designee will ensure fall risk rating has been completed after each fall. Will review all the falls to ensure fall risk completed.
Standard #:	22VAC40-73-450-C
Complaint related:	Yes
Description:	Based on the record review it was determined that the facility failed to ensure the comprehensive individualized service plan (ISP) shall include the following: A description of identified needs based upon the admission physical examination and other sources. Evidence: 1. The record for resident #2 contains the following: a ?Service/Yardi Points guidelines? form dated 06/20/23 that documents assistance needed with CPAP/BIPAP; a physical examination dated 07/05/23 documents ?obstructive sleep apnea w/ CPAP;? a vial of life form dated 07/10/23 documents ?Sleep apnea;? a nursing noted dated 09/02/23 documents ?CPAP mask was applied to the resident?s face.? 2. Resident?s #2 ISP dated 07/10/23 did not include the need for a CPAP machine and the diagnosis of Sleep Apnea.
Plan of Correction:	The HCD or designee will complete UAI/ISP Audit weekly for the next 8-weeks, to monitor compliance for all residents in the community. The Executive Director/Designee will be responsible for directing additional corrective action, based on audit findings.
Standard #:	22VAC40-73-660-A
Complaint related:	No
Description:	Based on observation it was determined that the facility failed to ensure medications shall be stored in a manner consistent with current standards of practice and the storage area shall be locked. Evidence: 1. During a tour of the facility on 02/06/24 at 10:37 a.m., two medication carts located on the 2nd Floor was observed to be unlocked and unstaffed. 2. During a tour of the facility on 02/06/24 at 10:41 a.m., the medication cart located on the 3rd Floor was observed to be unlocked and unstaffed.
Plan of Correction:	Director of Health Services/Designee will randomly audit unsecured workstations at the community 1x daily for 8x weeks to ensure compliance. All RMA?s and nurses to be in serviced on Harmony standards and DSS standards to store all medications properly.
Standard #:	22VAC40-73-860-I
Complaint related:	No
Description:	Based on the onsite observation it was determined that the facility failed to ensure each facility shall store cleaning supplies and other hazardous materials in a locked area. Evidence: 1. During the onsite observation on 02/06/24 at 9:41 am in the safe, secure unit, the Licensing Inspector (LI) observed Clorox and Comet cleaning products located in the unlocked medication room. 2. The medication room was unstaffed during the observation and was accessible by residents.
Plan of Correction:	HCD/HSD will ensure that all cleaning supplies are kept secured at all times. All staff members to be in-serviced to lock up all hazardous materials.
Standard #:	22VAC40-73-990-B
Complaint related:	Yes
Description:	Based on the record review it was determined that the facility failed to ensure the procedures in the plan for resident emergencies required in subsection A of this section shall be reviewed by the facility at least every six months with all staff. Documentation of the review shall be signed and dated by each staff person. Evidence: 1. The record for staff #4, hire date 10/29/22, did not include evidence staff #4 reviewed the facility?s written plan for resident emergencies at least once every six months. 2. The record for staff #5, hire date 10/29/22, did not include evidence staff #5 reviewed the facility?s written plan for resident emergencies at least once every six months. 3. The record for staff #9, hire date 06/02/19, did not include evidence staff #9 reviewed the facility?s written plan for resident emergencies at least once every six months. 4. Staff #8 acknowledged the facility did not have evidence of staff #4, staff #5, and staff #9 reviewing the facility?s written plan for resident emergencies at least once every six months.
Plan of Correction:	The HCD will ensure this training is completed during orientation. The ED will ensure this review is done for all staff at least every six months. This training will be done when fire and safety training is done. The ED will also ensure at least once every six months all staff currently on duty on each shift will participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of all training will be kept on file.