Harbor Point cited for repeat violations of individualized treatment planning

Harbor Point Behavioral Health Center was cited by the Virginia Department of Behavioral Health and Developmental Services (DBHDS) for deficiencies related to treatment planning, medication errors, and food safety. During the inspection, DBHDS issued a repeat citation to the facility after it found nine patients who did not have individualized treatment plans and the medical record only contained the signature page and nothing else. Inspectors also found discrepancies between the treatment objectives found in patient progress notes and the objectives listed in the treatment plan for four patients. DBHDS noted that because of these discrepancies, “progress cannot be determined” in the patient’s Individualized Service Plan. In noting these deficiencies, the inspection report cites a case in which one patient’s (I31) progress notes did not accurately describe his course of treatment or experience, nor was the treatment plan updated to accurately reflect changes. The patient injured his hand and was transported to the ER. DBHDS found progress note documentation that “indicated that I31 was participating in group activity and on the unit, this contradicts the nursing documentation that during this time he was in transit or in the emergency room.” Also during the inspection, inspectors completed a walk-through of the kitchen facility and found lunch packages that were not dated, trays of chicken and servings of tuna with expired usage dates, and unsealed boxes of food in the refrigerator. The inspectors had previously noted to facility staff that containers of hard boiled eggs, pasta salad and fruit all had expired usage dates on them. The inspectors came back in the afternoon to see the same containers still in the refrigerator but with the old usage dates crossed off and a new date written by hand. An inspector spoke with the CEO and indicated that “the serving of expired food was a health and safety concern.” The facility was also issued another repeat violation during this inspection after DBHDS found 18 Medication Administration Record (MARs) in the month of October that contained a number of omissions and documentation errors. The facility submitted a plan of correction to address these cited deficiencies.