VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Harmony Collection at Roanoke Memory Care
4414 Pheasant Ridge Road
Roanoke, VA 24014
(540) 685-4900

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: July 8, 2019

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 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. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 SANCTIONS.

Comments:

On 7/8/2019 one inspector conducted a renewal study (8am to 4:45pm). 57 residents were in care. Eight resident records were fully reviewed, and one additional record was partially reviewed. Four staff records were fully reviewed, and all new staff records (three) were reviewed for back ground checks. A medication pass was observed, residents and staff were interviewed, a medication cart was reviewed, and a physical plant tour was done. The management staff and LI discussed methods and documentation [of attempts at] obtaining POA signatures on documents, ISP documentation and using the ISP model form, clarification of posting the in-charge person, activated charcoal no longer required by be in the first aid kit, ways to post documents and not have them removed by residents, and when there are many changes to be made to comprehensive individualized service plans it is best to rewrite it rather than having staff try to figure out what is current and what isn't. Please respond to the violation notice by 7/20/2019 or sooner. If you have questions, call your licensing inspector.

Violations:

Standard #:	22VAC40-73-220-B
Description:	Based on record review, the facility failed to obtain, in writing, information on the type and frequency of the services to be delivered to the resident by private duty personnel. EVIDENCE: 1. The file for sitter 1 lacks information on the type and frequency of the services to be delivered to the resident by sitter.
Plan of Correction:	Business Office Manager to obtain and document the type and frequency of the services to be delivered to the resident for all residents who currently receive services from private duty personnel. Administrator and/or Business Office Manager will ensure the type and frequency of services provided by private duty personnel will be documented prior to the start of services in the future.
Standard #:	22VAC40-73-250-C
Description:	Based on staff record review, the facility failed to have a criminal history record check in a staff file. EVIDENCE: 1. The record for staff 5, hired 5/2/2019, lacks the results of a Virginia State Police Criminal History Record check.
Plan of Correction:	Business Office Manager to obtain and file the results of a Virginia State Police criminal history check for staff #5. Administrator and/or Business Office Manager to ensure all staff members have a criminal history record check in their file prior to starting employment.
Standard #:	22VAC40-73-250-D
Description:	Based on staff record review, the facility failed to ensure that TB screenings were done on new staff. EVIDENCE: 1. There is no documentation in the records to support that staff 1 (hired 7/1/2019), staff 3 (hired 6/6/2019), and staff 4 (hired 5/23/2019) had TB screenings prior to beginning work.
Plan of Correction:	Staff #1, Staff #3, and Staff #4 had TB screenings prior to beginning work, although not documented as such. Healthcare Coordinator will document TB screenings on Staff #1, Staff #3, and Staff #4. Administrator and/or Healthcare Coordinator to ensure all staff members receive a TB screening prior to beginning work.
Standard #:	22VAC40-73-260-C
Description:	Based on observation and interview, the facility failed to have a posted list of staff who have current certification in first aid and CPR. EVIDENCE: 1. The LI was unable to locate the posted list, and several staff people looked in areas where the list is normally posted, and they could not locate it, either.
Plan of Correction:	The listing of staff who are currently certified in first aid and CPR had been removed for updates. Listing was re-posted on the day of the inspection. Administrator and/or Business Office Manager to ensure a current listing is posted at all times.
Standard #:	22VAC40-73-440-A
Description:	Based on review of resident records, the facility failed to ensure that the uniform assessment instrument (UAI) was completed in accordance with Assessment in Assisted Living Facilities (22VAC30-110). EVIDENCE: 1. The UAI for resident 1, done 4/30/2019, shows that this resident is both oriented, and disoriented to some spheres (time and place), some of the time. 2. The UAI for resident 2, done 12/5/2018, shows that this resident requires supervision with bathing, and the comprehensive individualized service plan (C-ISP) shows this resident also requires mechanical assistance. Staff interview confirms that both mechanical assistance and supervision are required. The same UAI shows that resident 2 both needs no assistance with wheeling, and that it is not performed. 3. The UAI for resident 3, dated 10/1/2018, shows two different assessments for medication administration, and two separate assessments for behavior pattern. 4. The UAI for resident 6, dated 7/24/2018, shows this resident requires supervision only with mobility outside of the facility (a memory care unit). This resident cannot leave the facility without supervision due to a serious cognitive impairment, so resident 6 should have been assessed as confined. The ISP indicates this resident is confined, but moves about [inside the facility]. 5. The UAI for resident 7, dated 6/6/2019, shows this resident both needs no help with using a wheelchair, and that wheeling is not performed. If help is required, no other entries should be made.
Plan of Correction:	The UAI?s for resident #1, #2, #3, #6, and #7 to be updated by the Healthcare Coordinator to accurately reflect the resident?s care needs. Licensing Inspector to provide UAI and ISP training.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to address some needs on comprehensive individualized service plans (C-ISP). EVIDENCE: 1. The C-ISP for resident 3, dated 10/1/2018, shows this resident has inappropriate behaviors (wandering, attempted elopements, and verbal abuse), and the services to be given to address these issues are not listed, other than to report changes in behavior. 2. The uniform assessment instrument (UAI) for resident 6, dated 7/24/2018, shows this resident needs mechanical and human help with physical assistance for bathing and the C-ISP, dated 6/29/2018, does not show the mechanical assistance or the physical assistance to be given. The UAI for resident 6 shows this resident needs mechanical and human help with supervision when using the toilet, and the ISP does not address the mechanical help, and it shows that hands on help, instead of supervision is given. The UAI for resident 6 shows this resident is independent with walking, and the C-ISP shows this resident has both mechanical and human assistance. The UAI for resident 6 shows this resident needs physical assistance when using a wheelchair, and the C-ISP shows the resident is both independent, and requires physical assistance. The UAI for resident 6 shows that supervision only is required with mobility outside of the facility (a memory care unit), and the ISP shows physical and mechanical assistance is given. The C-ISP for resident 6 shows the resident has several medication allergies, and services to help with this need show that allergies are listed in several areas, and that the pharmacy has been notified. The services don't address what steps the facility will take to avoid future contact with the allergens, reactions staff should watch for, and what to do if it is discovered the resident has ingested a drug the resident has an allergy to. The UAI for resident 6 shows she is disoriented to place, time, and situation all of the time. The services listed on the C-ISP show "Right now resident 6 states that she is "not crazy, only forgetful". Re-orient her for now to where she is and the time of the evening thru TB shows she is used to watching." The ISP does not show how to re-orient the resident, dealing with time during the day, or re-orientation to place and situation. 3. The UAI for resident 9, dated 4/20/2019, shows this resident needs mechanical and human help with physical assistance when using the toilet. The C-ISP, dated 4/20/2019, does not specify the nature of the mechanical assistance.
Plan of Correction:	Services to be provided to address resident #3?s behaviors to be added to the C-ISP by the Healthcare Coordinator. The UAI and C-ISP for resident #6 to be updated by the Healthcare Coordinator to accurately reflect the residents care needs. The C-ISP for resident #9 to be updated by the Healthcare Coordinator to specify the nature of mechanical assistance needed for toileting. Licensing Inspector to provide UAI and ISP training.
Standard #:	22VAC40-73-450-D
Description:	Based on resident record review, the facility failed to include all hospice services on the comprehensive individualized service plan. EVIDENCE: 1. The C-ISP for resident 6, dated 6/29/2018, shows that hospice services began on 3/31/2018, and services to be provided by the hospice are not complete. The C-ISP notes that additional shared duties are in Hospice notes.
Plan of Correction:	The C-ISP for resident #6 does include some services to be provided by hospice. Healthcare Coordinator to update the C-ISP to include all services to be provided by hospice. Healthcare Coordinator to ensure all services provided by hospice are on the C-ISP in the future.
Standard #:	22VAC40-73-450-E
Description:	Based on document review, the facility failed to obtain required signatures on a comprehensive individualized service plan (C-ISP). EVIDENCE: 1. The C-ISP for resident 3, dated 10/1/2018 lacks a signature by the resident or his legal representative. 2. The C-ISP for resident 9, dated 1/31/2019, has had updates on 2/11/2019, 2/14/2019, 4/19/2019, and 4/20/2019, and the updates are lacking all required signatures.
Plan of Correction:	Attempts to obtain signatures on the C-ISP for resident #3 and #9 have been made by the Healthcare Coordinator. Healthcare Coordinator to ensure signatures are obtained in the future.
Standard #:	22VAC40-73-950-E
Description:	Based on document review and interview, the facility failed to conduct a semi-annual review of the emergency preparedness and response plan for all residents, and volunteers, with emphasis placed on an individual's respective responsibilities. This document must be signed and dated. EVIDENCE: 1. There is no documentation to support that the semi-annual review was conducted with residents or volunteers/sitters, and this was confirmed by interview with facility management.
Plan of Correction:	Administrator and/or Life Enrichment Director to conduct review of emergency preparedness and response plans with residents, volunteers, and private duty staff.