VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Harmony Collection at Roanoke Assisted Living
4402 Pheasant Ridge Road
Roanoke, VA 24014
(540) 970-3524

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: Oct. 28, 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 10/28/2019 one inspector, supervised by the Licensing Administrator, conducted a monitoring visit (8:15am to 11:40pm) for a facility that was recently licensed. 21 residents were in care. Six resident records and three staff records were fully reviewed, and an additional resident record was partially reviewed. All new staff records were reviewed for background checks. A medication pass was observed, the medication cart was checked, and staff and residents were interviewed. A physical plant tour was done. During the inspection and at the exit interview, the facility was given the opportunity to discuss the violations and to show that they were in compliance. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain the following: 1) steps to correct the noncompliance with the standard(s); 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions, please contact your licensing inspector at 540-309-3043.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on review of resident record, the facility failed to ensure the physical examination and report for a resident contained all required information. EVIDENCE: 1. The history and physical for resident 5, admitted on 09/10/2019, did not include the resident?s medications. The physician documented ?see snapshot list?; however, there was no attached list.
Plan of Correction:	1. Steps to correct the non-compliance: The ?snapshot list? of medications prescribed for resident 5 was filed under the physician?s orders section of the resident?s record. It was removed from this section and filed with the physical examination and report for this resident during the inspection once pointed out by the inspection team. 2. Measures to prevent reoccurrence: In the future, if a physician includes an attached list for the medications, the attached list will remain with the physical examination and report once filed in the resident?s record. 3. Persons Responsible for monitoring plan: The Healthcare Clinical Director or designee will be responsible for making sure information is filed in the appropriate section of the resident?s record and that the complete physical examination and report remains together.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to address some resident needs on comprehensive individualized service plans (ISP). EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 1 shows this resident is disoriented to time and place some of the time, and has a behavior pattern of wandering/passive - less than weekly. These needs are not addressed on the comprehensive ISP, dated 9/17/2019. 2. The uniform assessment instrument (UAI) for resident 3 shows this resident is disoriented to time and place some of the time, This need is not addressed on the comprehensive ISP, dated 10/2/2019.
Plan of Correction:	1. Steps to correct the non-compliance: The Healthcare Clinical Director reviewed the ISP?s for residents 1 and 3 on the date of inspection. The ISP?s were updated to include the disorientation and behavior patterns for both residents. 2. Measures to prevent reoccurrence: In the future, the Healthcare Clinical Director or designee will review and crosswalk the UAI & ISP once completed, to ensure that every detail matches and ensure that every need is addressed comprehensively on each resident?s ISP. 3. Persons Responsible for monitoring plan: The Healthcare Clinical Director or designee will be responsible for implementing and monitoring this plan.
Standard #:	22VAC40-73-650-E
Description:	Based on document review, the facility failed to have an order for a medication in a resident record. EVIDENCE: 1. The October 2019 medication administration record (MAR) for resident 3 shows this resident was prescribed Ibuprofen 400mg, as needed (PRN) on 9/30/2019. The resident's record does not have the order for this medication.
Plan of Correction:	1. Steps to correct the non-compliance: The physician?s order sheet for resident 3, which included the order for Ibuprofen 400 mg as needed, was reviewed and signed by the physician on the date of inspection. 2. Measures to prevent reoccurrence: The Healthcare Clinical Director or designee will review every medication order on the MAR and ensure that a signed physician?s order is maintained in the resident?s record for each order once sent to the pharmacy. 3. Persons Responsible for monitoring plan: The Healthcare Clinical Director or designee will be responsible for implementing and monitoring this plan.
Standard #:	22VAC40-73-660-B
Description:	Based on observation and document review, the facility failed to ensure that a resident who is capable of self-administering medication kept the medication in an out of sight place in her bedroom. EVIDENCE: 1. Resident 7 had a bottle of over- the-counter TheraTears sitting out in her room. The uniform assessment instrument (UAI) for resident 7, dated 10/7/2019, shows this resident is dependent in medication administration. The physical exam form for resident 7, dated 9/25/2019, shows this resident is unable to self-administer medication. There is no order in the chart to show resident 7 can self-administer this medication and keep it in her room.
Plan of Correction:	1. Steps to correct the non-compliance: The bottle of over-the-counter TheraTears was removed from resident 7?s apartment during the inspection. It was determined that the TheraTears belonged to the resident?s family member who had been visiting the resident on the weekend and was accidentally left behind. 2. Measures to prevent reoccurrence: When coming and going from residents? apartments to provide daily services, clinical and housekeeping staff will be mindful of their surroundings. They will alert management staff if medications are noticed sitting out in a resident?s apartment and management staff will address accordingly to maintain compliance. 3. Persons Responsible for monitoring plan: The Healthcare Clinical Director or designee will be responsible for implementing and monitoring this plan.