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 14, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

The LI, the administrator, and the Regional Director of Clinical Services discussed 440, 450-C, 550-F, and 990 to ensure that the facility had a thorough understanding of these standards.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 7/7/2020 and concluded on 7/9/2020. The facility Administrator was contacted by telephone to initiate the inspection. The facility Administrator and the Regional Director of Clinical Services reported that the current census was 58. The inspector emailed the Regional Director of Clinical Services a list of items required to complete the inspection. The inspector reviewed four resident records, four staff records, the Sworn Disclosure Statement and Criminal Record Report for all new staff members, resident roster, staff roster, staff schedule, facility health care oversight, fire and emergency drills, health department inspection, and dietitian oversight submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-440-D
Description:	440-D Based on record review, the facility failed to ensure that the uniform assessment instrument (UAI) is completed as required. EVIDENCE: 1. The UAI for resident 1, dated 6/11/2020, stated that mobility is performed by others; however, the individualized service plan (ISP), dated 6/11/2020, stated that mobility requires the physical assistance of staff and the mechanical assistance of her wheelchair and its features. 2. The UAI for resident 2, dated 6/7/2020, stated for orientation that the resident is disoriented to some spheres, some of the time with regard to time; however, the ISP, dated 6/29/2020, stated that the resident is disoriented to time, place, and situation. 3. Interview with staff 5 confirmed the UAIs were not completed as required, and the ISPs for both residents were correct.
Plan of Correction:	The UAIs were updated on date of inspection. The Healthcare Director/Designee will review ISP and UAI for accuracy. The Healthcare Director/Designee will be responsible for ongoing compliance.
Standard #:	22VAC40-73-720-A
Description:	720-A Based on record review, the facility failed to ensure that the written do not resuscitate (DNR) order is included in the individualized service plan (ISP). EVIDENCE: 1. The ISP for resident 2, dated 6/29/2020, stated that the code status is ?DDNR ? CPR will not be initiated?; however, under expected outcomes and goals on the ISP it stated ?Life saving measures WILL be performed; EMS will be called; Life sustaining measures will be continued?. 2. The signed DNR, dated 7/16/2019, was included in the resident's record. 3. Interview with staff 5 confirmed that the information in the expected outcomes and goals section of the ISP for resident 2 was incorrect.
Plan of Correction:	The ISP for resident #2 was updated on the day of inspection. The Health Care Director/Designee will review ISPs for accuracy before signing. The Health Care Director/Designee will be responsible for ongoing compliance.