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: Jan. 6, 2022

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 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Comments:

On 1/6/2022 two inspectors conducted an on-site annual monitoring inspection from 8:20 am through 3:05 pm. Nine resident records and three staff records were reviewed. A medication pass was observed and a physical plant tour was done. An exit interview was conducted the day of the inspection, on-site.

Violations:

Standard #:	22VAC40-73-1030-B
Description:	Based on staff record review, the facility failed to provide required staff training concerning residents with serious cognitive impairments within four months of starting employment. EVIDENCE: 1. Staff 2 began work on 8/4/2021, and there is no documentation to support that she had 4 hours of required training for a mixed population. A mixed population has both regular assisted living level of care residents and residents with serious cognitive impairments, but don't have a safe, secure environment) training. The physical examination for resident 6, done on 5/25/2021, shows that resident 6 in non-ambulatory by reason of mental impairment and is not capable of self-preservation without the assistance of another person, and a diagnosis of dementia. This was noted on 1/3/2022.
Plan of Correction:	What Has Been Done to Correct? Dementia classes added to Relias online learning and completed by staff #2. How Will Recurrence Be Prevented? Classes added to Relias upon hire with due date no more than four months after hire date. Person Responsible: BOM, ED, and/or designee
Standard #:	22VAC40-73-50-B
Description:	Based on resident record review, the facility failed to retain written acknowledgement of the receipt of the disclosure by the resident or his legal representative in the resident's record. EVIDENCE: 1. The record for resident 1 lacked written acknowledgment of the receipt of the disclosure by the resident or his legal representative.
Plan of Correction:	What Has Been Done to Correct? Resident 1 received disclosure statement and signed the acknowledgement. How Will Recurrence Be Prevented? Disclosure statement is in the process of the pre-admit/lease signing process with ED or designee. Audit file for completion. Person Responsible: DSM, ED, BOM
Standard #:	22VAC40-73-210-B
Description:	Based on staff record review, the facility failed to ensure that direct care staff had at least 18 hours of annual training. EVIDENCE: 1. Staff 3 began work on 2/10/2020, and the record documents that 14 hours of training was completed by 2/9/2021. Staff 3 does not meet an exception to the 18 hour requirement.
Plan of Correction:	What Has Been Done to Correct? Required training for staff #3 is scheduled. How Will Recurrence Be Prevented? Reminders sent to staff about courses due in Relias Person Responsible: BOM, ED, all department heads and supervisors
Standard #:	22VAC40-73-350-B
Description:	Based on resident record review, the facility failed to document in a resident record that a sex offender screening had been done. EVIDENCE: 1. The record for resident 1, admitted on 11/19/2021, lacked documentation to show that a sex offender screening had been done.
Plan of Correction:	What Has Been Done to Correct? Sex Offender Screening conducted and is now on file for Resident 1. How Will Recurrence Be Prevented? BOM, ED and/or designee to run name of potential resident prior to lease signing. Audit file for completion. Person Responsible: BOM, ED and/or designee
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review and interviews, the facility failed to complete complete uniform assessment instruments (UAI) in accordance with Assessment in Assisted Living Facilities (22VAC30-110). EVIDENCE: 1. The UAI for resident 4, dated 4/18/2021, shows conflicting information: the resident both needs no help walking, and that walking is not performed. Interviews with staff 1 and 5 indicate that "is not performed" is incorrect. 2. The UAI for resident 5, dated 9/30/2021, shows conflicting information: wheeling is assessed as both mechanical help only and "is not performed". Interview with staff 1 indicate that "is not performed" is incorrect. 3. The UAI for resident 2, dated 11/10/2021, shows conflicting information: both walking and stairclimbing the resident both needs mechanical help only, and that the activities are "not performed". Interview with staff 5 shows that "is not performed" is incorrect.
Plan of Correction:	What Has Been Done to Correct? UAI?s for residents 4, 5 and 2 have been corrected in accordance with Assessment in ALF. How Will Recurrence Be Prevented? Education workshop scheduled for staff members in community completing UAIs. All completed UAIs reviewed by HCD and ED. Person Responsible: HCD, ED, BOM
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to show a service on an individualized service plan (ISP). EVIDENCE: 1. The ISP for resident 1 dated 11/19/2021 shows "resident to bathe with staff assist" but does not describe what type of assistance is to be given by staff.
Plan of Correction:	What Has Been Done to Correct? ISP for resident 1 updated with details including type of assistance bathing. How Will Recurrence Be Prevented? ISPs will be reviewed by HCD and ED before presenting to resident/family for signatures. Person Responsible: HCD, ED
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review, the facility failed to obtain required signature(s) on an individualized service plan (ISP) EVIDENCE: 1. The ISP for resident 1 lacks signatures from the resident or the resident's representative.
Plan of Correction:	What Has Been Done to Correct? Signature was obtained on Resident 1?s ISP. How Will Recurrence Be Prevented? HCD, ED and/or designee will review and obtain signatures from resident and/or family upon completion of ISP. File audits to be completed for compliance. Person Responsible: HCD, ED and/or designee
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to update a resident's individualized service plan. EVIDENCE: 1. The ISP for resident 2 shows the "dates of expected outcome" are 10/31/2021. This was noted on 1/6/2022. 2. The ISP for resident 8 shows the dates of expected outcomes are 9/4/2021. This was noted on 1/6/2022.
Plan of Correction:	What Has Been Done to Correct? ISP for Resident 2 and 8 updated. Signatures obtained. How Will Recurrence Be Prevented? ISPs will be completed upon admission, annually or with significant changes. File audits to be completed for compliance. Person Responsible: HCD, ED and/or designee