VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Harmony Collection at Roanoke Independent Living
4428 Pheasant Ridge Road
Roanoke, VA 24014
(540) 400-6482

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: March 24, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

260-C, 550-G, 22VAC40-80-120-E.2

Comments:

The LI for The Harmony Collection at Roanoke Independent Living, along with an additional Licensing Inspector, conducted an unannounced monitoring study on 03/24/2022 from 8:45 AM until 3:00 PM, finding 38 assisted living residents in care. The inspection included a tour of the physical plant, observation of a medication pass, a review of the medication storage carts, staff/resident interviews, and observation of portions of the midday meal and craft activity. Eight resident records were thoroughly reviewed, and an additional five were partially reviewed in relation to the observation of the medication pass, special diets, or other services being received. Sworn disclosure statements and criminal record checks were examined for all newly hired staff, and the records of four staff were thoroughly examined. Additional facility documentation was surveyed for compliance with the Standards for Assisted Living Facilities. Findings were reviewed with facility staff during the inspection. An exit interview was conducted with the facility Administrator and General Manager on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. 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. If you have any questions, contact your licensing inspector at (540) 309-5982.

Violations:

Standard #:	22VAC40-73-210-B
Description:	210-B Based on record review, the facility failed to ensure that for a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. EVIDENCE: 1. The record for staff 1, hired 07/15/2014, did not contain annual training for the 07/15/2020 to 07/14/2021 training year. 2. The record for staff 2, hired 01/03/2020, did not contain annual training for the 01/03/2021 to 01/02/2022 training year.
Plan of Correction:	Staff #1 record was audited and training scheduled. Training needs will be reviewed monthly and scheduled accordingly by the Business Office Manager or designee.
Standard #:	22VAC40-73-220-B
Description:	220-B Based on resident record review and resident, collateral and staff interview, the facility failed to obtain, in writing, information on the type and frequency of the services to be delivered to the resident by a private duty personnel who is not an employee of a licensed home care organization. EVIDENCE: 1. During on-site inspection on 03/24/2022, collateral 1 observed that resident 9 had a private duty companion, staff 7. Staff 7 informed collateral 1 that she provides companion services to resident 9 throughout the week at the facility. 2. On date of inspection, staff 5 revealed to the LI that the facility did not have written information on the type and frequency of the services to that are being delivered to resident 9 by staff 7.
Plan of Correction:	List of duties was provided and signed by private duty personnel. In the future, the Business Office Manager will ensure that all new private duty will go through the Business Office before providing care to ensure all documents are in hand.
Standard #:	22VAC40-73-250-D
Description:	250-D Based on record review, the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility shall submit the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form, and the facility shall annually submit the results of a risk assessment, documenting that the individual is free of TB in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of health or a form consistent with it. EVIDENCE: 1. The most recent annual TB risk assessment for staff 1, hired 07/15/2014, was dated 01/02/2021. 2. The most recent annual TB risk assessment for staff 2, hired 01/03/2020, was dated 07/31/2020. 3. The initial TB risk assessment for staff 3, hired 06/14/2021 was not found in the staff record. 4. The most recent annual TB risk assessment for staff 4, hired 02/22/2021, was dated 02/22/2021.
Plan of Correction:	TB screenings will be obtained for staff 1, 2, 3, and 4. The Business Office Manager will ensure that a schedule has been created with staff anniversaries as a reminder for yearly TB screening updates.
Standard #:	22VAC40-73-325-B
Description:	325-B Based on record review and staff interview, the facility failed to ensure the fall risk rating was reviewed and updated for residents who meet the criteria for assisted living care after a fall. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 5, dated 12/15/2021, indicated that the resident is assisted living level care. 2. The record for resident 5 contained progress notes by facility staff that the resident fell on 02/11/2022 and 02/13/2022. Interview with staff 5 revealed that there were no fall risk ratings conducted by staff for these two falls on these dates.
Plan of Correction:	Resident #5 ISP was updated to reflect the needs. The Health Care Director or designee will ensure that ISP certified staff will be trained on updating the ISP.
Standard #:	22VAC40-73-440-D
Description:	440-D Based on record review and staff interview, the facility failed to ensure that the uniform assessment instrument (UAI) was completed as required. EVIDENCE: 1. The UAI for resident 2, dated 01/11/2022, indicated that the resident does not need assistance with dressing; however, the individualized service plan (ISP), dated 01/22/2022, indicated that the resident needs mechanical assistance with dressing. 2. Interview with staff 5 revealed that the ISP is correct and the UAI is incorrect.
Plan of Correction:	UAI was corrected for resident #2 to reflect the accurate assistance needed for the resident. In the future, the Health Care Director or designee will ensure that the UAI will be updated at the time of change.
Standard #:	22VAC40-73-450-C
Description:	450-C Based on record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) was completed as required. EVIDENCE: 1. The UAI for resident 2, dated 01/11/2022, indicated that the resident needs mechanical assistance with transferring and wheeling; however the ISP for the resident, dated 01/22/2022, did not indicate these identified needs. 2. Staff 5 confirmed that the UAI is accurate and that these identified needs need to be included on resident 2?s ISP. 3. The UAI for resident 3, dated 01/25/2022, indicated that the resident needs mechanical help and human physical help with transferring; however, the ISP for resident 3, dated 01/25/2022, indicated that the resident only needs mechanical help with transferring. 4. Staff 5 revealed that the UAI is correct and the ISP is incorrect. 5. The UAI for resident 6, dated 12/20/2021, indicated that the resident needs mechanical help with stairclimbing and mobility; however the ISP for resident 6, dated 12/20/2021, did not indicate these identified needs. 6. Staff 5 confirmed that the UAI is accurate and that these identified needs need to be included on resident 6?s ISP.
Plan of Correction:	ISPs were corrected for resident 2, 3, and 6 to reflect the accurate assistance needed for each resident. In the future, the Health Care Director or designee will ensure that ISPs will be updated at the time of change in UAI.
Standard #:	22VAC40-73-560-I
Description:	560-I Based on record review, the facility failed to ensure that a current picture of each resident shall be readily available for identification purposes, or if the resident refuses to consent to a picture, there shall be a narrative physical description, which is annually updated, maintained in his file. EVIDENCE: The record for resident 7, admitted 7/14/2021, did not contain a photo nor a narrative physical description of the resident.
Plan of Correction:	A photo has been added to resident #7 chart. The Health Care Director or designee will ensure that all pictures will be added to resident chart on admission.
Standard #:	22VAC40-73-640-A
Description:	640-A Based on observation, the facility failed to implement its written medication management plan specifically for the use of methods to prevent the use of outdated, damaged, or contaminated medications. EVIDENCE: 1. The facility?s current medication management plan, revised 02/2018, states ?Nurses and RMA?s are responsible for ensuring that all medications, including over-the-counter, supplements, and or samples are in the original packaging, undamaged and used within the appropriate date of use, or expiration.? 2. On the date of inspection at approximately 9:00 AM, while performing an audit of medication cart #1, LI and staff 1 observed that the Lantus Solostar 100u/mL 8:00 PM insulin pen for resident 6 did not indicate the date that the pen was initially opened for use; therefore, staff could not be certain of its expiration date.
Plan of Correction:	Ordered and obtained new insulin for resident #6. Label was placed on the pen with open date. The Health Care Director or designee will ensure that cart audits will be performed weekly.
Standard #:	22VAC40-73-680-B
Description:	680-B Based on observation, the facility failed to ensure that medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. EVIDENCE: On the date of inspection at approximately 9:00 AM, while performing an audit of medication cart #1, LI and staff 1 observed a round unmarked white pill laying on the bottom of the second drawer of cart #1.
Plan of Correction:	Pill was removed and carts were cleaned out to ensure no other loose medication was found. The Health Care Director or designee will ensure that Medication staff will be trained to make observation of the medication cart on each shift.
Standard #:	22VAC40-73-680-D
Description:	680?D Based on resident record review, the facility failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 6 contained physician?s orders dated 05/19/2021, for insulin Lispro 100 unit/ML pen (generic for: Humalog Kwikpen 100U/ML) check blood sugar 3 times daily before meals and inject sub-q per SSI: </equal to 150=0U(units), 151-250=2U(units), >250=4U(units). 2. The March 2022 medication administration record (MAR) for resident 6 showed that on 03/01/2022 the resident?s blood sugar was 164 at 8:00AM and 241 at 12:00PM and on 03/15/2022 the resident?s blood sugar was 173 at 8:00AM. The resident should have been administered 2 units of Humalog; however, the MAR contains documentation that staff 4 administered 4 units of Humalog on each date/time.
Plan of Correction:	Medication staff responsible received additional training. The Health Care Director or designee will ensure that RMAs will attend training on sliding scale and diabetes management.