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: May 10, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/10/2022, 10:10 am to 1:35 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 2/11/2022 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 67 Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Susan Mallory, Licensing Inspector at (540) 309-3043 or by email at susan.mallory@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on documentation review, the facility failed to report an incident that threatens the health of a resident within 24 hours. EVIDENCE: 1. On 2/11/2022 the facility sent an incident report concerning an incident discovered on 1/20/2022 with resident 1. 2. The incident report stated, ?Order on file for Xarelto following neuro visit at UVA and paperwork returned by daughter. Med list faxed to pharmacy and Xarelto added to MAR as of 12/31. Med to begin on 1/1. MAR shows med was given as ordered, however medication in question was not present in the community until January 20 ? .?
Plan of Correction:	What Has Been Done to Correct? Self-Report completed How Will Recurrence Be Prevented? Incidents meeting standard to be reported to DSS Licensing will be reported within 24 hours of occurrence. Person Responsible: ED, HCD and/or designee
Standard #:	22VAC40-73-650-C
Description:	Based on resident record review, the facility failed to obtain an order signed by a physician or other prescriber within 14 days of an oral order to discontinue a medication. EVIDENCE: 1. An oral order dated 1/27/2022 to discontinue Xarelto for resident 1 was not signed on the day of inspection, 5/10/2022. The facility later submitted the order signed on 5/12/2022.
Plan of Correction:	What Has Been Done to Correct? Order was reviewed by physician and signed. How Will Recurrence Be Prevented? Verbal orders to be placed in physician binder for signature directly following verbal order given. Person Responsible: Charge nurse, HCD, and/or designee
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and staff interviews, the facility failed to administer a medication in accordance with a prescriber?s order. EVIDENCE: 1. The facility reported on 2/11/2022 in an incident report that Xarelto had not been administered to resident 1 because it was not in the facility until 1/20/2022. The order in the record for resident 1 was signed on 12/31/2021. 2. Interviews with staff 1 and 2 show that they discovered on 1/20/2022 that the Xarelto for resident 1 was never in the facility.
Plan of Correction:	What Has Been Done to Correct? Med discontinued as reported. How Will Recurrence Be Prevented? Process for orders, med processing, and administration streamlined; Training completed with all med-techs and nurses; 4-Hr refresher completed; Complete audit of orders in chart matched to meds on cart and MAR completed by Express Care Pharmacy. Person Responsible: HCD; Regional Clinical support
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to correctly document a medication record (MAR). EVIDENCE: 1. The MAR for December 2021 shows that Xarelto was administered to resident 1 on 12/31/2021. 2. The MAR for January 2022 shows that Xarelto was administered to Resident 1 on 1/1/2022 through 1/19/2022. 3. Interviews with staff 1 and 2 reveal that they discovered on 1/20/2022 that the Xarelto for resident 1 was not in the facility on 12/31/2021 and 1/1/2022 through 1/19/2022.
Plan of Correction:	What Has Been Done to Correct? Training completed with all med-techs and nurses; 4-hr refresher completed; full audit completed by Express Care pharmacy How Will Recurrence Be Prevented? Weekly review of MAR system (accuflo) and audit of cart Person Responsible: Charge nurse, HCD, ED and/or designee