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: Aug. 30, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 08/30/2023 from 09:00 AM until 11:30 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on documentation review and staff interview, the facility failed to implement a portion of its medication management plan regarding methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes. EVIDENCE: 1. The facility?s Medication Management Plan, dated 02/2018, states that narcotics and other controlled substances will be counted shift to shift between the on-coming and off-going medication staff and the hand off of the medication cart keys will take place after a correct inventory has been documented. 2. The facility?s Controlled Medication Count Record states that by signing the count record that staff acknowledge that the controlled drugs on hand have been counted and the quantities of each medication count agree with the quantity that is stated on the Controlled Drug Administration Record. 3. On the date of inspection (08/30/2023), the LI reviewed the Controlled Medication Count Records for the 400-hall medication cart for August 1-30, 2023. The Controlled Medication Count Record was not signed by both the on-coming and off-going medication staff, as required by the facility?s medication management plan to ensure accurate counts of all controlled substances, as follows: ? On the 1st shift (7am-3p) - Out of the 30 days there were 10 dates not signed by both staff. ? On the 2nd shift (3p-11p) - Out of the 30 days there were 12 dates not signed by both staff. ? On the 3rd shift (11P-7A) - Out of the 30 days there were 10 dates not signed by both staff. 4. Interview with staff 5 on the date of inspection revealed that oncoming and off-going medication staff from each shift are supposed to count the controlled substances on each medication cart and sign the Controlled Medication Count Record log if all counts are correct.
Plan of Correction:	Cart audits that include checking the shift to shift counts for controlled substances will be done weekly by Healthcare Director or designee.
Standard #:	22VAC40-73-930-D
Description:	Based on resident record review, the facility failed to ensure that documentation of rounds that were made, which included the name of the resident, the date and time of the rounds, and the staff member who made the rounds for residents with an inability to use a signaling device. EVIDENCE: 1. The individualized service plan (ISP) in the record for resident 2, dated 08/22/2023, contains documentation that the resident is on safety checks every two hours from 10 PM to 6 AM daily due to the resident?s inability to use the call bell because of a cognitive or physical impairment. 2. An activities of daily living (ADL) log sheet for resident 2 contains handwritten documentation of ?round Q 2h 10p-6a? with the dates of 08/22/2023 through 08/29/2023 and staff initials signed one time, beside each of those dates. Alternately, the ADL log sheet does not indicate the specific times for each two hour round that was made nor did it indicate the staff person who made each two hour round from 08/22/2023 through 08/29/2023.
Plan of Correction:	This was corrected the day of inspection. Staff will ensure that two-hour rounds are added to MAR upon admission. Audit of random MAR bi-weekly to ensure two-hour rounds are being completed. Healthcare Director or designee.