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: Sept. 7, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint 58007 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/07/2023 from 09:00 AM until 12:00 PM and 11/03/2023 from 11:00 AM until 12:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 09/05/2023 regarding allegations in the area(s) of: Administration and Administrative Services; Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Resident care and related services. A violation notice was issued; any violation(s) not related to the complaint(s) 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to implement a portion of its medication management plan, specifically regarding its methods for monitoring medication administration and the effective use of MARs for documentation, and methods to ensure accurate counts of all controlled substances. EVIDENCE: 1. The facility?s medication management plan (MMP), effective 02/2018, section titled Narcotics and Preventing Drug Diversion, indicates that that when a routine dose of a controlled substance is administered, it is documented on the medication administration record (MAR) and is also documented on the Resident Narcotic Medication Control Record. 2. Per interview with staff 3 on 11/03/2023, resident 1?s LACOSAMIDE 100 MG TAB was retrieved from the locked controlled medication box on the medication cart and was administered as ordered on 09/02/2023 at the 09:00 AM dose; however, the corresponding Controlled Drug Record for the LACOSAMIDE 100 MG TAB for resident 1 does not contain an entry that it was administered on 09/02/2023 at 09:00 AM. 3. An interview with staff 2 and staff 4 confirmed, per their medication management policy, if a controlled medication is given, it must be documented on the corresponding Controlled Drug Record. Staff 2 and staff 4 acknowledged staff 3?s admission of administering the LACOSAMIDE 100 MG TAB for resident 1 on 09/02/2023 at 09:00 AM; however, staff 2 and staff 4 verified that it was not documented on the corresponding Controlled Drug Record. 4. The facility?s medication management plan (MMP), effective 02/2018, section titled Medication/Treatment Errors indicates that a medication error may be defined by several actions, one of which includes medication being given but not signed for. The section also indicates that when any medication errors occur, the Healthcare Coordinator should be notified immediately verbally and in the daily log, and to subsequently follow all instructions provided by the Healthcare Coordinator which may include, but are not limited to, the appropriate documentation in the EMAR/MAR and clinical record. 5. Interview with staff 3 on 11/03/2023 revealed that after administering the LACOSAMIDE 100 MG TAB medication to resident 1, she did not notify the Healthcare Coordinator that she made an error inputting the administration in the EMAR system nor was it documented in the daily log. 6. Interviews with staff 2 and staff 4 on 11/03/2023 revealed that they had been unaware of staff 3?s input error on the EMAR for resident 1, so they were unable to ensure that the appropriate documentation was contained in the EMAR and clinical record for resident 1.
Plan of Correction:	Re-educated RMAs on the medication management policy. Specifically, titled Narcotics and Preventing Drug Diversion.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure that the medication administration record (MAR) shall include the date and time given and initials of direct care staff administering a medication. EVIDENCE: 1. The physician?s orders for resident 1 and the September 2023 MAR for resident 1 indicate that the resident was taking the medication LACOSAMIDE 100 MG TABLET ?TAKE 1 TABLET BY MOUTH EVERY 12 HOURS FOR SEIZURES: 09:00 AM and 09:00 PM?. The September 2023 MAR also indicates that the LACOSAMIDE 100 MG TABLET was not administered on 09/02/2023 at 09:00 AM due to ?AWAITING DELIVERY FROM PHARMACY?. 2. An interview with staff 3 on 11/03/2023 revealed that the LACOSAMIDE 100 MG TAB was administered on 09/02/2023 at 09:00 AM; however, staff 3 stated that it was marked incorrectly on the MAR. Staff 3 clarified that at the 09:00 AM medication pass on 09/02, she could not find the LACOSAMIDE 100 MG TAB on the medication cart; therefore, she entered NOT ADMINISTERED on the MAR and noted ?AWAITING DELIVERY FROM PHARMACY?. Shortly after, staff 3 found the medication stored in the controlled medication drawer of the cart and then administered the LACOSAMIDE 100 MG TAB to resident 1. 3. Staff 3 admitted to LI that she had not notified the clinical staff member in charge about the incorrect entry on the MAR so that it could be updated to contain the date and time given and staff 3?s initials.
Plan of Correction:	Re-educated RMAs on the medication management policy. Thus, ensuring medications are properly documented for on the MARS.