VIRGINIA DEPARTMENT OF SOCIAL SERVICES

North Roanoke Assisted Living
6910 Williamson Road
Roanoke, VA 24019
(540) 265-2173

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: Dec. 9, 2019 and March 18, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

On 12/9/2019 one inspector began a complaint investigation alleging that medications were not given with time frames specified in the regulations. The facility's medication management policy outlines procedures and time frames for patient centered care medication administration. There is no preponderance of evidence to support the allegation, so the complaint is not valid. During the inspection and at the exit interview, the facility was given the opportunity to discuss the violations and to show that they were in compliance. 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. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain the following: 1) steps to correct the noncompliance with the standard(s); 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions, please contact your licensing inspector at 540-309-3043.

Violations:

Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on document review, the facility failed to have a required section in their medication management plan. EVIDENCE: 1. The regulations require "Identification of the medication aide or the person licensed to administer drugs responsible for routinely communicating issues or observations related to medication administration to the prescribing physician or other prescriber (650-A-13). The third page of the facility's medication management plan, in section 10. shows that "all medication aides and the Nurses are responsible for routinely communicating" ...etc. The standards require one person to be responsible, and the facility's plan shows everyone involved in medication administration is responsible.
Plan of Correction:	North Roanoke Assisted Living will comply with the Standard 22 VAC 40-73-(6)-A. As indicated in the Facility's medication plan with was previously approved by the Piedmont Licensing Office. The Facility's position is that all registered medication aides (RMA), Licensed Practical Nurses (LPN) and Registered Nurses (RN) who are involved in the medication administration are responsible as they are all governed by the Board of Nursing and Board of Health Professions. However, the facility's administrator and all medication personnel work along with a nursing consultant as it pertains to medication management. This plan of correction is submitted as required under State and Federal law. The submission of this Plan of Correction does not constitute an admission of the part of North Roanoke Assisted Living as to the accuracy of the surveyor's findings of the conclusions drawn therfrom. Submission of the Plan of Correction also does not constitute an admission that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the North Roanoke Assisted Living's policies and procedures should be considered subsequent remedial measures as that concept is employed inRule 407 of the Federal Rules of Evidence and any corresponding state rules of civil procedure and should be inadmissible in any proceeding on that basis. North Roanoke Assisted Living submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against North Roanoke Assisted Living or any employee, agent, officer, director, attorney, or shareholder of North Roanoke Assisted Living.