VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Friendship Assisted Living, Inc.
320 Hershberger Road
Roanoke, VA 24012
(540) 265-2244

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: July 23, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

This inspection resulted from an APS complaint received on 7/22/19. The complaint stated the facility was accepting residents for which the facility could not meet their needs. The investigation confirmed the complaint was invalid but one violation resulted not directly related to the complaint. At 1:42pm, the inspection commenced and concluded at 3:02 pm. The census was 83 residents. After completing the inspection, the facility staff and LI discussed the violation, possible corrective actions and had an open discussion. 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). Please contact your license inspector, if you have any further concerns - 540 309 5982.

Violations:

Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on residents' record review, the facility failed to ensure all identified needs were addressed on individualized service plans (ISPs). Evidence: 1. Resident 1's 6/11/19 UAI (uniform assessment instrument) assessed human help supervision with wheeling. Resident 1's 7/11/19 ISP did not address wheeling. Staff 1 confirmed the facility was not in compliance with this standard. 2. Resident 2's 7/3/19 UAI assessed needs help with bladder (incontinent less than weekly) and bowel (incontinent weekly or more). Resident 2's 4/3/19 ISP did not address bladder nor bowel. Staff 1 confirmed the facility was not in compliance with this standard.
Plan of Correction:	1. Corrections were made to the ISP?s for resident # 1 and # 2 on the day of inspection. Director of Nursing, or designee will complete random audits of UAI's and ISP's monthly to ensure compliance. Date to be corrected: 7/23/19