VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hermitage Roanoke
1009 Old Country Club Road, N.W.
Roanoke, VA 24017
(540) 767-6800

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: March 25, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 3/24/21 and concluded on 3/26/21. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 35. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, Medication Management and Infection Control Policies, Fire and Health Department inspections, health care oversight, dietician review for special diets, staff schedules and fire drill logs submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-200-B
Description:	Based on a review of resident records, the facility failed to ensure that direct care staff who are responsible for caring for residents with special health care needs only provided services within the scope of their practice and training. EVIDENCE: 1. The record for resident 3 has a physician order dated 3/11/2021 to cleanse open area on sacrum with sacrum, gently wash and pat dry, apply Clotrimazole 1% cream and cover with Zinc Oxide three times a day for moisture associated skin damage (MASD). The March 2021 medication administration record (MAR) for resident 3 has staff person's 2, 4 and 5's initials on several days for the completion of this treatment on resident 3's sacrum. These staff persons are registered medication aides and providing routine wound care needs is outside of their scope of practice.
Plan of Correction:	Resident 3?s treatment is now being performed by staff persons within appropriate scope of their practice and training. Clinical leadership have been educated on which staff persons may provide certain treatments based on the scope of their practice and training. Director of Nursing, or designee, will conduct an audit of all residents receiving treatments to ensure staff persons providing care are doing so within their scope of practice. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected resident files to ensure continued compliance.
Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records, the facility failed to ensure that direct care staff received certification in first aid within 60 days of the date of their employment. EVIDENCE: 1. The record for staff person 1, hired on 7/16/20 and staff person 3, hired on 3/25/20, did not contain documentation that these employees have received certification in first aid since their date of employment.
Plan of Correction:	Staff persons 1 & 3?s first aid training has been scheduled. Clinical leadership have been educated on the requirement for direct care staff to receive certification in first aid within 60 days of hire. Director of Nursing, or designee, will audit all direct care staff files to ensure all appropriate persons are certified in first aid within 60 days of hire. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected direct care staff files to ensure continued compliance.
Standard #:	22VAC40-73-320-A
Description:	Based on a review of resident records, the facility failed to ensure that a history and physical was obtained within 30 days of admission to the assisted living facility. EVIDENCE: 1. The record for resident, readmitted to the assisted living facility on 7/2/20, did not contain documentation that a history and physical examination was completed at the time of the residents readmission.
Plan of Correction:	Resident 1?s History & Physical has been obtained. Clinical leadership have been educated on the requirement for History & Physicals to be obtained on readmission to the assisted living facility. Director of Nursing, or designee, will audit all resident files to ensure History & Physicals are in place for all residents. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected resident files to ensure continued compliance.
Standard #:	22VAC40-73-440-D
Description:	Based on a review of resident records, the facility failed to ensure that uniform assessment instruments (UAI) were completed as required. EVIDENCE: 1. The record for resident 2 has documentation in progress notes of the resident having behavior episodes on several occasions. The individualized service plan (ISP) dated 1/28/21 for resident 3 also has documentation of the resident having a history of behaviors. The UAI dated 8/20/20 in resident 3's record is inconsistent as it has that the residents behavior pattern is appropriate.
Plan of Correction:	Resident 2?s UAI has been updated to reflect behaviors as noted on the ISP and in progress notes. UAI trained staff have been educated on ensuring UAIs are updated when changes in behavior occur and when ISPs are revised. Director of Nursing, or designee, will audit all resident files to ensure UAIs are complete and accurate. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected resident files to ensure continued compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that all identified needs were addressed on individualized service plans (ISP). EVIDENCE: 1. The record for resident 1 has a physician order dated 10/1/20 for a regular diet with mechanical soft consistency. The special diet list in the facility kitchen also indicates that the resident is receiving a regular diet with mechanical soft consistency. The comprehensive ISP dated 2/10/21 in the record for resident 1 is incorrect as it has documentation that the resident is on a regular diet with regular consistency. 2. The record for resident 3 has a physician order dated 3/11/2021 to cleanse open area on sacrum with sacrum, gently wash and pat dry, apply Clotrimazole 1% cream and cover with Zinc Oxide three times a day for moisture associated skin damage (MASD). The comprehensive ISP dated 1/27/21 for resident 3 has documentation that the resident has assessed needs for wound care but the ISP does not include the services being provided for wound care treatment order.
Plan of Correction:	Resident 1?s ISP has been updated to reflect a regular diet with mechanical soft consistency and Resident 3?s ISP has been updated to include the services provided for wound care. ISP trained staff have been educated on appropriate process for ensuring identified needs are addressed on ISPs. Director of Nursing, or designee, will audit all resident records to ensure accuracy of ISPs. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected resident charts to ensure continued compliance.
Standard #:	22VAC40-73-450-D
Description:	Based on review of resident records, the facility failed to ensure that the services provided by both, the assisted living facility and the licensed hospice organization, were included on the individualized service plan (ISP). EVIDENCE: 1. The record for resident 1 shows the resident is receiving hospice services. The comprehensive ISP for resident 1, dated 2/10/21, indicates the resident is receiving hospice services, but does not include the services provided by the hospice organization. 2. The record for resident 3 shows the resident is receiving hospice services. The comprehensive ISP for resident 3, dated 1/27/21, indicates the resident is receiving hospice services, but does not include the services provided by the hospice organization.
Plan of Correction:	Resident 1 and 3?s ISPs have been updated to include services provided by the hospice organization. ISP trained staff have been educated on including specific services provided by hospice organizations on resident ISPs. Director of Nursing, or designee, will audit all hospice resident records to ensure appropriate services are noted on the ISP. Executive Director, or designee, will conduct a monthly audit of 5 randomly selected hospice resident charts to ensure continued compliance.