VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Meadow Hills Assisted Living Facility
5046 Williamson Road
Roanoke, VA 24012
(540) 400-7253

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

Inspection Date: April 1, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 complaint inspection was initiated on 4/1/2021 and concluded on 6/22/2021. A complaint was received by the department regarding allegations in the area of mental health services coordination and support. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-320-A
Complaint related:	No
Description:	320-A Based on record review, the facility failed to ensure that the documentation of a physical examination by an independent physician shall contain all required information. EVIDENCE: 1. The report of resident physical examination form for resident 1, dated 12/30/2020, indicated that the resident has allergies to an Ace Inhibitor, Erythromycin, Haldol, Morphine, Pseudoephedrine, and Ultram; however, the form did not contain descriptions of allergic reactions. 2. The report of physical examination form for resident 1, dated 12/30/2020, did not contain recommendations for care that included a list of current medications.
Plan of Correction:	The facility will review physical examination forms and contact the physician?s office for clarification as needed.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	450-C Based on record review, the facility failed to ensure that the individualized service plan (ISP) was completed as required. EVIDENCE: 1. The ISP for resident 1, dated 7/21/2020, indicated that the resident had a regular diet that was restrictive of the consumption of sweets; however, the physical examination form for resident 1, dated 12/30/2020, indicated that a low carb diet is recommended. 2. The ISP for resident 1, dated 7/21/2020, indicated that the resident receives mental health services; however, the ISP did not indicate what specific services will be provided to address identified needs, who will provide the services, and when and where the services will be provided.
Plan of Correction:	The facility will ensure residents ISP are updated accordingly as changes are indicated. Facility will document specific mental health services being provided to residents, who will provide said services and when/where those services will be provided.
Standard #:	22VAC40-73-510-C
Complaint related:	Yes
Description:	510-C Based on record review, the facility failed to ensure that efforts, which must be documented, shall be made by the assisted living facility to assist in ensuring that prescribed interventions are implemented, monitored, and evaluated for their effectiveness in addressing the resident?s mental health needs. EVIDENCE: 1. The Regional Discharge Assistance Project (RDAP) Agreement with Blue Ridge Behavioral Healthcare (BRBH) and the facility, signed on 11/1/2018, indicated that the facility would provide supervised residential living for resident 1 and ensure that additional community supports that met the clinical needs of the resident were provided. 2. The RDAP Agreement also indicated that the facility would prepare and submit detailed monthly invoices for services that were covered by BRBH in accordance with the approved DAP plan. 3. An interview with BRBH indicated the facility was contacted by BRBH on 5/7/2020 and 6/15/2020 to obtain the facility?s invoices for payment due to the upcoming fiscal year deadline for submissions on 6/19/2020; however, BRBH did not receive invoices from the facility, neither by fax nor email, after March 2020, and as a result, the resident?s DAP grant payment ceased effective 7/1/2020. 4. An interview with staff 1 indicated that the facility made attempts to fax the invoices from April 2020 to June 2020; however, the facility was unable to provide any documentation to verify that attempts were made to fax the invoices.
Plan of Correction:	The facility will continue to provide monthly invoices to BRBH as indicated for resident?s part of the Regional Discharge Assistance Project (DAP) The facility will maintain fax sent copies in resident invoice files going forward for confirmation of fax being sent and/or maintain email copies of email invoices sent to DAP coordinators.