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: May 11, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/11/2022 9:30am until 3:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on a review of resident records, medication administration records (MARs) and facility documentation, the facility failed to ensure that medications administered to resident 1 were in accordance with physician orders. EVIDENCE: 1. A facility self-reported incident has documentation that on 05/03/2022 at 8:00am a Duragesic 25mcg/hr patch belonging to resident 2 was placed on resident 1. 2. A review of the May 2022 MAR for resident 1 has documentation that the residents Fentanyl patch order is for 12mcg/hr transdermally every 72 hours. The May 2022 MAR for resident 2 has documentation that their Fentanyl patch order is for 25mcg/hr transdermally every 72 hours.
Plan of Correction:	Medications are being administered per physician?s instructions. Resident 1?s order for Duragesic patch was discontinued on 5/25/22. Clinical team members certified to administer medications have been educated on the facility medications management plan and appropriate processes. Director of Nursing, or designee, will conduct weekly audits of all medication carts to ensure medications are given per physician?s instructions. Executive Director, or designee, will audit all controlled substance count documents monthly to ensure continued compliance. Executive Director, or designee, will audit all medication carts monthly to ensure continued compliance.