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: June 4, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/4/2024 09:15am to 10:20am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 5/9/2024 regarding allegations in the area(s) of: administration and Administrative Services, and Admission, Retention, and Discharge of Residents Number of residents present at the facility at the beginning of the inspection: 20 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Admission, Retention, and Discharge of Residents A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 Angela Swink, Licensing Inspector at 276-635-6575 or by email at angela.swink@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-400
Complaint related:	Yes
Description:	Based on resident interview, resident record review, and staff interview, the facility failed to provide to a resident or the resident's legal representative, if one has been appointed, a monthly statement that itemizes any charges made by the facility and any payments received from the resident or on behalf of the resident during the previous calendar month and show the balance due or any credits for overpayment. EVIDENCE: 1. During an interview between the licensing inspector and resident 1 on 6/4/2024, resident 1 reported they have never received any monthly statements from the facility. The resident reported they are responsible for their own finances. 2. During an interview between the licensing inspector and staff person 1 on 6/4/2024, staff person 1 reported resident 1 had not received monthly statements for February, March, and April 2024. 3. The record for resident 1 did not contain any documentation for monthly statements.
Plan of Correction:	To address the deficiency related to providing monthly statements to residents, Meadow Hills Assisted Living Facility will implement the following Plan of Correction (POC) within 30 days: 1. Immediate Resolution: o We will promptly provide a detailed monthly statement to Resident 1 for the months of February, March, and April 2024. o The statement will itemize all charges made by the facility and any payments received from the resident or on their behalf. 2. Process Improvement: o Going forward, we will ensure that all residents receive monthly statements by the 15th day of each month. o These statements will clearly show charges, payments, and any credits for overpayment. 3. Staff Training: o We will train all staff members responsible for financial documentation on the importance of timely and accurate monthly statements. o Staff will be educated on the process for generating and delivering these statements to residents. 4. Documentation and Audits: o We will maintain a log to track the issuance of monthly statements. o Regular audits will verify compliance with this process. 5. Communication with Residents and Families: o We will inform all residents and their legal representatives about the revised process for monthly statements. o Residents will receive written communication explaining their right to receive these statements. 6. Quality Assurance: o Our Quality Assurance Committee representative will review the effectiveness of the new process during monthly meetings. o Any issues or discrepancies will be promptly addressed. By implementing this POC, Meadow Hills Assisted Living Facility aims to ensure full compliance with regulations and enhance transparency in financial matters for our residents. We apologize for any inconvenience caused and appreciate your understanding.