VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Harmony Collection at Roanoke Assisted Living
4402 Pheasant Ridge Road
Roanoke, VA 24014
(540) 970-3524

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: Feb. 20, 2020

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 SANCTIONS.

Comments:

On 1/22/2019, two inspectors conducted a renewal study (8:05AM to 3:15PM). 31 residents were in care. Six resident records were fully reviewed, and several others were partially reviewed. Three staff records were fully reviewed, and all new staff records were reviewed for background checks. Two medication passes were observed, meals and activities were observed, and staff and residents were interviewed. A physical plant tour was done. During the inspection and at the exit interview, the facility was given the opportunity to discuss the violations and to show that they were in compliance. 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). If you have any questions, please contact your licensing inspector at 540-309-3043.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on review of staff record, the facility failed to ensure that each staff person had on or within seven days prior to the first day of work at the facility submitted the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. EVIDENCE: 1. The date of hire for staff three was 11/16/2019. The ?REPORT OF TB SCREENING? for staff three lacked the date the TB screening was conducted.
Plan of Correction:	What Has Been Done to Correct? The TB screening form for staff person 3 was updated with the date the screening was completed by the RN. How Will Recurrence Be Prevented? Each piece of pre-hire paperwork will be reviewed during the pre-hire process to ensure that each document is filled out entirely and signed and dated appropriately when completed. Person Responsible: Business Office Manager
Standard #:	22VAC40-73-260-A
Description:	Based on review of staff record, the facility failed to ensure that each direct care staff member who does not have current certification in first aid received certification in first aid within 60 days of employment. EVIDENCE: 1. The date of hire for staff three was 11/16/2019. Staff three?s record lacked documentation of having received and completed first aid training.
Plan of Correction:	What Has Been Done to Correct? Staff # 3 will complete first aid training. How Will Recurrence Be Prevented? The Business Office Manager will ensure that first aid training is scheduled within 60 days of employment and prior to certification expiration dates for staff members moving forward. Person Responsible: Business Office Manager or designee
Standard #:	22VAC40-73-440-A
Description:	Based on document review and interview, the facility failed to have a need correctly assessed on a private pay uniform assessment instrument (UAI). EVIDENCE: 1. The UAI for resident 2, dated 10/31/2019, shows resident 2 requires supervision when using a wheelchair. The individualized service plan (ISP), dated 11/30/2019, shows that human help is given. An interview with staff 5 confirms the ISP is correct.
Plan of Correction:	What Has Been Done to Correct? The UAI for resident 2 was updated to reflect the accurate assessment that the resident needs human help with pushing their wheelchair at times instead of just supervision. How Will Recurrence Be Prevented? Once completed, the assessor/designee will complete a second review to ensure it accurately reflects the resident?s needs and it matches the ISP. Person Responsible: Healthcare Director or designee
Standard #:	22VAC40-73-640-A
Description:	Based on document review, the facility failed to implement their medication management plan regarding methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes and failed to successfully implement the medication management plan for methods to ensure the effective use of the medication administration records (MARs) for documentation. EVIDENCE: 1. The facility?s current medication management plan states that all narcotics will be packaged by company policy so as to maintain accuracy of count and maintain appropriate infection control. Narcotics and other controlled substances will be counted shift to shift between the on-coming and off-going medication staff. Direct staff to staff hand off of the keys to the medication carts will take place after a correct inventory has been documented. Should a shift to shift count not be accurate, the administrator, healthcare coordinator and regional clinical director will be immediately notified and an investigation will be conducted. Notification will be made to all required agencies. At approximately 8:30AM on the date of inspection, the ?NARCOTIC SHIFT COUNT RECORD? was missing the signature for the ?7-3 SHIFT? on 01/22/2020. 2. The record for resident 5 had a physician?s order dated 12/17/2019 for Metolazone 2.5MG tab give one tab PO on Tuesday and Thursday. The medication administration record (MAR) for resident 5 states that on 01/14/2020 the order changed to Metolazone 2.5MG take one tablet by mouth every other day 30 mins prior to furosemide for edema. There was no physician?s order in the resident record for this change. 3. On the medication cart, there was a loose small white pill with a score mark on one side and N18 on the other side inscribed located in the second big drawer down. In the last drawer of the medication cart was a small golden oval gel tablet. 4. The Tramadol HCL 50MG card for resident four contained a broken seal on #29. 5. Resident six has a physician?s order dated 12/23/2019 for Oxycodone HCL 5MG tablet take ? tablet (=2.5MG) by mouth every 4 hours as needed for pain. This order is not on the January 2020 medications administration record (MAR) for the resident.
Plan of Correction:	What Has Been Done to Correct? Loose pills were destroyed during the date of inspection, narcotics count sheet was signed by the staff person who counted shortly after she began the medication pass, the POS was corrected for resident 6 and MAR was corrected for resident 5. How Will Recurrence Be Prevented? Re-education was completed on 01/27/2020 with all medication staff on the medication management plan. An audit will be completed to ensure continued compliance. Person Responsible: Healthcare Director or designee
Standard #:	22VAC40-73-680-M
Description:	Based on review of resident record, observation and interview, the facility failed to ensure that medications ordered for PRN administration were properly stored and properly labeled for the specific resident. EVIDENCE: 1. The record for resident 7 contained a physician?s order for PRN hydrocortisone cream topical as needed for itching dated 11/19/2019. This medication was listed on the January 2020 MAR. However, this medication was not labeled or stored in the medication cart. This medication was observed on the night stand in resident 7?s bedroom.
Plan of Correction:	What Has Been Done to Correct? The physician?s order already stated that resident could self- administer and keep the topical cream at bedside. The order was re-sent to the pharmacy to ensure that the order was accurately transcribed to the resident?s MAR. How Will Recurrence Be Prevented? Medications orders for self-administration will be reviewed once entered by the pharmacy to ensure that they accurately reflect the physician?s intent to allow a resident to self-administer a medication on the MAR. Person Responsible: Healthcare Director or designee
Standard #:	22VAC40-73-720-A
Description:	Based on document review, the facility failed to have a DNR order on the individualized service plan (ISP). EVIDENCE: 1. Resident 3 signed a Durable DNR order on 12/28/2019, and the ISP, updated 1/6/2020 does not address the need to honor the DNR,
Plan of Correction:	What Has Been Done to Correct? The ISP for resident 3 was updated to address the resident?s durable DNR which was signed after the ISP was completed. How Will Recurrence Be Prevented? In the future, any code status changes will be reported to the HCD to ensure that the change is added to the ISP. Clinical staff have been re-educated to report this information. Person Responsible: Healthcare Director or designee
Standard #:	22VAC40-90-30-B
Description:	Based on review of staff record, the facility failed to ensure that the sworn statement or affirmation was completed for the staff member. EVIDENCE: 1. The date of hire for staff four was 12/17/2019. The ?SWORN STATEMENT OR AFFIRMATION FOR AULT FACILITY EMPLOYEES? in the record was not completed by staff four for the following: have you ever been convicted of a law violation(s) but excluding offenses committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth offender law?, are you the subject of any pending criminal charges?, applicant?s signature and date.
Plan of Correction:	What Has Been Done to Correct? Staff person 4 completed a new sworn disclosure statement documenting the absence of criminal background as was already confirmed by the criminal background check which was in the record behind the incomplete sworn disclosure statement. How Will Recurrence Be Prevented? Each piece of pre-hire paperwork will be reviewed during the pre-hire background check process to ensure that each document is filled out entirely and is signed and dated by the applicant for employment. Person Responsible: Business Office Manager