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: April 16, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint 59127 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/16/2024 from 10:00 AM until 01:00 PM 05/15/2024 from 11:00 AM until 01:00 PM 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 03/20/2024 regarding allegations in the area(s) of: Resident care and related services and Staffing and Supervision. Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Resident care and related services. A violation notice was issued; any violation(s) not related to the complaint(s) 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on record review and staff interview, the facility failed to implement a portion of its medication management plan, specifically regarding the methods to ensure accurate counts of controlled substances whenever assigned medication staff changes. EVIDENCE: 1. The facility?s medication management plan, revised 02/2018, states ?narcotics and other controlled substances will be counted shift to shift between the on-coming and off-going medication staff. Direct care staff to staff hand off of the keys to the medication carts will take place after a correct inventory has been documented.? 2. The Controlled Medication Count Record for March 2024 for the 2nd floor medication cart contains the following statement: ?Signing below acknowledges that you have counted the controlled drugs on hand and have found that the quantities of each medication counted agrees with the quantity stated on the Controlled Drug Administration Record. Medication cart is not to be accepted with an inaccurate narc count or missed meds.? 3. On March 1 through March 23, 2024, and March 27, 28, and 29, the controlled medication count record for the 2nd floor medication cart was not signed as counted by the off-going 11p ? 7a medication staff with the oncoming 7a ? 3p medication staff. 4. On March 1 through March 22, 2024, and March 26, 27, and 28, the controlled medication count record for the 2nd floor medication cart was not signed as counted by the oncoming 11p ? 7a med staff with the off-going 3p ? 11p medication staff. 5. On March 30, the controlled medication count record for the 2nd floor medication cart was not signed as counted by the oncoming 7a ? 3p medication staff with the off-going 11p ? 7a medication staff; was not signed as counted by the off-going 7a- 3p med staff; not signed as counted by the oncoming 3p ? 11p med staff; and not signed as counted by the off-going 3p ? 11p med staff with the oncoming 11p ? 7a medication staff. 6. On March 31, the controlled medication count record for the 2nd floor medication cart was not signed as counted by the oncoming 3p ? 11p med staff with the off-going 7a ? 3p medication staff, and the record was not signed as counted by the off-going 3p ? 11p med staff with the oncoming 11p ? 7a medication staff. 7. An interview with staff 3 and staff 1 revealed that based on the content of the controlled medication count record for the 2nd floor medication cart, it could not be confirmed that staff counted the narcotic medications together at shift change, as indicated in their medication management plan.
Plan of Correction:	Not available online. Contact Inspector for more information.