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: June 11, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint 59633 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/11/2024 from 11:00 AM until 02:00 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 05/20/2024 regarding allegations in the area(s) of: Personnel. Number of residents present at the facility at the beginning of the inspection: 90 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: 1 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 the allegation(s) of non-compliance with standard(s) or law, and violation(s) were 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 #:	22VAC40-73-140-E
Complaint related:	Yes
Description:	Based on record review and staff interview, the facility failed to ensure that for a facility licensed for both residential and assisted living care, the administrator shall be licensed as an assisted living facility administrator or nursing home administrator by the Virginia Board of Long-Term Care Administrators pursuant to Chapter 31 (? 54.1-3100 et seq.) of Title 54.1 of the Code of Virginia. EVIDENCE: 1. The current license for this facility, effective 03/03/2024 through 03/02/2025, allows for the facility to operate to provide residential and assisted living levels of care. 2. On 04/16/2024, LI received an email from staff 2 reporting that staff 1 will serve as the administrator on record at the assisted living building, effective on that date. The email also included the Virginia ALF Administrator (ALF-A) license number for staff 1. 3. During the night of 05/20/2024, LI received an anonymous report that staff 1 has been working under an expired license. On 05/21/2024, LI received a separate anonymous report of the same information. 4. On 05/21/2024, LI searched the Virginia Department of Health Professions license lookup webpage with the license number that was provided for staff 1. The results of the search revealed that staff 1?s ALF-A license had expired on 03/31/2024. 5. Separate discussions with staff 1 and staff 3 on 05/21/2024 confirmed that staff 1?s license had expired on 03/31/2024 and was still expired on 05/21.
Plan of Correction:	The Harmony Collection at Roanoke separated employment with staff 1 on 5/21/2024. A licensed assisted living administrator was appointed to cover the facility and this information was communicated to the Licensing Inspector on same day. The Human Resources Department conducted an audit of all licensed personnel to ensure that all licenses are current. Audits will be conducted on a regular basis to ensure that the licensed personnel have current licensure in their respective positions.