VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Banister Residential Care Facility, Inc.
1017 Bethel Road
Halifax, VA 24558
(434) 476-8811

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: July 21, 2020 and July 28, 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 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Technical Assistance:

Note: this inspection was interrupted because of a temporary office closing, which limited access to retrieving faxes.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 7/21/2020 and concluded on 7/30/2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was ten. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed two resident records, two staff records, partial staff record (from a prior violation), health and fire reports, staff schedule, medication management plan, fire/evacuation drill records, and dietitian report submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-620-B
Description:	Based on document review, the facility failed to obtain a complete dietitian or nutritionist oversight report. EVIDENCE: 1. The most recent dietitian report dated 1/23/2020 is lacking documentation of: (620-B-1) a review of the physician's or other prescriber's order and the preparation and delivery of the special diet; (620-B-2) an evaluation of the adequacy of the resident's special diet and the resident's acceptance of the diet; (620-B-3 - subsection 3) certification that the requirements of this subsection were met, including the date of the oversight and identification of the residents for whom the oversight was provided. The administrator shall be advised of the findings of the oversight and any recommendations. All of the requirements of this subdivision shall be (i) in writing, (ii) signed and dated by the dietitian or nutritionist, (iii) provided to the administrator within 10 days of the completion of the oversight, and (iv) maintained in the files at the facility for at least two years, with any specific recommendations regarding a particular resident also maintained in the resident's record; The one resident referred to in the report is not identified, the report is undated (date was found in the email chain), the report is not signed, and the email chain the report was attached to shows it was sent to the facility on 5/7/2020. (640-B-4) There is no documentation to support that upon receipt of recommendations noted in subdivision 3 of this subsection, the administrator, dietitian, or nutritionist shall report them to the resident's physician. Documentation of the report shall be maintained in the resident's record. (640-B-5) There is no documentation to show what action was taken in response to the recommendations noted in subdivision 3 of this subsection.
Plan of Correction:	The administrator shall ensure dietitian complete a oversight report for residents and the facility. Spoke with the dietitian and request she address these issues in her report. - Review physician's order preparation and special diets and document. - to discuss and findings with the administrator when oversight report is complete, signed and date. - Any questions or concerns the dietitian may have the staff is to contact the physician for changes if needed. - The administrator/staff shall document action taken on the follow up Report from the dietitian.
Standard #:	22VAC40-73-680-E
Description:	Based on review of medication administration records (MAR) the facility failed to document that treatments or procedures ordered by a physician or other prescriber were provided according to his instructions and documented. EVIDENCE: 1. The July 2020 MAR for resident 3 sowed "MONITOR DIALYSIS SHUNT SITE DAILY FOR ACTIVE BLEEDING TO RIGHT FEMORAL" on each of three shifts, daily. There is no documentation to support that this is being done on second or third shift. The MAR shows this was initially ordered on 9/26/2017. 2. The July 2020 MAR for resident 3 showed " BILATERAL KNEE HIGH T.E.D. HOSE - PUT ON IN MORNING REMOVE AT NIGHT. There is no documentation on the MAR to show that this is being done. The MAR shows this was initially ordered on 9/11/2015.
Plan of Correction:	The administrator shall ensure that staff follow-up on physician orders. And kept in Resident's Chart. Resident 3 physician was contact on 7/23/2020 about and order and stated nothing we really can do but to watch it for redness, swelling or bleeding. Resident 3 stated she doesn't like the hoses all the time will put on when her big ol feet swells
Standard #:	22VAC40-73-970-A
Description:	Based on documentation review, the facility failed to have fire drills done in accordance with the Virginia Statewide Fire Prevention Code. EVIDENCE: 1. There is no documentation to support that fire drills were conducted on 3rd shift (11PM to 7AM) in the past quarter. The most recent 3rd shift drill was on 1/31/2020.
Plan of Correction:	The administrator will ensure that a fire drill will be done between 11-7A. Although we only have (2) shifts at our facility.