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: April 6, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/6/2022, 11:55 am to 1:35 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 12 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 4 Number of interviews conducted with staff: Additional Comments/Discussion: This was a focused monitoring inspection to review high risk violations previously found at the renewal inspection done in January 2022. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 Susan Mallory, Licensing Inspector at (540) 309-3043 or by email at susan.mallory@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-240-C
Description:	Based on volunteer record review, the facility failed to maintain required documentation on volunteers. EVIDENCE: 1. The record for volunteer 1 lacks: address, tele- phone number, emergency contact information, information on any qualifications, orientation, training, and education required, including any specific relevant information. This was con- firmed in an interview with staff 1.
Plan of Correction:	Administrator will maintain required documentation on volunteers, on or before start date.
Standard #:	22VAC40-73-260-A
Description:	Based on staff record review and interview, the facility failed to ensure that new direct care staff had certification of First Aid training within 60 days of hire. EVIDENCE: 1. Staff 2, who provides direct care, began work on 11/12/2021, and as of 4/6/2022 the staff file has no documentation to support that first aid training has been done. According to a schedule obtained at a prior inspection, staff 2 frequently works without any other staff people in the building. This was confirmed in an interview with staff 1.
Plan of Correction:	Administrator will ensure new direct care staff will have certification of First Aid training within 60 days of hire
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure that a physical exam done within 30 days prior to admission addressed some required components. EVIDENCE: 1. The physical exam for resident 1 done within 30 days of admission showed the resident is allergic to penicillin and there was no description or mention of the resident's reactions. This was initially cited 10/25/2021 and as of 4/6/2022 the information has not been obtained. The most recent physical exam dated 3/11/2021 also lacks this information.
Plan of Correction:	Administrator will ensure physical exam will be done within 30 days prior to admission and a model form from website will be used.
Standard #:	22VAC40-73-450-F
Description:	Based on review of resident records. the facility failed to ensure that individualized service plans (ISP) were reviewed and updated at least every 12 months and as needed as the condition of a resident changes. EVIDENCE: 1. The uniform assessment instrument (UAI) dated 3/2/2022 shows resident 1 needs mechanical help with bathing, transferring, walking, stair climbing, and mobility (outside the facility), needs help with shopping., and has abusive/aggressive behavior less than weekly. The ISP dated 3/30/2022 for resident 1 does not address help with shopping, does not address abuse/aggressive behavior, shows that supervision and mechanical assistance help are given with walking (staff 1 verified that supervision is not required), and assistance with bathing, transferring, stair climbing, and mobility are not addressed. 2. The record for resident 2 has documentation of a physician order dated 12/28/2021 for a no added salt and no concentrated sweet diet. The ISP dated 7/30/2021 for resident 3 does not address this need. 3. The UAI dated 4/21/2021 for resident 3 shows this resident needs mechanical help only with bathing. The ISP dated 5/10/2021 show that supervision is given instead.
Plan of Correction:	Administrator will ensure individualized service plans are reviewed and updated at least 12 months and as needed as a condition of a resident changes
Standard #:	22VAC40-73-490-B
Description:	Based on document review, the facility failed to obtain an on-site health care oversight with all of the required information. EVIDENCE: 1. The Health Care Oversight dated 7/21/2021 lacks documentation showing: monitoring direct care staff performance of health-related activities, evaluating the need for staff training, monitoring conformance to the facilities medication management plan and the maintenance of required medication reference materials, evaluation of the ability of residents who self-administer medications to continue to safely do so, and observing infection control measures and consistency with the infection control program of the facility.
Plan of Correction:	Administrator will ensure on-site health care oversight with all of the required information is done every 6 months
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to maintain the interior of the building in good repair. EVIDENCE: 1. The closet door in room 5 had a broken bracket and the floor under it was damaged. 2. The wall in the hall way between rooms 3 and 4 had holes in it.
Plan of Correction:	Administrator will ensure interior of building is in good repair.
Standard #:	22VAC40-73-950-E
Description:	Based on lack of documentation and staff interview, the facility failed to have semi-annual reviews of the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review is required to be documented by signing and dating. EVIDENCE: 1. There was no documentation to support that a semi-annual review of the emergency preparedness and response plan for all staff, residents, and volunteers was completed. This was confirmed in an interview with staff 1.
Plan of Correction:	Administrator will ensure emergency preparedness and response plan for all staff, residents and volunteers will be signed and dated after completion of the emergency preparedness and response plan.
Standard #:	22VAC40-73-990-C
Description:	Based on lack of documentation and staff inter- view, the facility failed to conduct, at least once every six months, an exercise in which the procedures for resident emergencies are practice with all staff on duty on each shift. Documentation of this is required to be maintained in the facility for at least two years. EVIDENCE: 1. There was no documentation to support that the practice exercise had been done within the past six months. In an interview, resident 1 stated it had not been done.
Plan of Correction:	Administrator will ensure resident emergencies are practiced with all staff on duty each shift at least once every six months, on staff every shift.
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation, the facility failed to post the findings of the most recent inspection of the facility. EVIDENCE: 1. The most recent violation notice was not posted.
Plan of Correction:	Administrator will ensure a posting of findings of the most recent inspection of facility is posted.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to obtain a Virginia State Police Criminal History Record report on new staff on or prior to the 30th day of employment. EVIDENCE: 1. The record for staff 3, who began work in the facility on 10/25/2021 lacks the results of a Virginia State Police Criminal History Record report. This was noted previously on 1/25/2022 and again during this inspection, on 4/6/2022. The lack of the VSP Criminal History Record report was confirmed by staff 1.
Plan of Correction:	Administrator will ensure Virginia State Police Criminal History Record on new staff will be done on or prior to 30th day of employment.