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, 2022 and Sept. 20, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint 56063 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/21/2022, 1:10 pm to 4:40 pm and 9/20/2022, 1:20 pm to 2:45 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 6/28/2022 regarding allegations in the areas of: Resident Care and Related Services; Personnel; and Administration and Administrative Services. 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: 10 Number of staff records reviewed:7 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law was: Administration and Administrative Services. A violation notice was issued; any violation(s) not related to the complaints 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. 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 #:	22VAC40-73-80
Complaint related:	Yes
Description:	Based on observation and record review, the facility failed to maintain a written accounting of money received and disbursed by the facility that shows a current balance [for resident funds]. EVIDENCE: 1. On 7/21/2022 the following was noted: a.) The resident funds record for resident 1 was most recently calculated on 5/27/2022. Prior to that date, AG funds were shown to go in ($82 in November, December 2021, February and March 2022. On 10/18/2021 laundry fees were taken out for July, August, September, and October 2021. This does not support that monthly accounting is done, and the monthly AG personal needs allowance (PNA) seems to be missing for January, May, June, and July 2022. b.) The resident funds record for resident 2 stops accounting for funds on 1/24/2022, and shows blank entries with dates for 2/14/2022, 3/11/2022, 4/11/2022, and 5/16/2022. The Auxiliary Grant Check Receipt for resident 2 shows the resident last signed for getting funds in 2/2022 (no exact date recorded), but amounts entered for March, April, and May 2022. The balance is unknown. c.) The resident funds record for resident 3 has no accounting past 5/16/2022. d.) The resident funds record for resident 4 has no entries after 1/14/2022 with no additions or withdrawals after that. e.) The resident funds record for resident 5 has no entries after 5/16/2022 and does not clearly show what the balance is. f.) The resident funds record for resident 5 shows no entry after 6/16/2022 and the balance has not been calculated as of 7/21/2022. g.) The resident funds record for resident 7 shows the most recent entry was on 4/11/2022, with date 5/2022 and 6/2022 written in with no entries in any financial column. 2. Cash is kept in envelopes with resident?s names, but the dollar amounts on the envelopes (if any were written) don?t match the amounts inside. 3. On 9/20/2022 the LI saw a bank bag with cash in it and was told it belonged to some of the residents, but there was no accounting of how much went to what person.
Plan of Correction:	Administrator will maintain a written accounting of money received and disbursed by the facility that shows a current balance of resident funds.
Standard #:	22VAC40-73-400
Complaint related:	Yes
Description:	Based on resident record review and interview, the facility failed to have monthly statements that itemize charges made by the facility and any payments received that shows the balance due or any credits for overpayment. This is required to be kept in the record. EVIDENCE: 1. There were no monthly statements for any resident in the regular charts or financial book.
Plan of Correction:	Administrator will have monthly statements that itemize charges made by the facility and any payments received that shows balance due or any credits for overpayment.