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 18, 2024

Complaint Related: Yes

Areas Reviewed:

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

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/18/2024 9:00am until 11:00am 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 04/11/2024 regarding allegations in the area(s) of: Personnel; resident care and related services. Number of residents present at the facility at the beginning of the inspection: 7 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 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 were: Personnel A violation notice was issued; any violation(s) not related to the complaint 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-130-A
Complaint related:	Yes
Description:	Based on review of facility documentation and staff interviews, the facility failed to ensure that staff who are mandated reporters under 63.2-1606 of the Code of Virginia reported suspected abuse, neglect, or exploitation of a resident in accordance with that section. EVIDENCE: 1. Documentation of staff interviews made available to the licensing inspector (LI) for review on 04/18/2024 has notations that on 04/09/2024 staff were aware that resident 1 had a bruise on his right arm and that on 04/10/2024 resident 1 told a staff member that he was grabbed on the arm by the fat lady and that the fat lady punched me. 2. In an interview conducted on 04/18/2024 with staff person 1, staff person 1 expressed that they were not made aware of any allegations made by resident 1 until 04/11/2024 when the local APS began a complaint investigation. 3. In a phone interview conducted with staff person 2 on 05/09/2024, staff person 2 expressed that on 04/10/2024 resident 1 had told him that ?the fat lady grabbed me and pulled me out of the bed?. Staff person 2 expressed that he did not report the allegations because other staff members were also aware of resident 2?s allegations. 4. In an interview conducted on 04/11/2024 with collateral witness 1, collateral witness 1 expressed that the facility did not report as mandated any allegations regarding resident 1 to the local APS.
Plan of Correction:	Administrator had a staff meeting on 4/22/24 to discuss the incident of alleged physical abuse that occurred. Went over the regulations and citation BRCF received. Incident report was discussed, and a new incident report book was created and placed in front office for all to use. Staff went over procedures to fill out an incident report. Mandate reporter was discussed. DSS was asked to schedule a training on mandate reporter and contact the Administrator with date.