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: June 17, 2024

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 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

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: 06/17/2024 8:45am until 12:30pm 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: 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: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-A
Description:	Based on staff record review, the facility, which is licensed for residential living care only, failed to ensure that staff received the required numbers of training annually. EVIDENCE: 1. The record for staff person 2, hired on 05/15/2023, has documentation that this employee only received 9 hours of training between 05/15/2023 and 05/15/2024. This employee is a certified nursing assistant (CAN) and is required to attend at least 12 hours of training annually.
Plan of Correction:	The administrator has scheduled training for the staff person with a contracted individual.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to ensure that individualized service plans (ISP) were reviewed and updated at least annually or when a change in a residents condition occurred. EVIDENCE: 1. The record for resident 2 has documentation on the history and physical dated 03/04/2020 that the resident is allergic to penicillin. The uniform assessment instrument (UAI) dated 04/24/2024 has documentation that the resident requires mechanical assistance with stairclimbing. The record also has documentation that resident 2 attends a mental health day support program. The ISP dated 05/21/2024 does include these identified needs. 2. The ISP in the record for resident 3 has documentation that the last review/update was completed on 05/04/2023. In an interview conducted with staff person 1 on 06/17/2024, staff person 1 expressed that this was correct. This is a repeat violation from the 03/26/2024 inspection.
Plan of Correction:	The administrator will ensure in the future that all UAI and ISP will be updated annually or when changes occur. Correction is scheduled for June 26, 2024
Standard #:	22VAC40-73-550-G
Description:	Based on resident record review, the facility failed to ensure that a review of resident rights was completed annually with residents and staff. EVIDENCE: 1. The record for resident 3 does not have documentation that a review of resident rights was completed annually for this resident. This is a repeat violation from the 01/30/2024 and 03/26/2024 inspections.
Plan of Correction:	The administrator has reviewed with resident and placed a copy of resident rights in his record.
Standard #:	22VAC40-73-950-E
Description:	Based on staff record and facility documentation review and staff interviews, the facility failed to ensure that a semi-annual review of the facility emergency preparedness plan was completed with all staff. EVIDENCE: 1. The LI requested to review documentation of a semi-annual review of the facility emergency preparedness plan with all staff on 06/17/2024, the day of inspection. In an interview with staff 1 conducted on 06/17/2024, staff 1 expressed that there is not documentation of a semi-annual review of the facility emergency preparedness plan with staff. This is a repeat violation from the 01/30/2024 and 03/26/2024 inspections.
Plan of Correction:	Administration has scheduled training in all facets of emergency situations and assigned duties to cover all emergencies.
Standard #:	22VAC40-73-990-B
Description:	Based on staff record and facility documentation review and staff interviews, the facility failed to ensure that a semi-annual review of the facility plan for resident emergencies with all required components was completed with all staff. EVIDENCE: 1. The LI requested to review documentation of a semi-annual review of the facility plan for resident emergencies with all staff on 06/17/2024, the day of inspection. The LI noted that a review of the facility plan for residents with mental health emergencies was not documented. In an interview with staff 1 conducted on 06/17/2024, staff 1 expressed that there is not documentation of a semi-annual review of the facility plan for residents with mental health emergencies with staff.
Plan of Correction:	The administrator has scheduled training for handling residents emergencies with all involved.