VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hairston Home for Adults
601 Armstead Ave
Martinsville, VA 24112
(276) 638-5121

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: Jan. 31, 2023

Complaint Related: No

Areas Reviewed:

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 BUILDINGS AND GROUND

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: 01/31/2023 from 09:30 AM until 12:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-120-A
Description:	Based on record review, the facility failed to ensure that all new staff shall receive facility orientation and training as required in subsections B and C of this standard within the first seven working days of employment. EVIDENCE: 1. The record for staff 3, hired 07/22/2022, did not contain the required new staff orientation and training. 2. Interview with staff 4 indicated that the documented training for staff 3 still does not exist.
Plan of Correction:	Certificate of completion of D/C (direct care) in file.
Standard #:	22VAC40-73-250-C
Description:	Based on record review, the facility failed to ensure that personal and social data shall be maintained on staff and included in the staff record. EVIDENCE: 1. The records for staff 1, 2, and 3 still did not contain documentation of having received a job description. 2. The records for staff 2 and 3 still did not contain verification of completion of a required approved direct care training course. 3. Interview with staff 4 confirmed that this documentation was not maintained in the staff records.
Plan of Correction:	Completed certificates in file with approved document of D/C (direct care) check off.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment and shall maintain current first aid certification. EVIDENCE: 1. The record for staff 3, hired 07/22/2022, did not contain documentation of having received first aid certification. 2. Interview with staff 4 confirmed that staff 3 still had not yet received first aid certification since her hire date.
Plan of Correction:	Administration will schedule CPR/First Aid when class is available.
Standard #:	22VAC40-73-870-E
Description:	Based on observation, the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers shall be kept clean and in good repair and condition. EVIDENCE: A blue overstuffed interior chair with a hole in the arm was observed sitting on the outside porch at the back of the facility.
Plan of Correction:	Chair was removed from porch.
Standard #:	22VAC40-73-870-F
Description:	Based on observation, the facility failed to ensure that all inside and outside steps, stairways, and ramps shall have non-slip surfaces. EVIDENCE: The stairs on the back exterior of the building had a black rug on approximately four of the steps which created a slip/trip hazard.
Plan of Correction:	Black rug was removed from stairs.