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: Sept. 24, 2019

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 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 SANCTIONS.

Comments:

On 9/24/2019 one inspector conducted a renewal study (9:05am to 7pm). 34 residents were in care. Six resident records were fully reviewed and three staff records were fully reviewed, and other records were partially reviewed. All new staff records were reviewed for background checks. A physical plant tour was done. A medication pass was observed and the medication carts were checked. Staff, resident, and family interviews were conducted. The LI and management staff had a discussion regarding double checking public pay uniform assessment instruments (UAI) for accuracy, and what to do if one is discovered to have inaccurate assessments. When a resident consistently refuses a medication, consider asking the prescriber to discontinue it, or change it to PRN (as needed). Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain the following: 1) steps to correct the noncompliance with the standard(s); 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions, please contact your licensing inspector at 540-3-9-3043.

Violations:

Standard #:	22VAC40-73-250-C
Description:	Based on staff record review, the facility failed to have some required information in a staff file. EVIDENCE: 1. The record for staff 5 lacks a job description. 2. Staff 4 was hired either 4/19/2019 or 4/26/2019 (the record is not clear) and the Sworn Disclosure was done on 7/18/2019 (it is due upon application) and the Virginia State Police Criminal Record check was not done until 6/4/2019 (this is due within 30 days of hire). 3. Staff 8 was hired 8/15/2019 and there is no Virginia State Police Criminal Record check in the record.
Plan of Correction:	Job Description was completed in file. State Police Reports will be done by ALF staff & supervised by Administration to ensure compliancy with regulation. (copy included) State Police report was completed 9/9/19, within the 30 day of employment.
Standard #:	22VAC40-73-250-D
Description:	Based on staff file review, the facility failed to have TB screenings done on or within seven days prior to hire for new staff. EVIDENCE: 1. Staff 4 was hired either 4/19/2019 or 4/26/2019 (the record is not clear) and the TB screening was done on 7/26/2019. 2/ Staff 5 was hired on 7/8/2019 and the TB screening was done on 7/26/2019.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-290-B
Description:	Based on observation, the facility failed to implement a procedure for posting the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public. EVIDENCE: 1. The name of the person in charge was not posted.
Plan of Correction:	- Charge erson was indicated on schedule > copy is attached.
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to obtain some required information on a pre-admission physical exam for a resident. Based on resident record review, the facility failed to have a TB screening done on a resident within 30 days prior to admission. EVIDENCE: 1. The pre-admission physical for resident 1, dated 2/19/2019, is lacing the height, weight, and ambulatory status of the resident. 2. Resident 1 was admitted on 3/6/2019 and the TB screening was done on 1/19/2019.
Plan of Correction:	DON & Administrator will be responsible for checking all [dates] are within time frame according to regulation.
Standard #:	22VAC40-73-325-A
Description:	Based on resident record review, the facility failed to have a fall risk rating done for a resident by the time the comprehensive individualized service plan (ISP) was completed. EVIDENCE: 1. Resident 1 was admitted on 3/6/2019 and the comprehensive ISP was done on the same day. The only fall risk rating available is dated 9/23/2019.
Plan of Correction:	LPN & DON/LHCP will ensure fall risk is completed upon admission with ISP.
Standard #:	22VAC40-73-325-B
Description:	Based on document review, the facility failed to do annual fall risk ratings. EVIDENCE: 1. The most recent fall risk ratings for residents 4, 5, and 6 are dated 8/15/2018, and the most recent fall risk rating for resident 3 is dated 8/18/2018. This was noted on 9/24/2019.
Plan of Correction:	LPN and LHCP will be responsible for scheduling Falling Risk assessments annually and PRN effective 11-1-19.
Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to obtain some required social data for a new resident. EVIDENCE: 1. The Personal Social Data Information form for resident 1 lacks information regarding allergies and the responsible party.
Plan of Correction:	ALF will implement uso of new social data sheets on new residents going forward.
Standard #:	22VAC40-73-430-H-1
Description:	Based on document review, the facility failed to have complete information on a resident discharge statement. EVIDENCE: 1. The discharge statement for resident 2 lacks the discharge date.
Plan of Correction:	Administrator & LHCP will ensure data on D/C paperwork is completed.
Standard #:	22VAC40-73-440-A
Description:	Based on document review and interview, the facility failed to have a resident assessed face to face using the uniform assessment instrument (UAI) in accordance with Assessment in Assisted Living Facilities (22VAC30-110). EVIDENCE: 1. The UAIs for resident 4, dated 8/20/2019, resident 5, dated 5/28/2019, and resident 1, dated 5/28/2019, show that medications must be administered by professional nursing staff. Staff interviews and observation reveal that medications are administered by lay people (registered medication aides), and that professional nursing staff (RN, LPN) are not required. 2. The UAI for resident 4, dated 8/20/2019, shows the resident is continent of bowel and bladder; according to facility staff and the individualized service plan, the assessment is incorrect. Services are provided for occasional incontinence. 3. The UAI for resident 3, dated 5/28/2019, is lacking an assessment for toileting, adn shows this resident needs help with mobility, but the level of help has not been assessed.
Plan of Correction:	Administration spoke with the Case Mgr. Supervisor regarding the accuracy of UAI completion.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to address a need on the comprehensive individualized service plan (ISP). EVIDENCE: 1. The uniform assessment instrument for resident 1, dated 3/5/2019, shows the resident is incontinent of bladder weekly or more. This need is not addressed on the comprehensive ISP, dated 3/6/2019.
Plan of Correction:	ISP will be corrected by LHCP and review with resident. LHCP & LPN will be responsible to monitor and change ISP PRN.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to do annual reviews and updates of individualized service plans (ISP). EVIDENCE: 1. The ISPs for residents 3 and 6 were most recently updated on 5/31/2018. 2. The ISP for resident 3, dated 5/31/2018, does not addressed the assessed need of assistance with medication administration.
Plan of Correction:	LPCP & LPN staff will monitor ISP & kee to date. > LHCP will update ISP > LHCP will update ISP
Standard #:	22VAC40-73-610-D
Description:	Based on observation, interview, and documentation, the facility failed to serve special diets to residents. EVIDENCE: 1. An interview with staff 9 reveals that the residents get the same food, with the exception of food allergies, or chopped diets. Resident 5 has a prescribed diet with a 1500 ml liquid restriction, and this is not served. Resident 1 has a prescribed diet, dated 7/2/19 from a hospital discharge order, for a diabetic and renal diet, and this is not served.
Plan of Correction:	DON of ALF will request house diets for residents from MD - House diets are written by our dietician. Fluid restriction is monitored & encouraged by staff - MD notified for noncompliancy.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to administer medications as prescribed. EVIDENCE: 1. Resident 5 was prescribed Brovana 15mcg/2ml solution via nebulizer twice daily on 8/2/2019. The medication administration record (MAR) shows this was not administered at 8am and 8pm scheduled dosing times on September 1, 2, 5, 6, 10, 11, 14, 15, 16, and the 8am dose on 9/24/2019 due to "not available - contacted pharmacy." Other doses were documented as being missing because the resident refused. The record has no order to discontinue this medication, and the MAR clearly shows the resident does not get it as prescribed. 2. The MAR for resident 8 shows that on 9/1/2019 the resident missed doses of valsartan 320 mg, simvastatin 20mg, and Advair Discus because they were "not available - contacted pharmacy." The MAR shows that resident 8 missed a dose of haloperidol de 100 mg/ml because it was "not available - contacted pharmacy." The MAR also shows that resident 8 missed doses of simvastatin 20mg, benztropine mes 0.5mg because "not available - contacted pharmacy." These medications were not given as prescribed because they were not in the ALF.
Plan of Correction:	Pharmacy will notify MD for any medication refills, insurance problems with filling the medication. Will obtain new orders or D/C order for MEAR starting immediately.
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to have a valid order for a resident to use supplemental oxygen. EVIDENCE: 1. The individualized service plan (ISP) and uniform assessment instrument (UAI) for resident 1 shows that oxygen is used. There is no order or prescription in the resident record for this.
Plan of Correction:	Order for O2 was on D/C instruction from hospital _ O2 order was sent to MediHome from hospital prior to D/C. > copies attached.
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility was not maintained in good repair and kept clean. EVIDENCE: 1. The window air conditioner in room 7 was inoperable. The plug has been cut off from the wiring from the unit. 2. There is a heavy build up of dust under the beds in room 15. 3. The paint is worn off the door of room 16.
Plan of Correction:	Window unit will be removed & replaced. Staff meeting re: cleaning routine Maintenance & facility upkeep is scheduled according to priority.
Standard #:	22VAC40-73-970-E
Description:	Based on interview and document review, the facility failed to have a record of required fire and emergency evacuation drills. EVIDENCE: 1. There is no documentation to support that a fire/emergency evacuation drill was conducted in August 2019.
Plan of Correction:	Administrator will ensure fire drills will be rotated between shifts monthly.