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 29, 2020 and April 30, 2020

Complaint Related: No

Areas Reviewed:

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 EMERGENCY PREPAREDNESS 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 4/23/2020 and concluded on 4/30/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 10. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed two resident records, two staff records, partial record review for one resident and two staff members, the updated medication management plan, health care oversight, fire inspection report, Health Department inspection report, Fire and Emergency drill logs, and the dietitian oversight report, submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-40-A
Description:	Based on document review, the facility failed to operate within the terms of their license. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 1 dated 2/6/2020 showed dependencies in two activities of daily living, medication management, and four dependencies in instrumental activities of daily living, which means resident 1 requires assisted living level of care. This facility has a residential only license.
Plan of Correction:	Date of reassessment Resident 1 was assessed by Social Services and was deemed appropriate for placement in the Residential Facility. Going forward the administrator will review the preview the preadmission paperwork prior to accepting a resident into the facility. Requested Social Services to reassess Resident. Social Services refused (5/13/20). Social Services will reassess resident on 6/15. (5/15/2020)
Standard #:	22VAC40-73-440-G
Description:	Based on resident record review, the facility failed to ensure that there was a completed UAI on record when a resident moved from another assisted living. EVIDENCE: 1. The UAI for resident 1, dated 2/6/2020, was not completed. The UAI showed this resident needs help with transferring, but the level of help needed was not indicated.
Plan of Correction:	Will have Social Service reassess the resident. Ongoing - The administrator will review UAIs of all residents to ensure accuracy and completion according to regulation.
Standard #:	22VAC40-73-450-A
Description:	Based on resident record review, the facility failed to complete preliminary plan of care on or within seven days prior to the day of admission. EVIDENCE: 1. Resident 1 was admitted on 3/30/2020. The plan of care in the resident record was a copy of the plan used by the resident?s previous assisted living facility, dated 2/12/2020.
Plan of Correction:	1. Reassess Resident to complete accurate ISP 2. Complete ISP 3. Ongoing, Administrator will endure ISPs are completed according to regulations.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review, the facility failed to obtain required signatures on an individualized service plan (ISP). EVIDENCE: 1. The undated ISP for resident 2 lacked signatures from the resident or representative and the licensee, administrator, or designee.
Plan of Correction:	Have residents sign ISP or indicate refuse. Dated/Accurate ISP signed by staff located at the facility with indication of the resident refusal to sign. Administrator/designee will ensure ISPs are signed according to regulations. Administrator will ensure that ALL ISPs will be updated when a resident' needs change.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to update an individualized service plan (ISP) when the resident?s needs changed. EVIDENCE: 1. The ISP for resident 2 did not address the following needs identified on the uniform assessment instrument (UAI) dated 12/4/2019: Mechanical help stairclimbing. An interview with staff 1 revealed resident 2 would use hand rails on stairs if he needed to.
Plan of Correction:	Ongoing Administrator will ensure that all needs identified won UIAs are accurate and reflect the residents current need and that forms are completed completely and accurately.
Standard #:	22VAC40-73-490-D
Description:	Based on document review, the facility failed to ensure that the licensed healthcare professional who provided the health care oversight certified that all of the requirements of subsection B of this section were met, and that the written documentation was signed by the healthcare professional. EVIDENCE: 1. The Healthcare Oversight Checklist dated 2/4/2020 did not include all requirements of subsection B of this standard, and was not signed by the healthcare professional.
Plan of Correction:	Upon review, discovered that correct documentation was indeed at the facility, but did not get included in the documents Faxed. Going forward Healthcare oversight documentation will be reviewed by the administrator for accuracy. The form was found @ the facility by the administrator.
Standard #:	22VAC40-73-620-B
Description:	Based on document review, the facility failed to ensure that a dietitian or nutritionist oversight report contained all required elements. EVIDENCE: 1. The dietitian report was lacking the date of the review; verification that the order, preparation, and delivery of the special diet were reviewed; the evaluation of the adequacy of the special diet; certification that the requirements of this regulation were met, including the date of the oversight and identification of the resident(s) for whom the oversight was provided; date the oversight/report was provided; and signature of the dietician or nutritionist.
Plan of Correction:	Obtained edited Dietitian report from Nutrition Plus Going forward the administrator will review dietitian report to ensure regulations are met.
Standard #:	22VAC40-73-640-A
Description:	Based on document review, the facility failed to have a complete medication management plan. EVIDENCE: 1. The medication management plan was missing the following sections: 640-A-2, standard operating procedures, including the facility?s standard dosing schedule (not specific) and any general restrictions specific to the facility; 640-A-10, methods to ensure that staff who are responsible for administering medications are adequately supervised, including periodic direct observation of medication administration; 640-A-13, identification of the medication aide or the person licensed to administer drugs responsible for routinely communicating issues or observations related to medication administration to the prescribing physician or other prescriber, and; 640-A-14, methods to ensure that staff who are responsible for administering medications are trained on the facility?s medication management plan.
Plan of Correction:	640-A-2: Medication administered time Ex: 8 am - 2 pm - 8 pm (TID) 8 am - 8 pm (BID) 8 am - 12 noon - 4 pm - 8 pm (QID) according to MD orders 640-A-10: Administrator or designee will perform periodic audit of medication cabinet with direct observation of med pass. 640-A-13: RMAs will communicate concerns/issues, observation to HCP as soon as they appear by phone call or FAX. Follow-up will occur daily until response is obtained. 640-A-14: All RMAs upon hire with will review medication management plan and verify and review by signature/date. Ongoing: Administrator will ensure that medication management plan is updated to include any missing sections.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to administer medication as ordered. EVIDENCE: 1. The medication list on the pre-admission physical dated 1/15/2020 showed that hydrocodone 5mg ? acetaminophen 350mg is scheduled to be administered three times each day. The April 2020 medication administration record (MAR) showed that this medication is as needed (PRN) and has not been administered in April.
Plan of Correction:	Current orders obtained from HCP/Pharmacy and Norco chaned to PRN on 5/9/2020. Ongoing Administrator, designee will ensure the current medication orders are at the facility.
Standard #:	22VAC40-73-680-E
Description:	Based on review of medication administration records (MAR) the facility failed to document that treatments ordered by a physician or other prescriber were provided according to his instructions and documented. EVIDENCE: 1. The April 2020 MAR for resident 1 showed ?MONITOR DIALYSIS SHUNT SITE DAILY FOR ACTIVE BLEEDING TO RIGHT FEMORAL? on each of three shifts, daily. There was no documentation on the MAR to support that this is being done. 2. The April 2020 MAR for resident 1 showed ?BILATERAL KNEE HIGH T.E.D. HOSE ? PUT ON IN MORNING REMOVE AT NIGHT?. There is no documentation on the MAR to show that this is being done.
Plan of Correction:	Obtained current orders from the pharmacy for residents. Re-education the RMAs on physician orders and provided guidance on how to carry out orders. Going forward the administrator will supervise the RMAs weekly for 3 months. Resident stated that she does not wear T.E.D hose unless her ankles and legs appear swollen. Contacted M.D. to obtain amendment to obtain order. Re-Educated staff on the following F.D. order and document in the guidelines.
Standard #:	22VAC40-73-680-I
Description:	Based on review of medication administration records (MAR) the facility failed to document the MARs as required. EVIDENCE: 1. The April 2020 MAR for resident 1 lacked documentation to support that the following medications were given: 7:30AM on 4/23/2020 - Amlodipine Besylate 5 mg, metoprolol Succ Er 100mg, pantazaprole DR 40mg, Qc Aspirin EC 81mg, Rena-Vite, Colace 100mg, Hydralazine 50mg, Vimpat 150mg, Lanthanum Carb 1000mg; 8:30PM on 4/21/2020 ? Colace 100mg, banophen 25mg, trazodone 50mg, hydralazine 50mg, vimpat 150mg; 12 noon and 5PM on 4/21/2020 ? lanthanum carb 1000mg;
Plan of Correction:	Re-educate RMAs on medication administration documentation. Ongoing Administrator/designee will audit MARs weekly for 3 months to ensure that all medications are given/documented according to regulations.
Standard #:	22VAC40-90-30-B
Description:	Based on staff record review, the facility failed to obtain a sworn disclosure statement from staff. EVIDENCE: 1. Staff 2 was hired on 4/6/2020, and the record did not contain the Sworn Disclosure Statement.
Plan of Correction:	Administrator will ensure that all staff sign Disclosure Statements upon hire.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for an employee. EVIDENCE: 1. Staff 4 was hired on 12/26/2019 and the record did not contain the results from a criminal history record report. The facility noted that they did not request the report until 4/18/2020.
Plan of Correction:	Going forward administrator will ensure that background checks are completed prior to staff working alone in the facility.