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. 18, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-90 The Criminal History Record Report

Technical Assistance:

70-C, 440-E, 620-B, 720-A

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 renewal inspection was initiated on 9/17/2020 and concluded on 9/22/2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 34. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, the sworn disclosure statement and criminal record report for all new staff members, resident roster, staff roster, staff schedule, facility health care oversight, fire and emergency drills, health department inspection, and dietitian oversight 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 #:	22VAC40-73-120-A
Description:	120-A Based on record review, the facility failed to ensure that staff orientation and initial training shall occur within the first 7 working days of employment. EVIDENCE: 1. The record for staff 1, hired 1/1/2020, did not contain documentation of new staff orientation training. 2. Interview with staff 10 indicated that all new staff receive initial training and orientation when they start employment; however, staff 10 could not confirm that the training for staff 1 was documented.
Plan of Correction:	The LHCP will be responsible for completing all new hire documentation within allotted time period.
Standard #:	22VAC40-73-250-C
Description:	250-C 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 record for staff 1 did not contain documentation of the sworn disclosure statement, CPR and First Aid certification, and Registered Medication Aide certification. 2. The record for staff 2 did not contain documentation of CPR and First Aid certification and Registered Medication Aide certification. 3. The record for staff 3 did not contain documentation of CPR and First Aid certification.
Plan of Correction:	The LHCP will be responsible for ensuring documentation is completed (i.e. sworn disclosure). The pharmacy nurse will ensure documentation is complete after future CPR trainings.
Standard #:	22VAC40-73-250-D
Description:	250-D Based on record review, the facility failed to ensure that each staff person on or within 7 days prior to the first day of work shall submit the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as evidenced by completion of the current screening form published by the Virginia Department of Health or one consistent with it. EVIDENCE: 1. The record for staff 1, hired 1/1/2020, contained an initial TB screening form that was completed on 2/7/2020.
Plan of Correction:	The LHCP will be responsible to ensure all new hire documentation is completed in a timely manner.
Standard #:	22VAC40-73-450-F
Description:	450-F Based on record review, the facility failed to ensure that individualized service plans (ISP) shall be reviewed and updated at least once every 12 months, and as needed as the condition of the resident changes. EVIDENCE: 1. The UAI for resident 1, dated 2/12/2020, indicated that the resident provides self-care when using an external device for bladder incontinence; however, bladder incontinence is not addressed on the ISP, dated 11/14/2019. 2. Interview with staff 10 indicated that resident 1 uses pull-ups for bladder incontinence and manages them herself; however, the ISP was not updated to reflect this. 3. The ISP for resident 3 was last completed on 2/20/2019.
Plan of Correction:	The LHCP is responsible for monitoring and updating the ISP as they come due.
Standard #:	22VAC40-73-550-G
Description:	550-G Based on record review, the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each staff person and written acknowledgment of the review shall be filed in the staff record. EVIDENCE: 1. The records for staff 1, staff 2, and staff 3 did not contain documentation of an annual review of resident rights.
Plan of Correction:	Administrator and LHCP will be responsible for annual review of residents rights and all other documentation.
Standard #:	22VAC40-73-680-I
Description:	680-I Based on record review, the facility failed to ensure that the MAR shall include the date and time medication was given and the initials of the direct care staff administering the medication. EVIDENCE: 1. The August 2020 MAR for resident 3 was incomplete for the following medications on the following dates and times: a. Aspirin EC 81 mg tablet on 8/13, 8/14, 8/15 at 8:00 AM; b. Benztropine MES 2 mg tablet on 8/31 at 8:00 PM; c. Budesonide 0.5 mg/2 mL susp on 8/31 at 8:00 PM; d. Cefdinir 300 mg caps on 8/31 at 8:00 PM; e. Divalproex 500 mg ER tablet on 8/31 at 8:00 PM; f. Docusate sodium 100 mg softgel on 8/31 at 8:00 PM; g. Enulose 10 g/15 mL on 8/31 at 8:00 PM; h. Folic acid 1 mg tablet on 8/31 at 8:00 PM; i. Furosemide 20 mg tablet on 8/31 at 8:00 PM; j. Myrbetriq 25 mg ER tablet on 8/31 at 8:00 PM; k. Quetiapine fumarate 400 mg tablet on 8/31 at 8:00 PM
Plan of Correction:	The LHCP will meet with all medication aides to review proper documentation and medication protocol.
Standard #:	22VAC40-90-40-B
Description:	22VAC40-90-40-B Based on record review, the facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The record for staff 1, hired 1/1/2020, contained CRC results that were dated 3/6/2020. 2. The record for staff 5, hired 12/1/2019, contained CRC results that were dated 1/6/2020. 3. The record for staff 6, hired 1/1/2020, contained CRC results that were dated 3/6/2020. 4. The record for staff 7, hired 1/1/2020, contained CRC results that were dated 6/7/2020. 5. The record for staff 8, hired 5/1/2020, contained CRC results that were dated 6/7/2020. 6. The record for staff 9, hired 5/1/2020, contained CRC results that were dated 6/7/2020.
Plan of Correction:	Administrator will be responsible for ensuring criminal history record will be completed prior to the 30th day of employment.