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: Oct. 25, 2021 , Oct. 26, 2021 , Oct. 27, 2021 and Oct. 28, 2021

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 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

A non-mandated monitoring inspection was initiated on 10/20/2021 and concluded on 10/28/2021. The administrator was contacted by telephone to conduct the investigation. The Administrator reported that the current census was 12. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The inspector reviewed three resident records, two staff records, activities calendar, menu, staff schedules, policies, fire and health inspections submitted by the facility to ensure documentation was complete. The licensing inspector conducted an on-site observation at the facility on 10/28/2021. An exit interview was conducted with the administrator on 10/28/2021, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. A final exit interview with the administrator was conducted by phone on 11/9/2021. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-100-A
Description:	Based on document review and interview, the facility failed to review on at least an annual basis their infection prevention policies and procedures. EVIDENCE: 1. At the prior inspection (7/2021) the facility was cited for the annual review being done 6/10/2020. The written infection control program was requested for the 10/2021 inspection and no documentation was submitted to show the written infection control program has been reviewed since the prior violation. 2. Staff 3 stated she sent in the parts of the infection control that were missing from the prior inspection however, the requested documentation listed in evidence 1. was not received.
Plan of Correction:	A registered nurse has been contacted to review the policy once it has been updated. She will sign off including the date, and this will be done once a year. Any changes will be reviewed with staff in in-service training.
Standard #:	22VAC40-73-100-C-2
Description:	Based on document review and interview, the facility failed to include required sections in their written infection control plan. EVIDENCE: 1. The facility written infection control plan does not include: the required plan for how the facility will determine if returning or prospective residents have acute infectious disease and how to prevent disease training; blood glucose monitoring practices consistent with CDC recommendations; handling, storing, processing, and transporting of linens, supplies and equipment in a manner that prevents the spread of infection; sanitation of equipment (such as medical equipment); handling, storing, processing, and transporting medical waste in accordance with applicable regulations; and an effective pest control program. 2. Staff 3 stated she sent in the parts of the infection control that were missing from the prior inspection. The specific sections cited previously, and not received, are listed in evidence 1.
Plan of Correction:	The administrator is updating the infection control plan.
Standard #:	22VAC40-73-100-C-4
Description:	Based on document review and interview, the facility failed to include a required section on their written infection control plan. EVIDENCE: 1. The facility infection control program submitted 10/2021 does not include product specific instructions for use of cleaning and disinfecting agents. 2. Staff 3 stated she sent in the parts of the infection control that were missing from the prior inspection, however, the section listed in evidence 1. was not received.
Plan of Correction:	The administrator will gather all current MSDS safety sheets for products used at the facility, and keep them in a notebook in the cleaning supply storage closet. The infection control plan will state where the sheets are kept.
Standard #:	22VAC40-73-210-A
Description:	Based on staff record review, the facility failed to ensure that staff attended at least 14 hours annually. EVIDENCE: 1. In the most recent completed training year for staff 2 (6/2/20 through 6/1/2021), documentation shows that staff 2 completed 7.5 countable hours out of 14 required hours of annual training.
Plan of Correction:	The administrator will review all staff records to see which staff people need additional training. In-service training will be scheduled and documented when it is done. The administrator will track staff training monthly.
Standard #:	22VAC40-73-250-D
Description:	Based on staff record review, the facility failed to obtain the results of a TB screening annually for a staff person. EVIDENCE: 1. The most recent TB screening for staff 2 was read 2/23/2018. This was noted on 10/26/2021.
Plan of Correction:	The administrator will check to staff files to see if any more are overdue, and from now on, all annual screening will be done in the same month each year. The administrator will follow up to ensure each person has had TB screening annually. Staff 1 has been screened.
Standard #:	22VAC40-73-290-A
Description:	Based on document review, the facility failed to maintain a written work schedule with an indication of whomever is in charge at any given time. EVIDENCE: 1. The October 2021 schedule sometimes has more than one person working at once, and when it does, the in-charge person is not indicated. This occurred on October 6, 11, 13, 15, 16, 17, and 21, 2021
Plan of Correction:	The administrator has corrected this on the schedule and will continue to do so.
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure that a pre-admission physical addressed all required components. EVIDENCE: 1. The pre-admission physical for resident 1 shows the resident is allergic to penicillin and there is no description or mention of the resident's reactions. The same physical is also missing a statement that resident 1 does not have any of the conditions or care needs prohibited by 22VAC40-73-310-H, a statement that specifies whether resident 1 is considered to be ambulatory or non-ambulatory, a statement that specifies whether resident 1 is or is not capable of self-administering medication, and the forms lacks the signature of the examining physician or designee.
Plan of Correction:	This was corrected for resident 1, and the model form will be used from now on. The administrator will review for completeness and corrections made prior to admission.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review, the facility failed to ensure that a uniform assessment instrument (UAI) was completed in accordance with Assessment in Assisted Living Facilities (22VAC30-110). EVIDENCE: 1. The UAI dated 8/17/2021 for resident 1 did not assess whether the resident was dependent in medication administration or not. There is no documentation to show that the assessor was notified of the incomplete assessment.
Plan of Correction:	This has been corrected for resident 1. From now on, the administrator will contact the assessor for incomplete UAIs to be corrected prior to move-in.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to address needs on a comprehensive individualized service plan (ISP). EVIDENCE: 1. The ISP for resident 1 dated 8/18/2021 shows an identified need of "allergic to penicillin." The description of services to be provided states, "Resident will be monitored for signs and symptoms of allergic reactions to Penicillin" however, it does not state what the signs and symptoms are.
Plan of Correction:	The ISP for resident 1 has been corrected. The administrator begun checking all ISPs for completeness, and updates are being made as needed.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review and interview, the facility failed to update an individualized service plan (ISP) to accurately reflect the level of service a resident needed. EVIDENCE: 1. The uniform assessment instrument (UAI) dated 4/21/2021 for resident 2 showed this resident needs mechanical help only when bathing. The ISP dated 5/10/2021 shows that "Resident will have assistance during bath times." Staff 3 confirmed that the resident needs mechanical help only and does not need assistance. The ISP does not address mechanical help.
Plan of Correction:	This has been corrected. From now on, when an ISP is completed, it will be double checked by another person.
Standard #:	22VAC40-73-580-A
Description:	Based on document review, the facility failed to have an annual report from the Virginia Department of Health. EVIDENCE: 1. The most recent health inspection report is dated 4/16/2019.
Plan of Correction:	This has been done. From now on, the administrator will use a date book or other calendar system to keep up with this and call the health department in advance.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to administer medications in accordance with the physician's or other prescriber's instructions, and administers medications for which they have no orders. EVIDENCE: 1. The facility submitted signed medication orders for resident 2 and the medications (listed below) are not in the facility and not on the medication administration record (MAR) for October 2021. Geodon 60 mg and Geodon 40 mg. The facility does not have discontinue orders for the two prescriptions. 2. The facility administers the following medications to resident 1, and there are no signed prescriber's orders: Vitamin D-3, Metformin HCL, Magnesium, Escitalopram, Trazodone, Famotidine, and Amlodipine-Benazepril. 3. The facility administers the following medications to resident 2, and there are no prescriber's orders: Aripiprazole, Metoprolol, and Benztropine.
Plan of Correction:	This has been corrected by obtaining the current signed medication orders from the physician and pharmacy. From now, the administrator will check new orders (which are now placed in a special file) daily to ensure the order is signed before it is filed in the resident record. All resident files will be checked to see if this problem is in other records, and will be corrected by contacting the physician and the pharmacy.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to have some required documentation on the medication administration records: EVIDENCE: 1. The October 2021 Medication Administration Record (MAR) for resident 1 is lacking some required information: route and diagnosis for Vitamin D3; diagnoses for metformin HCL, magnesium, escitalopram, trazodone, famotidine, and amlodipine. 2. The October 2021 MAR for resident 1 incorrectly shows the dose for metformin as 1/2 tablet of 1000 mg, and it should be 1/2 tablet of 500 mg. according to an unsigned order faxed to the facility from the pharmacy and what is on hand in the facility. Staff 3 stated that 500 mg is the correct pill mg, which is then cut in half by the pharmacy. 3. According to an unsigned order for resident 1 faxed from the pharmacy to the facility, the amlodipine (no strength listed on the MAR) should be amlodipine - benazepril 5-40 mg.
Plan of Correction:	After the order is transcribed to the MAR, it will be filed in a designated file and the administrator or designee will check to see that is has been transcribed correctly and completely. If any information is missing from the order, the physician will be contacted. If the order was transcribed incorrectly, the RMA will have in-service training, to include proper demonstration of accurate and complete transcription.
Standard #:	22VAC40-73-690-A
Description:	Based on resident record review, the facility failed to ensure that an annual medication review was conducted for a resident. EVIDENCE: 1. The record for resident 2 shows that the most recent medication review was done on 7/21/2020. This was noted on 10/27/2021.
Plan of Correction:	From now on, all medication reviews will be done at once. The originals will filed in the resident record and a copy will be kept in the administrator's office in a notebook. The administrator is working on a spreadsheet to see if that helps with keeping track of them. Resident files will be spot checked to make sure everything is filed in the correct place.
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to have the interior and exterior of the building maintained in good repair and kept free of rubbish. EVIDENCE: 1. The ceiling of the women's rest room had water damage. 2. The bedroom hallway has a loose switch plate. 3. The floor near the French doors in the living room have damaged flooring and there is a bumpy, uneven, grey substance there. 4. There is a heavy build up of dust in the ceiling vent in the medication room. 5. The tiles near the toilets in the unisex bathroom and the men's bathroom are coming loose from the floor. 6. The closet door in room 5 is inoperable. It is off the tracks, and the floor under it is damaged. 7. In room 8 the ceiling access panel is cracked. 8. The wall in the hallway between rooms 3 and 4 has holes in it. 9. The baseboard near the women's rest room is coming loose and sticks out. 10. There are tall weeds near the AC unit at the back of the building. 10. The side of the building has discoloration in the area above the propane tank. 11. A broken wooden pallet is leaning against the building right next to the propane tank. 12. The back of the property is littered with: a tote full of paint cans, an old walker, a wheelchair laying on its side, a folded wheelchair leaning against the corner of the building, a broken empty plastic tote (near the outbuilding), an old water heater laying on its side, and a shower chair surrounded by overgrown weeds/grass.
Plan of Correction:	The yard has been cleaned up, and other problems are being corrected during the month. They are expected to be done by the end of December 2021.
Standard #:	22VAC40-73-920-C
Description:	Based on observation, the facility failed to have ventilation to the outside in a bathing area. EVIDENCE: 1. The vent in the shower/bathing area of the unisex bathroom is inoperable.
Plan of Correction:	A repair person has been contacted to replace the vent.
Standard #:	22VAC40-73-970-A
Description:	Based on document review, the facility failed to have fire and emergency evacuation drills in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). EVIDENCE: 1. The facility conducted a fire and emergency evacuation drill for first shift on 10/19/2021, and for second shift on 9/30/2021, 8/30/2021, and 7/31/2021. The most recent drill for third shift was 6/2/2021. Drills are required to be for each shift every quarter.
Plan of Correction:	From now on, drills will be done in a regular order so no shifts are missed. Documentation will be double checked by a person who did not conduct a drill.