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: June 22, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS

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: 6/22/2022, to 12:35 pm to 4:20 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 12 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 6 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. 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 Susan Mallory, Licensing Inspector at (540) 309-3043 or by email at susan.mallory@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on resident record review, the facility disclosure statement does not contain some required information. EVIDENCE: 1. The unsigned/unacknowledged copy of the facility disclosure statement lacks information regarding: whether or not the facility maintains liability insurance that provides at least the minimum amount of coverage established by the board for disclosure purposes set forth in 22VAC40-73-45 to compensate residents or other individuals for injuries and losses from negligent acts of the facility, and the amount of coverage; whether or not the facility has an on-site emergency electrical power source for the provision of electricity during an interruption of the normal electric power supply. ?; written acknowledgement of this disclosure evidence by the signature or initials of the resident or initial of the resident or legal representative immediately following the on-site emergency electrical power source disclosure statement; and notation that additional information about the facility that is included in the resident agreement is available upon request.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-50-B
Description:	Based on resident record review, the facility failed to obtain written acknowledgement of the receipt of the [facility] disclosure by the resident or legal representative and keep it in the resident record. EVIDENCE: 1. Resident 1 was admitted on 6/21/2022 and the record does not have written acknowledgement by the resident or legal representative that it was received.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-80
Description:	Based on resident record review, the facility failed to obtain delegation of personal funds from a resident. EVIDENCE: 1. The individualized service plan (ISP) dated 6/22/2022 for resident 1 shows that the facility has permission to handle the resident?s personal funds; however, the record does not have signed and dated permission to do so.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-150-C
Description:	Based on this and prior violation notices, the administrator failed to show responsibility for maintaining compliance with applicable laws and regulations. EVIDENCE: 1. This violation notice contains 19 incidents of non-compliance with 22VAC40-73 Standards for Licensed Assisted Living Facilities, six of which are repeat violations with several of them repeated for the third or fourth time. The violations demonstrate that the administrator is failing to take responsibility.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-250-C
Description:	Based on staff record review, the facility failed to maintain documentation of training in a staff file. EVIDENCE: 1. Staff 1 developed an individualized service plan (ISP) for resident 2 dated 8/26/2022 [sic] and on the day of the inspection, the file for staff 1 had no documentation to support that ISP training had been completed. This was noted on 6/22/2022, and the documentation was sent to Licensing on 6/24/2022.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-310-D
Description:	Based on resident record review, the facility failed to have a copy of the written assurance signed by the resident or legal representative in the resident?s record. EVIDENCE: 1. There was no copy of a signed written assurance letter in the record for resident 1.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-350-B
Description:	Based on resident record review, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and shall document in the resident?s record that this was ascertained and the date the information was obtained. EVIDENCE: 1. Resident 1 was admitted on 6/21/2022, and the record had no documentation to support that a sex offender screening was obtained. This was noted on 6/22/2022.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-390-A
Description:	Based on resident record review, the facility failed to have a written agreement/acknowledgement of notification (resident agreement) dated and signed by the resident or the appropriate legal representative, and by the licensee or administrator at or prior to the time of admission. Based on review of the copy of the unsigned resident agreement in a resident record, the agreement is missing some required sections. EVIDENCE: 1. Resident 1 was admitted on 6/21/2022 and the resident agreement was not signed by the resident or legal representative. The administrator signed it for a future date, 7/21/2022. This was noted on 6/22/2022. 2. Review of the unsigned resident agreement in resident 1?s record shows it is missing the following: a list of services included under the auxiliary grant rate; it does not indicate that advance deposits cannot be charged to auxiliary grant recipients; it does not stipulate whether ownership of personal property, real estate, money or financial investments are to be transferred to the facility; the refund policy does not cover what happens when transfer of ownership, closing of the facility, or resident transfer occurs; and the following specific acknowledgements are not in the agreement: that the resident has been informed of the policy required by 22VAC40-73-840 regarding pets living in the facility; that the resident has been informed and had explained to him that he may refuse release of information regarding his personal affairs and records to any individual outside the facility, except as otherwise provided in law and exempt in case of his transfer to another caregiving facility; that the resident has been informed that interested residents may establish and maintain a resident council, that the facility is responsible for providing assistance with the formation and maintenance of the council, whether or not such a council currently exists in the facility, and the general purpose of a resident council; and that the resident has been notified in writing whether or not the facility maintains liability insurance that provides at least the minimum amount if coverage established by the board for disclosure purposes set forth in 22VAC40-73-45 to compensate residents or other individuals for injuries and losses from negligent acts of the facility. In addition, it was noted that the facility disclosure form shows that the base rate is $1196 per month, and the resident agreement is charging $1609 per month.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-A
Description:	Based on resident record review, the facility failed to do either a preliminary plan of care on or within seven days prior to admission or a comprehensive individualized service plan (ISP) on the day of admission. EVIDENCE: 1. Resident 1 was admitted on 6/21/2022, and the ISP was done on 6/22/2022. There was no preliminary plan of care in resident 1?s record.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-B
Description:	Based on resident record review, the facility failed to ensure that staff who develop individualized service plans (ISP) have successfully completed the department approved ISP training, provided by a licensed health care professional practicing within the scope of his profession. EVIDENCE: 1. The record for staff 6, who developed the ISP for resident 1 dated 6/22/2022, and the ISP for resident 3 dated 3/30/2022 and 4/7/2022, lacks documentation to support that required ISP training has been completed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to address an assessed need on a comprehensive individualized service plan (ISP). EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 1 dated 6/17/2022 shows this resident needs help with taking medications, and this is not addressed on the ISP dated 6/22/2022.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review, the facility failed to obtain required signatures on individualized service plans (ISP). EVIDENCE: 1. The ISP for resident 3 dated 4/7/2022 lacked a signature from the resident.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-560-A
Description:	Based on interview, the facility failed to have a written policy for documentation and recordkeeping to ensure that the information in resident records is accurate and clear and that the records are well organized. EVIDENCE: 1. The LI noted that physician orders were scattered in the resident records, in several sections, some were in a separate book that was not part of a specific resident record, and some were missing (cited as 650-E). The LI asked staff 1 to see the resident record policy, and she was unable to locate it.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-560-I
Description:	Based on resident record review, the facility failed to obtain a photograph or narrative description for a resident. EVIDENCE: 1. The record for resident 1, admitted on 6/21/2022, did not have a photograph or a narrative physical description of the resident.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-650-E
Description:	Based on resident record review, the facility failed to have signed physician orders in a resident?s record. EVIDENCE: 1. The June 2022 medication administration record (MAR) for resident 2 shows that the resident is to have Artificial Tears, two drops in affected eye as needed for dryness. The record for resident 2 has no order for this. 2. The June 2022 MAR for resident 2 shows that Qc Medicated Foot Powder is to be applied freely up to 3 or 4 times daily and as needed for fungus. The record for resident 2 has no order for this.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to administer medication to a resident as ordered. EVIDENCE: 1. Resident 2 is getting twice as much risperidone (Risperdal) as currently prescribed. The June 2022 medication administration record (MAR) shows that resident 2 is administered Risperidone .05 mg twice a day, however, the most recent order in the record dated 1/11/2022 shows this should be given every night at bedtime.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to be maintained in good condition. EVIDENCE: 1. Water was observed dripping from the ceiling in room 2 from a hole that also had exposed wires coming out of it. There was a puddle of water on the floor under the drip. 2. The closet door in room 5 does not stay on the track when the door is opened or closed, and the floor under it is damaged.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-950-E
Description:	Based on lack of documentation, the facility failed to have semi-annual reviews of the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual?s respective responsibilities. The review is required to be documented by signing and dating. EVIDENCE: 1. There was no documentation to support that the entire emergency preparedness and response plan was reviewed with all staff, residents, and volunteers. On 3/21/2022 a document labeled ?Quarterly Practice Exercise Emergency Preparedness & Response Plan 930-C? shows that ?Hurricane? was practiced with staff. On 4/12/2022 a document labeled ?Every 6 months Practice Exercise Emergency Preparedness & Response Plan 930-C? shows that ?Smell of toxic fumes from the kitchen? was practiced with staff and residents.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-990-C
Description:	Based on lack of documentation the facility failed to conduct, at least once every six months, an exercise in which the procedures for resident emergencies are practiced with all staff on duty on each shift. Documentation of this is required to be maintained in the facility for at least two years. EVIDENCE: 1. There is no documentation to support that a practice exercise was conducted with all staff for resident emergencies, to include a resident physical emergency, a resident mental health breakdown, and a resident elopement.
Plan of Correction:	Not available online. Contact Inspector for more information.