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. 22, 2022

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

320-A, 390 (DOLP contact information)

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/22/2022 09:00 AM ? 04:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at 540-309-5982, or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-120-A
Description:	Based on record review, the facility failed to ensure that all new staff shall receive facility orientation and training as required in subsections B and C of this standard within the first seven working days of employment. EVIDENCE: 1. The record for staff 3, hired 07/22/2022, did not contain the required new staff orientation and training. 2. Interview with staff 4 indicated that the training for staff 3 does not exist.
Plan of Correction:	Administrator and DON will ensure all personnel files/paperwork will be completed with the allotted time for all future employees.
Standard #:	22VAC40-73-190-C
Description:	Based on record review, the facility failed to ensure that prior to being in charge, the staff member shall be informed of and receive training on his duties and responsibilities and provided written documentation of such duties and responsibilities. EVIDENCE: 1. The records for staff 1, 2, and 3 did not contain written documentation of being informed of and trained in charge duties and responsibilities prior to being placed in charge. 2. Interview with staff 4 indicated that the training for staff 1, 2, and 3 does not exist.
Plan of Correction:	Administration will include the responsibilities of "charge person" on job duties of RMA.
Standard #:	22VAC40-73-250-C
Description:	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 records for staff 1, 2, and 3 did not contain documentation of job description. 2. The records for staff 2 and 3 did not contain verification of completion of a required approved direct care training course. 3. Interview with staff 4 confirmed that this documentation was not maintained in the staff records.
Plan of Correction:	Administration will include staff social data sheet in chart. Will add to employee packet.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment. EVIDENCE: 1. The record for staff 3, hired 07/22/2022, did not contain documentation of having received first aid certification within 60 days of employment. 2. Interview with staff 4 confirmed that staff 3 had not yet received first aid certification.
Plan of Correction:	Administration will schedule CPR/First Aid for all employees within 60 days of employment.
Standard #:	22VAC40-73-260-C
Description:	Based on observation, the facility failed to ensure that a listing of all staff who have current certification in first aid and CPR shall be posted in the facility so that the information is readily available to staff at all times. EVIDENCE: 1. While completing the physical plant inspection with staff 5 on the date of inspection, LI did not observe a posted current first aid and CPR list. 2. Interview with staff 4 and 5 indicated that there is no posted list.
Plan of Correction:	CPR and First Aid listing will be posted in nurse's desk.
Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to obtain all required personal and social information on a person. EVIDENCE: Resident 6 was admitted to the facility on 08/08/2022. The document ?resident ?personal/social data? did not include the following required information: birthplace, marital status, legal representative (if applicable), the name, address, and telephone number of next of kin if known, personal dentist (if known), clergyman (if applicable), service in the armed forces (if applicable), special interests and hobbies, any known allergies, information regarding advance directives (if applicable), pervious mental health or intellectual disability if any, current behavioral and social functioning including strengths and problems and any substance abuse history (if applicable).
Plan of Correction:	Administration/DON will ensure social data sheet is completed upon admission to facility.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure that the individualized service plan (ISP) addressed all identified needs. EVIDENCE: 1. The ISP for resident 2, dated 07/01/2021, did not contain documentation of the Discharge Assistance Payment (DAP) contract for services with the facility. 2. The ISP for resident 3, dated 07/20/2022, did not contain documentation of the DAP contract for services with the facility.
Plan of Correction:	ISPs for DAP residents will include DAP contract.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, the facility failed to ensure that the ISP shall be reviewed and updated at least once every 12 months. EVIDENCE: The most current ISP for resident 2 on the date of inspection was dated 07/01/2021.
Plan of Correction:	Administration will ensure ISPs are reviewed and updated monthly.
Standard #:	22VAC40-73-550-G
Description:	Based on resident record review and staff interview, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities were reviewed annually with each resident or his legal representative or responsible individual. EVIDENCE: 1. The records for residents 2, 4, 5, 7 and 8 did not include documentation that an annual review of residents? rights and responsibilities had been conducted with the aforementioned residents. 2. Interview with staff 4 confirmed this was accurate.
Plan of Correction:	Administration will have meeting annually with residents re: resident's rights and responsibilities.
Standard #:	22VAC40-73-650-A
Description:	Based on resident record review and staff interview, the facility failed to ensure medication was not changed or discontinued without a valid order from a physician or other prescriber. EVIDENCE: 1. The record for resident 8 contained a physician?s order, dated 06/30/2022, for Victoza (insulin) inject 1.8MG daily at 8:00AM. When collateral 2 asked staff 1 to see the aforementioned medication, staff 1 indicated that it was not at the facility. 2. Interview with staff 4 revealed that there was a discontinued order for the medication dated 06/07/2022; however, staff 4 was not aware of the signed physician?s order dated 06/30/2022 for Victoza inject 1.8MG daily at 8:00AM and that staff have not been administering Victoza to the resident.
Plan of Correction:	DON will ensure review of medication (EMAR) monthly to maintain accuracy of med order. DON spoke to the pharmacy to D/C Victoza per PCP order.
Standard #:	22VAC40-73-650-F
Description:	Based on resident record review and staff interview, the facility failed to ensure that the primary physician was aware of all medication orders and document any contact with the physician regarding new orders whenever a resident is admitted to a hospital for treatment of any condition. EVIDENCE: 1. The record for resident 6 contained an after visit summary from the hospital, dated 09/07/2022, that indicated the resident?s currently prescribed Pregabalin 100MG three times daily for pain was to be changed to only be administered two times daily. 2. Interview with staff 1 and 4 revealed that the aforementioned information was not relayed to the resident?s primary physician and during on-site inspection on 09/22/2022 it was confirmed that the resident was still receiving Pregabalin 100MG three times daily.
Plan of Correction:	DON will review medication list and make PCP sign all outpatient notes and orders.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, staff interview and collateral interview, the facility failed to ensure medications were administered consistently with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. The Commonwealth of Virginia Board of Nursing Medication Aide Curriculum for Registered Medication Aides, revised 05/21/2031, includes the following information regarding clients? (residents?) refusals of medications: ?7.6 Identify Reasons for Clients? Refusal to Take Medications and Respond Appropriately. Section D. Strategies for dealing with client?s refusal: 2. Notify the HCP (health care provider) or supervisor when a client refuses medication and 8. If the refusals continue, explore other options with the HCP.? 2. The September 2022 medication administration record (MAR) for resident 4 indicated that the resident refused every day her prescribed Ammonium Lactate 12% lotion, prescription dated 09/10/2021, apply to both feet twice daily for dry skin. 3. The September 2022 MAR for resident 6 indicated that the resident refused multiple dates/times for the following prescribed medications (signed physician?s order dated 08/18/2022): Antacid Double Strength tablets, Breo Ellipta inhaler and Miralax powder. 4. The September 2022 MAR for resident 7 indicated that the resident refused daily the following prescribed medications (signed physician?s order dated 12/20/2021): Albuterol inhaler and Novolog give 15 units two times daily with a meal for diabetes (scheduled at 8:00AM and 8:00PM). 5. Interview with staff 1 during on-site inspection on 09/22/2022, who is a registered medication aide, indicated that resident 7 refuses to have his blood sugar checked in the evenings therefore he has not received the prescribed Novolog any evening in the month of September 2022. 6. Interview with Collateral 1 (resident?s health care provider) during on-site inspection on 09/22/2022 indicated that she had not been notified by facility staff of any of the aforementioned refusals regarding residents 4, 6 and 7.
Plan of Correction:	DON will have in-service for medication aides re: refusal of medications and documentation. DON and med aides will monitor usage of meds and notify PCP appropriately. Resident 4 Ammonium Lactate 12% lotion changed to PRN. Resident 6 Antacid Double Strength tablets, Breo Ellipta inhaler, and Miralax powder change to PRN or D/C. Educated resident 7 about importance of compliance of blood sugar checks. He advised he did not want to check at night because he knew it was going to be high and did not want to know. Will speak to PCP. DON will ensure PCP is notified of all changed in resident's medication compliance. Document as much.
Standard #:	22VAC40-73-680-E
Description:	Based on resident record review and staff interview, the facility failed to document treatments ordered by a physician or other prescriber. EVIDENCE: 1. The record for resident 4 contained a physician?s order, dated 08/04/2022, for oxygen at two liters per minute via nasal cannula; however, there was no documentation in the resident?s record that the oxygen is being provided according to the physician?s or other prescriber?s instructions. 2. Interview with staff 4 confirmed this is accurate.
Plan of Correction:	Obtained new order while LI was on site.
Standard #:	22VAC40-73-690-G
Description:	Based on resident record review and staff interview, the facility failed to ensure that the action taken in response to the recommendations noted in the residents? medication review were documented in the residents? record. EVIDENCE: 1. The records for residents 4, 7 and 8 contained documentation that a medication review was performed on 04/22/2022 and recommendations were made by the pharmacist for all the aforementioned residents. The records for resident 4, 7 and 8 did not contain documentation of the action taken in response to these recommendations. 2. Interview with staff 4 confirmed this was accurate.
Plan of Correction:	DON will ensure that PCP reviews recommendations and document of sending recommendations were sent to PCP.
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to ensure that a valid physician?s order for oxygen contained all required components. EVIDENCE: The record for resident 4 contained a physician?s order, dated 08/04/2022, for oxygen at two liters per minute via nasal cannula. The order did not include the oxygen source.
Plan of Correction:	DON obtained order from PCP while LI was in facility for O2 via NC 2L/min via concentrator @ hs PRN.
Standard #:	22VAC40-73-700-2
Description:	Based on observation during a tour of the physical plant, the facility failed to post ?No Smoking-Oxygen in Use? signs in a room of the building where oxygen is in use. EVIDENCE: Interview with staff 4 revealed that resident 4 uses oxygen at night. There was no ?No Smoking-Oxygen in Use? sign observed in or around the resident?s room. This was also observed by staff 4.
Plan of Correction:	Oxygen in use sign was posted on wrong door. Sign was moved to appropriate door.
Standard #:	22VAC40-73-870-E
Description:	Based on observation, the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, shall be kept in good repair and condition. EVIDENCE: While completing the physical plant inspection with staff 5 at 10:08 AM, LI and staff 5 observed that the headboard on the first bed in room 16 was broken.
Plan of Correction:	Administration fixed headboard in resident's room.
Standard #:	22VAC40-90-40-B
Description:	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 2, hired 03/30/2022, did not contain verification that a criminal history record report response was obtained. 2. The record for staff 3, hired 07/22/2022, did not contain verification that a criminal history record report response was obtained. 3. The record for staff 6, hired 03/01/2022, did not contain verification that a criminal history record report response was obtained. 4. The record for staff 7, hired 03/10/2022, did not contain verification that a criminal history record report response was obtained. 5. The record for staff 8, hired 08/02/2022, did not contain verification that a criminal history record report response was obtained. 6. Interview with staff 4 indicated that criminal history record reports had not been received on those staff members as of the date of inspection.
Plan of Correction:	Administration will follow up on background check requests prior to the 30th day of employment for all future employees.