VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Essex House
17976 Tidewater Trail
Tappahannock, VA 22560
(804) 443-5921

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: Nov. 1, 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 ?2 2VAC40-73 EMERGENCY PREPAREDNESS

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility: 11/1/22, 10:15-11:30 am 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: 9 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: resident/staff interaction, postings, medication storage Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standards or law, and violations 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 Yvonne Randolph, Licensing Inspector at (804) 662-7454 or by email at yvonne.randolph@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on a review of four resident files, the facility failed to obtain the results of a risk assessment, documenting the absence of tuberculosis in a communicable form for one resident. Evidence: The results of a risk assessment was not found for resident 1.
Plan of Correction:	Risk Assessment was obtained on Resident #1 after 4 attempts.
Standard #:	22VAC40-73-450-E
Description:	Based on a review of four resident files, individualized service plans were not signed and dated by the resident or the resident?s responsible party or legal representative. Evidence: The service plans for residents 1 and 3 did not have the signature of the resident or the resident?s responsible party or legal representative.
Plan of Correction:	ISP was reviewed with POA of Resident 1 on 11 /1 /22 via phone. Will get his signature on next visit. ISP was reviewed with Resident 3 and POA on 11/1/22 via phone. Will get his signature on next visit.