VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Henry and William Evans Home
330 East Leicester Street
Winchester, VA 22601
(540) 662-8520

Current Inspector: Kevin Lassiter (804) 241-2093

Inspection Date: Jan. 30, 2023 and Feb. 7, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-151 Administration 22VAC40-151 Residential Environment 22VAC40-151 Programs and Services 22VAC40-151 Programs and Services 22VAC40-151 Disaster or Emergency Planning

Technical Assistance:

Discussed monitoring and evaluating service quality and service effectiveness on a systematic and ongoing basis as noted in the ?Standards for Licensed Children?s Residential Facilities? - 22 VAC 40-151-120.D. Discussed discharge information as noted in the ?Standards for Licensed Children?s Residential Facilities? - 22 VAC 40-151-680.E. Discussed the annual review of behavior intervention techniques, policies and procedures as noted in the ?Standards for Licensed Children?s Residential Facilities? - 22 VAC 40-151-840.K.

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: 1/30/23 from 2:15 PM ? 4:35 PM and 1/31/23 from 9:43 AM ? 5:19 PM. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents in care at the beginning of the inspection: 3 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident?s records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Additional Comments/Discussion: An entrance conference was held on 1/30/23. Reviewed a current resident record and a discharged resident record. Reviewed medication administration records for both residents. Two discrepancies were found with the CRF matrix, which will be shared with the IV-E unit for follow-up. Other documentation reviewed during this inspection included, but was not limited to the following: emergency drill documentation, menus, staff work schedules, and daily log entries. The Executive Director and the Program Director were available and accessible during the inspection on both dates. Both were interviewed on 1/31/23 in order to seek clarification about several documents that were reviewed. An exit meeting was conducted on 2/7/23 to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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 Michele Freeman, Licensing Inspector at (804) 662-7062 or by email at michele.freeman@dss.virginia.gov.