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. 11, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-151 ADMINISTRATION 22VAC40-151 RESIDENTIAL ENVIRONMENT 22VAC40-151 PROGRAMS AND SERVICES

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: January 11, 2024 from 10:50 AM to 3:40 PM. The Acknowledgement of Inspection form was signed and left at the facility on January 11, 2024. Number of residents in care at the beginning of the inspection: 2 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: 3 (includes a discharged resident) Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Staff and Residents records appeared to be well organized. Additional Comments/Discussion: An entrance conference was held on 1/11/24. Reviewed two current residents? records and a discharged resident record. Reviewed to ensure required documentation including background checks were observed in staff records. Other documentation reviewed during this inspection included but was not limited to the following: annual health and fire safety inspections, and activities schedules. Also, reviewed and discussed standards that were the focus of the monitoring inspection onsite visit. The Executive Director and the Program Director were available and accessible during the inspection. An exit meeting was conducted to review the inspection findings on February 5, 2024. 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 Kevin Lassiter, Licensing Inspector at (804) 241-2093 or by email at kevin.lassiter@dss.virginia.gov

Violations:

Standard #:	22VAC40-151-660-H-1
Description:	Violation: Based on review of CR2?s record, the agency failed to clearly show the resident?s involvement in developing the quarterly progress report. Findings: 1) In review of CR2?s record on 1-11-24 it was observed in the record that the Quarterly Progress Report (QPR) due 11-25-23 was filed; however, there was no evidence observed in the record or on the document QPR that demonstrated CR-2?s involvement in developing the quarterly progress report dated 11-25-23. 2) The last page of the quarterly progress report QPR dated for 11-25-23 lists the parties who were involved in the development of the QPR; however, the line item where CR2?s name/signature would be included, was not reflected on the document. 3) The day of the inspection (1-11-24) S3 acknowledged forgetting to involve and review the QPR with CR2 and the legal guardian, and further acknowledge via post-it notes attached to the QPR dated 11-25-23, that the document was ?unsigned by client or parent?and is scheduled to meet with CR2, on tomorrow [1-12-24] to review it.? 4) The day of the inspection (1-11-24), the Licensing Inspector inquired as to whether a written correspondence or any other form of contact was made or sent to CR2 and/or legal guardian to provide input in developing the QPR dated 11-25-23, S3 replied, ?no?. 5) The findings were discussed during the preliminary review and S3 acknowledged the findings.
Plan of Correction:	In the future, should the Program Director be pulled away for an extended period of time due to a family emergency, the Executive Director will follow up with regard to any time sensitive documents being due and will assure the resident?s involvement in developing the Quarterly progress report.
Standard #:	22VAC40-151-660-H-2
Description:	Violation: Based on review of CR2?s record, the agency failed to clearly show the resident?s legal guardian?s involvement in developing the quarterly progress report. 1) In review of CR2?s record on 1-11-24 it was observed in the record that the Quarterly Report due 11-25-23 was filed; however, there was no evidence observed in the record or on the document that demonstrated CR2?s legal guardian?s involvement in the developing the quarterly progress report dated 11-25-23. 2) The last page of the quarterly progress report QPR dated for 11-25-23 lists the parties who were involved in the development of the QPR; however, the line item where the legal guardian?s name/signature would be included, was not reflected on the document. 3) The QPR does indicate CR2?s biological parent?s interaction with CR2 in the ?Family Involvement? section of the document and indicates that the biological parent is also CR2?s legal guardian in the same section. The biological parent is listed as CR2?s legal guardian on the first page of the QPR as well. 4) The day of the inspection (1-11-24) S3 acknowledged forgetting to involve and review the QPR with CR2 and legal guardian, and via post-it notes attached to the QPR dated 11-25-23, that the document was ?unsigned by client or parent?and is scheduled to meet with CR2, on tomorrow [1-12-24] to review it.? 5) The day of the inspection (1-11-24), the Licensing Inspector inquired as to whether a written correspondence or any other form of contact was made or sent to CR2 and/or legal guardian to provide input in developing the QPR dated 11-25-23, S3 replied, ?no?. 6) The findings were discussed during the preliminary review and S3 acknowledged the findings.
Plan of Correction:	In the future, should the Program Director be pulled away for an extended period of time due to a family emergency, the Executive Director will follow up with regard to any time sensitive documents being due and will assure the resident?s legal guardians involvement in developing the Quarterly progress report. A copy was provided to guardian with a request for input. A response has not yet been received.
Standard #:	22VAC40-151-660-I
Description:	Violation: Based on review of CR2?s record, the agency failed to distribute a copy of the quarterly progress report dated 11-25-23 to CR2 and the legal guardian. 1) The last page of the quarterly progress report (QPR) dated for 11-25-23 lists the parties who should receive a copy of the QPR, and as applicable. 2) The column labeled as ?Plan distribution made?, did not reflect that a copy of the document was distributed to CR2 nor CR2?s legal guardian. 3) The QPR does indicate CR2?s biological parent?s interaction with CR2 in the ?Family Involvement? section of the document and indicates that the biological parent is also CR2?s legal guardian in the same section. The biological parent is listed as CR2?s legal guardian on the first page of the QPR dated 11-25-23 as well. 4) The day of the inspection (1-11-24) S3 acknowledged forgetting to involve and review the QPR with CR2 and the legal guardian, and further acknowledged via post-it notes attached to the QPR dated 11-25-23, that the document was ?unsigned by client or parent?and is scheduled to meet with CR2, on tomorrow [1-12-24] to review it.? 5) The findings were discussed during the preliminary review and S3 acknowledged the findings.
Plan of Correction:	In the future, should the Program Director be pulled away for an extended period of time due to a family emergency, the Executive Director will follow up with regard to any time sensitive documents being due and will assure distribution of the quarterly report to both resident and legal guardian. 1-12-24 (resident) & A copy was provided to guardian with a request for input. A response has not yet been received.