VIRGINIA DEPARTMENT OF SOCIAL SERVICES

StepStone Family & Youth Services
2965 Colonnade Dr
Ste. 130
Roanoke, VA 24018
(540) 394-7110

Current Inspector: Dawn Espelage (540) 759-8852

Inspection Date: June 19, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-131 ORGANIZATION AND ADMINISTRATION 22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN'S SERVICES 22VAC40-131 ADDITIONAL REQUIREMENTS FOR SPECIFIC PROGRAMS

Comments:

An unannounced inspection was conducted on 06/19/2019 from 11:38 AM to 3:25 PM in response to a complaint that was received by the licensing office on 05/30/2019. The complaint involved provision of and consent for treatment and monitoring of the provider home. A follow-up inspection and interview of staff was scheduled and conducted on 06/27/2019 from 9:20 AM - 1:28 PM. One provider home record and three children's records were reviewed. Two staff were interviewed regarding treatment and services provided to the youth and placement of youth in the provider home. Seven violations were cited as a result of the investigation; therefore, the complaint is determined to be valid. At the time of the inspection, Braley and Thompson reported seven (7) provider homes and eight (8) children in placement. An exit interview was conducted with the Program Manager and Team Leader on June 27, 2019 to discuss the results of the inspection. An acknowledgement form was signed. Upon the receipt of the violation notice, the licensee should identify the necessary corrective action and develop a plan of correction for each violation. The plan of correction should include the following: The steps to correct noncompliance with the standard(s); measures to prevent re-occurrence of noncompliance; person(s) responsible for implementation and monitoring of preventative measure(s); and date by which noncompliance will be corrected. The licensee has five (5) calendar days from receipt of the inspection documentation to complete the section titled Plan of Correction, sign each page of the documentation and return it to the Licensing Office. The licensee should retain a copy to be posted at the facility. Results of the inspection documentation are subject to public disclosure and will be posted on the VDSS web site within 5 days, regardless of whether the Plan of Correction is completed.

Violations:

Standard #:	22VAC40-131-40-B
Complaint related:	No
Description:	Violation: Based on a review of the record for Provider Home 1 (PH1), Foster Child 1 (FC1) and interview with Staff 1 (S1), the licensee failed to follow its own policies and procedures. Evidence: 1. Placement agreement for FC1 in PH1 contained the following understanding of the legal guardian: "I/we retain legal guardianship of the child including all written consents, decisions, or responsibilities therein". 2. The Licensee's Policy and Procedures Manual: Service Element - Written Informed Consent states: "It is the policy of Braley & Thompson, Inc. to obtain written informed consent for medication from the legal guardian at the time of admission..." and Procedures: 2. "The signed Agency Terms of Admission will serve as the written informed consent for the use of medication that is prescribed by the foster child/youth's attending physician." 3. The Terms of Admission signed by the licensee and legal guardian at the time of FC1's admission did not contain an element granting the licensee permission to consent for routine medical care and treatment. 4. FH1 signed consents for medication at a psychiatric intake appointment for FC1. 5. Staff 1 (S1) acknowledged that the Agency Terms of Admission did not contain a provision in which the legal guardian consented for the licensee to consent to medication. S1 stated that the "language" of the agreement only addressed emergency treatment.
Plan of Correction:	All staff will be retrained on the Medication Policy of the agency and the importance of following the policy as written to guarantee Best Practice and safety for the consumers. Per the Agency Policy and Procedures, the agency Terms of Admission Form will be revised to include a statement that the guardian gives permission through this signed written informed consent, for the use of medication that is prescribed by the foster child/youth's attending physician. All staff will be retrained to obtain the signed authorization at the time of placement for each youth.
Standard #:	22VAC40-131-230-A
Complaint related:	No
Description:	Violation: Based on a review of the record for provider home 1 (PH1) and an interview with staff 1 (S1), the agency failed to visit the home to monitor the performance of the provider every 90 days. Evidence: 1 1. A Foster Parent Evaluation form for PH1 was completed on 10/4/2018. This is the form used by the licensee for foster parent monitoring. A subsequent Foster Parent Evaluation form was completed on 01/16/2019; 104 days later. 2. The record did not contain a Foster Parent Evaluation form for a monitoring visit within 90 days of the 01/16/2019 visit. 3. Staff 1 and staff 2 (S1, S2) agreed that documentation of a provider monitoring visit was not in the record.
Plan of Correction:	Team Lead and Program Manager will develop spread sheets of due dates for all reports including foster parent evaluations to ensure they are completed within 90 days ongoing. All staff will attend a mandatory compliance training.
Standard #:	22VAC40-131-230-H
Complaint related:	No
Description:	Violation: Based on review of the record for provider home 1 (PH1) and interview with staff 1 (S1), approval certificate failed to contain the licensee's recommendations regarding the number of children that the home can successfully handle as stated in the re-evaluation; required element by 22VAC40-131-230-F-4. Evidence: 1. The foster home re-evaluation for provider home 1 (PH1) listed the maximum number of placements for the provider home as four (4). The certificate of approval signed the same date as the re-evaluation lists the maximum number of placements for the provider home (PH1) as six (6). The certificate did not reflect the recommendations for number of children as documented in the re-evaluation narrative.
Plan of Correction:	Team Lead and Program Manager/Compliance staff will audit all new foster parent charts as well as recertifications to ensure that all documents indicate the same number of placements for the provider home. All staff will attend compliance training.
Standard #:	22VAC40-131-240-B
Complaint related:	No
Description:	Violation: Based on a review of the record for provider home 1 (PH1) and interview with staff 1 (S1), a written justification approved by a child-placing supervisor prior to the placement of additional children was not completed. Evidence: 1. The provider home record for PH1 contained the Foster Parent and Youth Matching Form of previously-placed youth (FC2, FC3). Foster child 2 and 3 (FC2, FC3) were placed in provider home 1 (PH1) while foster child 1 and her two siblings were in placement, bringing the total number of children placed to 5. 2. A written justification was not completed. 3. Staff 1 agreed that a written justification was not completed.
Plan of Correction:	Team Lead and Program Manager will complete monthly audits of files to ensure that all forms are completed to include the Foster Parent and Youth Matching Form when additional children are placed in a home that already has 2 or more placements.
Standard #:	22VAC40-131-340-K
Complaint related:	No
Description:	Violation: Based on a review of the record for foster child 1 (FC1) and interview with staff 1 and staff 2 (S1, S2), the agency failed to provide of copy of the child's quarterly progress report to the custodial placing agency. Evidence: 1. There was no documentation in the file of foster child 1 (FC1) that the custodial agency received copies of the quarterly report. 2. The final page of the quarterly summary report contains boxes which are checked to indicate individuals to whom the licensee provided copies of the report. Staff 2 (S2) stated that she "forgot to check the box" which verifies that a copy was provided to the custodial agency.
Plan of Correction:	Team Lead and Program Manager will complete monthly audits of files to ensure that all boxes are checked on the last page of the quarterly summary report which indicated whom the licensee provided copies of the report to. All staff will attend compliance training.
Standard #:	22VAC40-131-350-B-11
Complaint related:	No
Description:	Violation: Based on a review of the record for foster child 1 (FC1) and interview with staff 2 (S2), the licensee failed to address a list of medication used by the child in the quarterly progress summary. Evidence: 1. The physician ordered a medication to address medical needs of the child during the reporting period of the quarterly progress summary. The medication was not listed in the report. 2. Staff 2 (S2) stated that this was oversight due to the medication being an over-the-counter medication.
Plan of Correction:	Team Lead and Program Manager will complete monthly audits of files to ensure that all medication sincluding short term and over the counter medications are addressed and listed in all quarterly reports . All staff will attend a mandatory training.
Standard #:	22VAC40-131-350-B-7
Complaint related:	No
Description:	Violation: Based on a review of the record for foster child 1 (FC1) and interview with staff 1 and staff 2 (S1, S2), the agency failed to address new needs of the child by failing to add new goals and objectives and target dates for accomplishment in the quarterly progress summary as required by 22VAC40-131-350-B-7. Evidence: 1. The Written Assessment, Individual Comprehensive Treatment and Service Plan and Progress Summary Report, 90 day behavioral and emotional summary of progress sections in the 90 Day Progress Summary Report and Comprehensive Treatment and Service Plan Update, assessment by a private provider, contact notes, Home Visit Progress Notes, a VEMAT, and Monthly Reviews in the record of foster child 1 (FC1) documented new needs of the child. The new needs were not addressed by the addition of new goals and objectives and target dates in the 90 day progress summary report and comprehensive treatment service plan update for foster child 1 (FC1). 2. Staff 1 and staff 2 (S1, S2) agreed that the new needs and behaviors were not addressed in the goals and objectives included on the quarterly progress summary dated 12/24/2018.
Plan of Correction:	Team Lead and Program Manager will review all Written Assessments, Individual Comprehensive Treatment and Service Plans and Progress summaries reports to ensure all needs are being addressed and or addition of new goals and objectives are documented in such reports. In addition, all staff will attend a mandatory compliance training.