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: May 29, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-131 PERSONNEL 22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN?S SERVICES 22VAC40-131 ADDITIONAL REQUIREMENTS FOR SPECIFIC PROGRAMS 22VAC40-191 BACKGROUND CHECKS FOR CHILD WELFARE AGENCIES

Technical Assistance:

22VAC40-131-290.C.9 Discussion regarding leaving no blank items on a physical exam, even if addressed elsewhere.

Comments:

Type of inspection: Monitoring A monitoring inspection was initiated on 5/29/24 and concluded on 6/11/24. The Treatment Director was contacted by telephone to initiate the inspection. The Treatment Director reported that the current census was 5. The inspector emailed the Treatment Director a list of items required to complete the inspection. The inspector reviewed 1 resident record, 1 provider home record, and 2 staff records submitted by the facility to ensure documentation was complete. An exit interview was conducted with the Treatment Director on 6/11/2024 where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during 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 Dawn Espelage, Licensing Inspector at 540-759-8852 or by email at dawn.espelage@dss.virginia.gov

Violations:

Standard #:	22VAC40-131-350-A
Description:	Violation: Based on record review and interview, the agency failed to complete a quarterly review addressing all elements within 90 days of placement for Foster Child (FC)1. Findings: 1) FC1 was placed on 12/14/23. 2) The record contained a quarterly review dated 4/4/24. 3) The quarterly review had no information listed in the diagnoses/medication sections. 4) The quarterly review did not address progress of goals from the original comprehensive service plan. 5) S1 acknowledged the finding.
Plan of Correction:	PM will review all reports for completion prior to signature. Quality Manager will review all docs during monthly chart audits.
Standard #:	22VAC40-191-40-C-1-f
Description:	Violation: Based on record review and interview, the agency failed to obtain national criminal background checks on two household members in PH1 prior to approval. Findings: 1) PH1?s home study indicated two other adults residing in the home at time of application and approval (1/20/24). 2) PH1?s file contained a completed Sworn Statement and Central Registry for HM2. 3) The record did not contain a completed national background check for HM3. 4) PH1?s file contained a completed Sworn Statement and Central Registry for HM3. 5) The file did not contain a completed national background check for HM3. 6) S1 acknowledged the findings.
Plan of Correction:	Treatment Director will complete home licensure staff training with licensing specialist and program managers. PM will review all PH prior to certification.
Standard #:	22VAC40-191-40-D-1-b
Description:	Violation: Based on record review and interview, the agency failed to obtain criminal history and central registry background checks for Staff (S) 2 within 30 days of hire. Findings: 1) S2 was hired on 1/10/24. 2) Items provided from the personnel record included a receipt from the Virginia State Police dated 2/15/24 stating ?no identifiable records?. 3) The agency was provided an opportunity to locate the results letter but no other documentation was provided. 4) The file did not contain a central registry background check. 5) Upon request, a receipt was provided by the agency showing that a record request had been paid for. There was no date on the request and no typed name. 6) The agency was provided additional time to locate the central registry results but none were provided. 7) The findings were discussed at exit.
Plan of Correction:	PM will receive copies of staff checks prior to case assignment.
Standard #:	22VAC40-191-40-D-5
Description:	Violation: Based on record review and interview, the agency failed to obtain a Central Registry Background Check for Household Member (HM) 1 in Provider Home (PH) 1 prior to approval. Findings: 1) PH1 was approved on 1/20/24. 2) The file did not contain a background check for HM1, who was 16 years old. 3) The agency was provided additional time to locate the background check but was unable to find any record that the check had been completed. 4) The finding was discussed at exit.
Plan of Correction:	Quality Manager does monthly chart audits and sends to PM for compliance. PM will staff PH weekly with CM for compliance.