VIRGINIA DEPARTMENT OF SOCIAL SERVICES

People Places, Inc.
1215 N. Augusta Street
Staunton, VA 24401
(540) 885-8841

Current Inspector: Kevin Lassiter (804) 241-2093

Inspection Date: Dec. 14, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-131 ORGANIZATION AND ADMINISTRATION 22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN?S SERVICES

Comments:

An unannounced non-mandated investigation was completed on 12/14/2023 from 11:07am. to 1:55 p.m. The Acknowledgement of Inspection form was signed and a preliminary finding was held on the same day of 12/14/2023. Number of children in care: 31 Number of approved provider homes: 36 Number of children?s records reviewed: 1 Number of provider homes reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting was held February 14, 2024 A self-reported incident was received by VDSS Division of Licensing on November 2, 2023 regarding a serious incident report. The evidence gathered during the investigation 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 #:	22VAC40-131-40-B
Description:	Violation: Based on review of the agency?s Medication Use, Disbursement, and Storage Policy, the agency failed to comply with its own policies and procedures. 1) In review of FC1?s record on 12-14-23 it was observed in the record that FC1 gained access to a nonprescription medication due to the nonprescription medication not stored in a locked area, out of reach of FC1. 2) It was noted by staff in case note dated 11-2-23, that though [nonprescription] ?(vitamins & supplements) are not required to be locked but should be kept out of the reach of children, especially if there is concern that they might access them?it was determined that FP1 followed medication policy but was not as diligent as the team had recently been asking?? 3) However, according to the agency?s own policy, ?Prescribed and non-prescribed medication are stored separately from food in a locked area out of reach of children?.
Plan of Correction:	Action Step 1: Provide training to all current and future TFC staff members covering: ? Diligent supervision practices for higher risk individuals ? Review of PPI?s Medication Use, Disbursement and Storage Policy including requirement to lock all prescription and non-prescription medication, including over the counter medications such as pain relievers, vitamins, supplements, cough suppressant and antihistamines. Completion Date: 4/15/2024, ongoing training provided to new staff via Relias Learning System platform. Responsible Parties: TFC Supervisors Action Step 2: Provide training to all Teaching Parents covering: ? Diligent supervision practices for higher risk individuals ? Review of PPI?s Medication Use, Disbursement and Storage Policy including requirement to lock all prescription and non-prescription medication, including over the counter medications such as pain relievers, vitamins, supplements, cough suppressant and antihistamines. Completion Date: 5/31/2024 Responsible Parties: Teaching Parent Coordinators Action Step 3: Update agency Pre-Service Training on diligent supervision practices for higher risk individuals, and appropriate OTC medication storage. Completion Date: 5/15/2024 Responsible Parties: Regional Directors Action Step 4: Incorporate updated information on ensuring appropriate OTC medication storage per PPI?s Medication Use, Disbursement and Storage Policy into each Quarterly Home Checklist form completed by Family Consultants. Completion Date: 5/31/2024 Responsible Parties: Regional Directors, TFC Supervisors, Family Consultants
Standard #:	22VAC40-131-190-V
Description:	Violation: Based on review of the record, the agency failed to keep a nonprescription medication in a locked area, out of the reach of FC1. Findings: 1) In review of FC1?s record on 12-14-23 it was observed in the record that FC1 gained access to a non-prescription medication due to the non-prescription medication not stored in a locked area, out of reach of FC1. 2) It was noted by staff in case note dated 11-2-23, that though [nonprescription] ?vitamins & supplements are not required to be locked but should be kept out of the reach of children, especially if there is concern that they might access them?it was determined that FP1 followed medication policy but was not as diligent as the team had recently been asking?? 3) According to the agency?s own policy, ?Prescribed and non-prescribed medication are stored separately from food in a locked area out of reach of children?. 4) The record of FC1 included a Serious Incident Report dated 11-2-23, documenting the series of events that led to a higher level of care and treatment for FC1. 5) The findings were discussed and acknowledged during the preliminary review with S1, S4 & S5.
Plan of Correction:	Action Step 1: Provide training to all current and future TFC staff members covering: ? Diligent supervision practices for higher risk individuals ? Review of PPI?s Medication Use, Disbursement and Storage Policy including requirement to lock all prescription and non-prescription medication, including over the counter medications such as pain relievers, vitamins, supplements, cough suppressant and antihistamines. Completion Date: 4/15/2024, ongoing training provided to new staff via Relias Learning System platform. Responsible Parties: TFC Supervisors Action Step 2: Provide training to all Teaching Parents covering: ? Diligent supervision practices for higher risk individuals ? Review of PPI?s Medication Use, Disbursement and Storage Policy including requirement to lock all prescription and non-prescription medication, including over the counter medications such as pain relievers, vitamins, supplements, cough suppressant and antihistamines. Completion Date: 5/31/2024 Responsible Parties: Teaching Parent Coordinators Action Step 3: Update agency Pre-Service Training on diligent supervision practices for higher risk individuals, and appropriate OTC medication storage. Completion Date: 5/15/2024 Responsible Parties: Regional Directors Action Step 4: Incorporate updated information on ensuring appropriate OTC medication storage per PPI?s Medication Use, Disbursement and Storage Policy into each Quarterly Home Checklist form completed by Family Consultants. Completion Date: 5/31/2024 Responsible Parties: Regional Directors, TFC Supervisors, Family Consultants