VIRGINIA DEPARTMENT OF SOCIAL SERVICES

KidsPeace National Centers of North America, Inc.
7631 Hull Street Road
N. chesterfield, VA 23235
(804) 745-2153

Current Inspector: Kevin Lassiter (804) 241-2093

Inspection Date: Oct. 8, 2019 and Oct. 9, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-131 PERSONNEL 22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN'S SERVICES 63.2 General Provisions.

Technical Assistance:

Technical assistance provider regarding improving internal processes related to standard 22VAC40-131-40-access to records and standard 22VAC40-131-210-corporal punishment and confidentiality requirements to home providers.

Comments:

An unannounced monitoring inspection was conducted on October 8, 2019 from 8:40 am to 4:30 pm and October 9, 2019 from 8:40 am to 4:30 pm at Kids Peace, Inc. The agency reports thirty-seven (37) children in care and twenty-seven (27) approved provider homes. During this inspection, the following actions were taken: 1.Reviewed four (4) complete children records. 2.Reviewed three (3) complete provider home records. 3.Reviewed six (6) additional new provider records (background only). 4.Reviewed three (3) new employee records 5.Reviewed background checks for all board officers. 6.A physical plant inspection was conducted. 7.Interviews were conducted. An exit interview was conducted with the Program Director at 2:30 pm on October 9, 2019 to discuss preliminary inspection findings. An acknowledgement form was signed and left onsite. There were nine (9) citations for violations of the Standards for Child Placing Agencies. Please see the violation notice on the Department's web site for violations of the Standards. Upon receipt of the violation notice, the licensee must develop a plan of correction for each violation. The plan of correction must include the following: the steps to correct non-compliance with the standard(s); measures to prevent re-occurrence of non-compliance; person(s) responsible for implementation and monitoring of preventative measure(s); and date by which non-compliance will be corrected. The licensee has five (5) calendar days from receipt of the inspection documentation to complete the section entitled "Plan of Correction", sign each page of the Plan of Correction and return it to the Licensing Office. The licensee retains a copy to be posted at the facility. Results of the inspection are subject to public disclosure and will be posted on the VDSS web site within five (5) days, regardless of whether or not the Plan of Correction has been completed.

Violations:

Standard #:	22VAC40-131-180-J-2
Description:	22VAC40-131-180.J.2.d Violation: Based on an interview with an agency representative and based on the review of the records for FH1, FH2 and FH3, the licensee failed to document a list of the names and roles of each individual involved in completing the home study. Evidence: (1)The foster home provider record (FH-1, FH2 and FH3) contained documentation of signatures of the person completing the home study but failed to document the names and roles of each individual involved in completing the home study. (2)During the exit interview, AR1 reviewed the foster home provider records and acknowledged that the names and roles of the individuals completing the home study is not being documented for FH1 and FH2. 22VAC40-131-180.J.2.e Violation: Based on an interview with an agency representative and based on the review of the record for FH1, FH2 and FH3, the licensee failed to document a summary of content information from interviews. Evidence: (1)The foster home provider records (FH-1, FH2 and FH3) contained dates of interviews with the foster parents with no documentation of a summary of content information from the interviews. (2)During the exit interview, AR1 reviewed the foster home provider record and determined that there was no summary documented of interviews with the foster parent in the FH records. 22VAC40-131-180.J.2.g (A-1) Violation: Based on an interview with an agency representative and based on the review of the record for FH3, the licensee failed to document signed and dated confidentiality statements for applicants of FH3. Evidence: (1)The foster home provider record (FH3) did not contain signed and dated confidentiality statements for applicants of FH3. (2)During the exit interview, AR1 reviewed the foster home provider record (FH3) and determined that the signed and dated confidentiality statements for applicants of FH3 were not in the record.
Plan of Correction:	Program manager will review this standard with Family Resource Specialists and will ask them to write their title next to their names until the E H R can be updated to also include their role. Program manager will review this standard with Family Resource Specialists and will ask them to include this in new home studies that they complete after 10/15/2019. Program manager will speak with IT department to add this into the current home study in the E H R system. Program manager will review this standard with the Family Resource Specialists and they will include the actual policy in the E H R system and not just the sign off stating that they received it.
Standard #:	22VAC40-131-260-B-4
Description:	Violation: Based on an interview with an agency representative and based on the review of the foster child (FC) record for FC1, the licensee failed to document the child?s family?s structure, relationships and involvement with the child. Evidence: (1)The social history located in the foster child record for FC1 did not contain documentation of the child?s family?s structure, relationships and involvement with the child. (2)During the exit interview, AR1 reviewed the foster child record and acknowledged that the social history for FC1 did not contain documentation of the child?s family?s structure, relationships and involvement with the child.
Plan of Correction:	Program manager will ensure that the correct documents are being reviewed. Program manager will also ensure that this standard is met on all future social histories (biopsychosocial and addendum to biopsychosocial) completed.
Standard #:	22VAC40-131-290-C
Description:	Violation: Based on interviews and based on the review of the foster child (FC) record for FC4, the licensee failed to document a medical examination that contained all of the required elements. Evidence: (1)The medical exam located in the record for FC4 did not contain the following required areas: signature and title of examiner, growth and development, visual acuity, auditory acuity, allergies, including food and medication allergies, disabilities and evidence of freedom from communicable diseases. (2)During the exit interview, AR1 carefully reviewed the record and determined that the medical examination located in the record for FC4 did not contain the following areas: signature and title of examiner, growth and development, visual acuity, auditory acuity, allergies, including food and medication allergies, disabilities and evidence of freedom from communicable diseases.
Plan of Correction:	Program Manager will review medical documentation once received to ensure that it meets requirements. Family consultants will review current medical documentation and ensure that medical exams are completed on KidsPeace forms to ensure compliance.
Standard #:	22VAC40-131-290-C-12
Description:	Violation: Based on an interview with an agency representative and based on the review of the foster child (FC) record for FC1, the licensee failed to document a copy of the record of immunizations the child has received since his last examination. Evidence: (1)The foster child record for FC1 did not contain an immunization record for FC1. (2)During the exit interview, AR1 reviewed the foster child record and acknowledged there was no immunization record in the record for FC1.
Plan of Correction:	FC1 just completed his 30 days of care within KidsPeace at the time of the licensing review and Program Manager has asked Family Consultant to upload the immunization record from DSS agency into the E H R system in a timely manner.
Standard #:	22VAC40-131-290-L-1
Description:	Violation: Based on an interview with an agency representative and based on a review of the Foster Home Provider?s Record for Foster Home (FH) 1, the licensee failed to document a medical examination administered and signed by a license physician, his designee, or an official of a local health department. Evidence: (1)The foster home provider record (FH-1) did not contain a medical examination. (2)During the exit interview, AR1 carefully reviewed the electronic record for FH1 and was not able to locate a medical examination for this foster parent. During this interview, AR1 acknowledged that there was no medical examination administered and signed by a license physician, his designee, or an official of a local health department located in the record for FH1.
Plan of Correction:	Program manager will review this standard with Family Resource Specialists to ensure that this does not occur again. If applicable, Family Resource Specialist will obtain a physical exam on FH1 to get into compliance.
Standard #:	22VAC40-131-330-G-4
Description:	Violation: Based on an interview with an agency representative and based on the review of the foster child record for FC2, the licensee failed to document an interview with the child privately at least one time each month for the month of July 2019. Evidence: (1)The foster child record for FC2 did not contain documentation of a private interview for the month of July 2019. (2)During the exit interview, AR1 reviewed the documentation located in the record for FC2 and could not locate a private face to face interview with FC2 in the record. Violation: Based on an interview with an agency representative and based on the review of the foster child record for FC3, the licensee failed to document an interview with the child privately at least one time each month for the month of July 2019. Evidence: (1)The foster child record for FC3 did not contain documentation of a private interview for the month of July 2019. (2)During the exit interview, AR1 reviewed the documentation located in the record for FC3 and could not locate a private face to face interview with FC3 in the record.
Plan of Correction:	Program manager will review this standard with Family Consultants and will ensure that they complete a private session at least once a month with each child and document it.
Standard #:	22VAC40-131-340-B-1
Description:	Violation: Based on an interview with an agency representative and based on the review of the foster youth records (FC1, FC2 and FC3), the licensee failed to complete individualized service plans that included specific measurable objectives and strategies describing services to be provided to the children. Evidence: (1)The foster child records for FC1, FC2 and FC3 did not contain individualized service plans that included specific measurable objectives and strategies describing services to be provided to the children. The objectives were 1-2 words and were not measurable. The strategies were 1-2 words and did not fully describe the services to be provided. (2)During the exit interview, AR1 reviewed the foster parent records and determined that the objectives for FC1, FC2 and FC3 were not measurable. AR1 acknowledged that strategies could provide additional details which would describe services to be provided to the children.
Plan of Correction:	Program manager will review this standard with those completing the individualized service plans and will ensure that the objectives are specific and measurable.
Standard #:	22VAC40-131-340-E-3
Description:	22VAC40-131-340.E.3.a Violation: Based on an interview with an agency representative and based on the review of the foster youth (FY) record (FY2 and FY4), youth over the age of 14, the provider failed to complete individualized service plans that included specific independent living services to be provided to assist the youth in meeting his goals. Evidence: (1)The foster youth?s record contained individualized service plans and service plan updates that did not include specific independent living services to be provided to assist the youth (FY2 and FY3) in meeting his goals. (2)During the exit interview, AR1 reviewed the service plans for FY2 and FY4 and acknowledged that the plans did not include specific independent living services to be provided to assist the youth (FY2 and FY3) in meeting his goals. During this discussion, AR1 expressed an understanding of compliance in this area and discussed a plan to come into compliance in this area.
Plan of Correction:	Program Manager will ensure that Family Consultant?s add an independent living goal to all 14+ children in care on their next service plan reviews.
Standard #:	22VAC40-131-370-F
Description:	Violation: Based on the review of 9 provider home records and interview with AR1 and AR2, files were determined to be in a non-uniformed and unorganized manner. Findings: (1)Foster Home Provider records for FH 3 thru 9 were unorganized as evidenced by required documentation (i.e. background check results, medical clearances and other documentation) located in a "file folder" on AR2's desk and at the time of the audit not a part of the electronic record. This documentation was completed more than 30 days prior to this inspection. (2)Required background checks for FH's 1-2 were located in the electronic file was located in several different sections of the electronic file "member information section" and "home requirements" section of the electronic record. During the interview, AR1 and AR2 reported that their internal policies is to file this information under "member information" section. However, some records information was filed under "home requirements" or elsewhere and some was filed in "member information," in a non-uniformed manner. (3)During the exit interview, AR1 acknowledged that the records were not organized and were not in a uniformed manner.
Plan of Correction:	Program manager will work with IT department and KidsPeace as a whole to ensure that files will be in a uniformed and organized manner n the E H R. Program manager will develop a system to audit on a regular basis to ensure documentation is in the E H R system.