VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Frontier Health
1431 Duff-Patt Highway
Addington Hall
Duffield, VA 24244
(276) 431-4370

Current Inspector: Jamie Morgan (276) 525-5656

Inspection Date: Nov. 17, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-131 ORGANIZATION AND ADMINISTRATION 22VAC40-131 PERSONNEL 22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN'S SERVICES 22VAC40-131 ADDITIONAL REQUIREMENTS FOR SPECIFIC PROGRAMS 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 63.2 General Provisions. 22VAC40-191 Background Checks for Child Welfare Agencies

Comments:

An unannounced renewal inspection was conducted on November 13, 2019 from 9:38 AM - 3:00 PM. VALUES reports a total of 2 provider homes and 2 foster children in placement. During this inspection, one provider home record, two foster child records (one current and one discharged youth), three Board Officer records, and three personnel records were reviewed. Two personnel were interviewed during the inspection. An exit interview was conducted at the conclusion of the inspection with the Executive Director to review preliminary inspection findings. An acknowledgement form was signed. There were six violations. Upon the 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 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 #:	22VAC40-131-110
Description:	Violation: Based on a review of the record for a foster child (FC1) and interview with personnel (S5), the agency failed to ensure that materials and information received by the licensee indicate the date received. Evidence: 1. The DSS service plan, documentation of medical and dental visits, CANS, application, and records from a prior placement did not indicate the date received. 2. S5 acknowledged that a the documentation did not indicate the date received.
Plan of Correction:	Stamps have been ordered and instructions given to all VALUES staff, including clerical staff at Addington Hall that information must be stamped when received.
Standard #:	22VAC40-131-250-I
Description:	Violation: Based on a review of the record for a foster child (FC1) and interview with personnel (S5), the agency failed to consider the elements required by 22VAC40-131-250.O.1-4 when making the decision whether to place a child in the foster home. Evidence: 1. The record for FC1 did not demonstrate consideration of the following information when making the placement decision: -250.I.1: The prospective foster family's specific skills, abilities, and attitudes necessary to (1) effectively work with the child: (ii) ensure implementation of the child's services plan; and (iii) provide effective behavior support techniques, crisis intervention, crisis stabilization, and supportive counseling, -250.I.2: The prospective foster family's ability to meet the needs and preferences of the child; -250.I.3: The prospective foster family's willingness to access resources required to meet the needs of the child; and -250.I.4: The prospective foster family's willingness and ability to work with the child's family. 2. S5 acknowledged that the foster parent/child matching documentationdid not address the components listed in 22VAC40-131-250.I.1-4.
Plan of Correction:	VALUES staff were doing an addendum as children are placed in foster homes but addendum did not contain all bullet points in 250.I. A note has been attached with the required elements.
Standard #:	22VAC40-131-250-M
Description:	Violation: Based on review of the record for a foster child (FC1) and interview with personnel (S5), the agency failed to prepare the child for placement and arrange a preplacement visit for the child in the prospective home. Evidence: 1. The Intake Assessment for FC1 stated that FC1 was referred eleven days prior to placement and accepted six days prior to placement. 2. The agency failed to provide preparation for FC1 and to arrange a preplacement visit. 3. S5 acknowledged that the placement did not meet the definition of an emergency placement and that a pre-placement visit did not occur.
Plan of Correction:	Attempts were made to do a pre-placement visit but VALUES staff had not documented these events properly. A note is attached showing the sequence of events and reasoning for not doing a pre-placement visit. However, it should be noted that all reasonable efforts will be made in the future regardless of logistics difficulties.
Standard #:	22VAC40-191-40-D-1-a
Description:	Based on background checks reviewed for board officers (BO) and interview with personnel (S5), the licensee failed to ensure background checks were completed on new individuals designated as an applicant within 30 days of the designation. Findings: 1. Board Officers (BO1, BO2, and BO3) were appointed as officers of the corporation on 01/01/2019. 2. The files of BO1, BO2, and BO3 did not contain a central registry finding. 3. The sworn statement or affirmations for BO1, BO2, and BO3 were dated more than 30 days after appointment. 4. The search of the criminal history record checks for BO1, BO2, and BO3 were dated more than 30 days after appointment. 5. The criminal history reports in the record for BO1, BO2, and BO3 were not completed according to the processes outlined in the Code of Virginia 63.2-1721.B.2. 6. S4 acknowledged that the files for BO1, BO2, and BO3 contained sworn statements or affirmations dated more than 30 days after appointment, did not contain central registry findings, criminal history reports were obtained more than 30 days after the date of appointment. 7. S4 acknowledged that the criminal history checks completed for the board officers were not issued by the Central Criminal Records Exchange, Department of State Police as referenced in 63.2-1721.B.
Plan of Correction:	Sworn Disclosures, Central Registry Checks and Criminal History checks were conducted as soon as it was made known to the new VALUES management team that this was necessary. The previous VALUES Program Coordinator did not do checks on BOD members at the last license renewal (2017) therefore this new staff assumed those were not necessary. Corrective action to be taken: 1) Executive Director is now aware of the standards and will not rely on past actions of previous administrators; 2) Checks will be done timely as set out by the standards, Executive Director has implemented a spreadsheet that list current background check information on every individual currently employed by or associated with VALUES and their next due dates for the next several 3 year cycles in an effort to assure checks are timely; 3) Criminal History Checks will be conducted through the Department of Social Services and not Behavioral Health, although these BOD members were cleared by the FBI and VA state police as having no criminal record. 2 of the Central registry checks for BOD members are attached as they came in after the site visit. We are still waiting on one Central Registry check on 1 board member. It will be submitted as soon as it arrives. Attached is also a list sent to Human Resources regarding what is required so that these mistakes are not made again.
Standard #:	22VAC40-191-40-D-1-b
Description:	Violation: Based on a review of the personnel file for employees (S3, and S4) and interview with personnel (S5), the agency failed to obtain required background checks before 30 days of employment at the facility ended. Evidence: 1. The criminal history record check for S3 was dated 73 days after the date of hire. S5 acknowledged that this check was not completed within 30 days of hire for S3. 2. The agency did not follow the correct process for obtaining the criminal history record check for S3 as defined by 62.2-1721.B.2 of the Code of Virginia. S5 acknowledged that the check was not processed by the Central Criminal Records Exchange, Department of State Police. 3. The agency did not follow the correct process for obtaining the criminal history record check for S4 as defined by 62.2-1721.B.2 of the Code of Virginia. S5 acknowledged that the check was not processed by the Central Criminal Records Exchange, Department of State Police.
Plan of Correction:	All checks were completed but not timely on S3. Executive Director is more educated on standard with regard to timeliness and appropriate processes for new hires. As for S4, all checks were done, including fingerprinting prior to allowing this staff to start as is Frontier Health policy. The Human Resources staff that registered and sent S4 to do printing is no longer with the company and HR is trying to track these prints. S4 remembers going for fingerprinting as well as to the Scott County Sheriff's Department. We only did fingerprinting and not a state police check, in that, it was misunderstood that fingerprinting which checks FBI and State police was sufficient. It has been noted that it is not. A Criminal History Check is being done today via the DSS website and fingerprinting scheduled to re-do.
Standard #:	22VAC40-191-40-D-1-c
Description:	Violation: Based on a review of the personnel file for an employee (S2) and interview with personnel (S5), the agency failed to obtain a central registry search, or criminal history record check within three years of the previous checks. Evidence: 1. S5 provided a copy of the search of central registry and criminal history record check for S2 via email on 11/20/2019. 2. The central registry check and criminal history record check for S2 was dated over three years ago. 3. S5 acknowledged that the central registry search and criminal history record check for S2 are dated more than three years ago and have not been resubmitted. S5 stated that she was unaware that repeat checks were required for this position.
Plan of Correction:	A new Central Registry Check was submitted prior to site visit but results were not in at the time of the visit and are still not in. As stated above Executive Director is more aware of the standards and has implemented a spreadsheet to better monitor. It was not known, based on the actions of the previous Program Coordinator that background checks needed to be maintained as they were not done at the last license renewal in 2017. However, as stated earlier Executive Director will no longer go on the actions of the past management but on newly obtained knowledge of the standards. A Criminal History Check is being done via DSS website today and fingerprinting scheduled.