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. 30, 2023 and Dec. 4, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-131 GENERAL PROVISIONS 22VAC40-131 ORGANIZATION AND ADMINISTRATION 22VAC40-131 PERSONNEL 22VAC40-131 PROGRAM STATEMENT 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:

22VAC40-131-330.B Discussion regarding detailed information in reference to foster children?s visitation and communication with birth families. 22VAC40-191-10 Discussion regarding staff considered involved in day-to-day operations. 22VAC40-80-160.D A discussion will be held regarding reasonable opportunity to review records.

Comments:

Type of inspection: Renewal An unannounced, mandated renewal inspection was completed on 11/30/2023 from 12:15 p.m. to 3:45 p.m. and virtually 12/4/23 as documents were e-mailed. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. An exit was held on 12/8/2023. Number of children in care: 11 Number of approved provider homes: 7 The licensing inspector completed a tour of the physical plant that included the office setting and conditions. Number of children?s records reviewed: 2 Number of provider home records reviewed: 1 Number of staff records reviewed: 4 Number of interviews conducted with staff: 1 in person, 1 via e-mail Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. 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 #:	22VAC40-131-160-B-5
Description:	Violation: Based on record review and interview, the agency failed to maintain annual performance evaluations for Staff 1 (S1) and S2. Findings: 1) S1?s personnel record contained a performance evaluation dated in 2019. 2) S2?s personnel record contained a performance evaluation dated in 2019. 3) The agency was given an opportunity to check other records to see if more recent performance evaluations had been completed. 4) S3 acknowledged that the performance evaluations were behind and the agency had a target date in December 2023 to have all completed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-290-L-1
Description:	Violation: Based on record review and interview, the agency failed to obtain a medical exam on Provider Home 1 (PH1) addressing their mental and physical condition in relation to their ability to take care of children. Findings: 1) PH1 was approved on 8/29/23. 2) PH1?s medical report, dated 8/29/23, had a statement that the individual was ?physically and mentally capable of living with another child who may be placed in the home.? 3) Staff 1 (S1) stated that the form used for PH1 is a form used for household members and that the wrong form must have been provided. 4) S1 provided a blank medical form given to providers with the correct language. 5) S1 acknowledged the finding.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-320-F
Description:	22VAC40-131-(6)-320-F.3 & 5-7 Violation: Based on record review and interview, the agency failed to meet all elements of reporting requirements when documenting an injury of Foster Child 1 (FC1). Findings: 1) FC1?s record contained documentation of an injury noted on 10/29/23. 2) FC1?s record did not contain documentation of the follow-up action taken as a result of the injury (the record noted the case manager would follow up and monitor; however, there were no notes indicating follow up or monitoring.) 3) The file did not contain documentation of reporting the injury to the custodial agency, the name of the licensee's staff person who notified the placing agency and/or the parent or legal guardian of the incident, accident, or injury; the time each notification was made; and the name of the person the staff person contacted and made the notification to. 4) S1 acknowledged the finding.
Plan of Correction:	Not available online. Contact Inspector for more information.