VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Residential Care
950 N. Washington Street
Suite 227
Alexandria, VA 22314
(202) 550-0545

Current Inspector: Kevin Lassiter (804) 241-2093

Inspection Date: May 17, 2021 and June 3, 2021

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

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 5/17/21. The inspection was concluded on 6/03/2021. The Child Placing Supervisor/Case Manager was contacted by email to initiate the inspection. The agency reports 3 children in care and 4 approved provider homes. The inspector emailed the Child Placing Supervisor/Case Manager a list of items required to complete the inspection. The inspector reviewed documents from 1 provider home record, 1 child's record and 3 personnel records submitted by the agency. An exit interview was conducted on 6/03/21 with the Executive Director and the Child Placing Supervisor/Case Manager. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the agency. 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 ten (10) 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 #:	22VAC40-131-190-R
Description:	Violation: Based on a review of the homestudy for a foster family (FH-1) and an interview with an agency representative (AR-1), the agency did not review with FH-1 or verify that possession of any weapons, including firearms, in the home shall comply with federal and state lawsand local ordinances. Evidence: 1) The homestudy for FH-1 contains information about the required home environment elements listed under 22VAC40-131-190. 2) The required information about weapons and firearms was not included. 3) In an exit interview with AR-1 on 5/28/21, AR-1 acknowledged that the specific language regarding firearms was not addressed in the homestudy.
Plan of Correction:	RCI has updated its home study to include a policy that will comply with the federal and state local ordinances. RCI will verify that any firearms and ammunition are stored separately in locked containers, compartments or cabinets RCI case manager will provide to the foster parent and home the following policy: 1. Any firearms and other weapons shall be unloaded and stored with weapon?s safety mechanisms activated in a locked closet. 2. Ammunition shall be stored in a locked location separate from the weapon. 3. Key or combination to the locked closet and cabinet shall at all times be maintained out of reach of all children in the home. Person(s) responsible Case manager Child Placement Supervisor
Standard #:	22VAC40-131-200-C
Description:	Violation: Based on a review of the homestudy including narrative documentation and other data collection formats for a foster family (FH-1) and an interview with an agency representative (AR-1), the agency failed to recommend approval of FH-1 based on careful assessment of the requirements for providers specified in in 22VAC40-131. Evidence: 1) The "Financial Information for Prospective Foster Parents" form for FH-1 documented that FH-1 earns a monthly net salary of $3,000 and an additional $1,000 monthly from a tenant. The form was not dated and did not document the current employer of FH-1. 2) The homestudy for FH-1 documented that FH-1 began a new job (position#2) in 11/19 and that FH-1 continues to work there. The home- study documented that prior to working at posi- tion #2, FH-1 worked for 23 years at position #1 and retired from position #1 in 2020. 3) The paystubs for FH-1 submitted to the agency were for pay periods from(5/24/20-6/6/20, and 6/7/20-6/20/20) after the date of approval on the hometudy (5/26/20). The paystubs were from position #1. There were no paystubs from position #2. 4) There was no information about the tenant inthe homestudy for FH-1. 5) In a phone conversation with AR-1 on 5/20/21, this licensing specialist asked for clarifi- cation regarding the current employment of FH-1 and for information about the tenant. AR-1 acknowledged that he didn't see the informa- tion on their "Financial Information for Prospective Foster Parents" form regarding the tenant. 6) In an email on 5/20/21, AR-1 clarified that FH-1 retired from position #1 in 12/20. FH-1 worked at position #2 from 12/20 until 3/21. FH-1 accepted a different job, position #3 in 3/21 and remains employed there. No informa- tion was provided regarding the tenant. 7) In an interview on 5/28/21, AR-1 stated that the tenant resides in a home that FH-1 helped one of her adult daughters purchase. 8) In an exit interview on 6/03/21, AR-1 acknowledged that the information regarding FH-1's income on the "Financial Information for Prospective Foster Parents" form and the home- study did not match.
Plan of Correction:	Child Placing Supervisor will update the Financial Information. The prospective foster parents form will reflect the accurate salary of the foster parent. The foster parent?s current employer will be reflected on the financial form as well as on the home study narrative. The form will also highlight the date of completion. Child placing supervisor will gather document paystubs from previous and current employers. Child placing supervisor will document accurately all sources of income for foster parents and collect documents verifying all sources of employment income. 1. RCI case manager will collect, review and verify all income from the foster parent. Including employment timelines for each paystub and when necessary with the foster parent?s knowledge gather pertinent information that verifies employment. Person (s) Responsible Case manager Child Placing Supervisor
Standard #:	22VAC40-131-200-G-2
Description:	Violation: Based on a review of the homestudy and the certificate of approval for a foster family (FH-1) and an interview with an agency repre- sentative (AR-1), the agency failed to address the correct issuance and expiration dates for the approval period for FH-1. Evidence: 1) The homestudy for FH-1 documents an approval date that isafter the approval date listed on the certificate of approval for FH-1. 2) In an exit interview on 5/28/21, AR-1 acknowledged that the approval date docu- mented on the certificate of approval for FH-1 was incorrect.
Plan of Correction:	RCI has corrected the certificate of approval for foster family in the home study and has corrected the issuance and expiration dates for the certificate of approval period RCI quality assurance team will carefully review all certificate of approval issuance and expiration dates to ensure that all documents have the same dates. Person(s) responsible Inhouse quality assurance team ? case manager, child placement supervisor and program director
Standard #:	22VAC40-131-210-C
Description:	Violation: Based on a review of the homestudy and training documentation for a foster home (FH-1) and an interview with an agency repre- sentative (AR-1), the agency failed to inform FH-1 that information about shaken baby syn- drome, its effects, and resources for help and support for caretakers isavailable on a website maintained by the Department prior to the approval of the foster home. Evidence: 1) There was no documentation of this training requirement in the homestudy for FH-1. 2) In a phone call with AR-1 on 5/20/2021, this licensing specialist requested documentation of the training requirement. Documentation was not provided. 3) In exit interviews with AR-1 on 5/28/2021 and on 6/03/21, AR-1 acknowledged that the link to the Department's website was not provided as required.
Plan of Correction:	RCI has provided to the foster parent the link for the information about the Shaken Baby Syndrome that is available on a website maintained by the Department. 1. RCI has immediately made the website a part of the pre service training. 2. Website with the link will also be a part of the Corporal punishment form signed by all FP. Person (s) responsible Child Placing Supervisor Case Manager
Standard #:	22VAC40-131-250-G
Description:	Violation: Based on a review of the "Pre-Placement and Intake Screening and Matching Tool" for a foster child (FC-1) and an interview with an agency representative (AR-1), the agency failed to gather, review, and document required informa- tion in the child's file prior to accepting FC-1 for placement. Evidence: 1) 250.G.2 The "Pre-Placement and Intake Screening and Matching Tool" does not include a list of services requested by the placing agency. 2) 250.G.3.a The "Pre-Placement and Intake Screening and Matching Tool" does not include current information regarding the child's health. The tool documents that FC-1 is not on medication in one paragraph then docu- ments that FC-1 is on medication in another. 3) 250.G.3.g The "Pre-Placement and Intake Screening and Matching Tool" does not docu- ment professional treatment received by FC-1 to meet the emotional and psychological needs and problems described. 4) 250.G.3.i The "Pre-Placement and Intake Screening and Matching Tool" does not docu- ment the permanency planning goal including the planned date of achievement. 5) 250.G.4 The "Pre-Placement and Intake Screening and Matching Tool" does not include the strengths and needs of the child's birth family. 6) 250.G.5 The "Pre-Placement and Intake Screening and Matching Tool" does not include the datesand names of persons involved in making preplacement visits. 7) 250.G.6 The "Pre-Placement and Intake Screening and Matching Tool" does not include the dates that FC-1's potential placement was staffed. 8) In exit interviews on 5/28/21 and 6/03/21, AR-1 acknowledged that required information was not gathered and documented.
Plan of Correction:	RCI Child placing supervisor will update Pre-Placement and Intake Screening and Matching Toll to include list of services requested by the placing agency. The Pre-Placement and Intake Screening and Matching Tool will be updated to include current information regarding FC-1 health. The Pre-Placement and Intake Screening and Matching Tool will be updated to include professional treatment received by FC-1 to meet emotional and psychological needs of the child. The permanency planning goal will also be documented on the tool as well as the date of permanency goal achievement. The strengths and needs of the child?s birth family will be outlined on the Pre-Placement and Intake Screening and Matching Tool . The tool will be updated to reflect the dates as well as names of persons present during pre-placement visits. The staffing date potential placement will also be highlighted on the Pre-Placement and Intake Screening and Matching Tool. 1. RCI will provide training to all case managers on how to effectively complete the Pre-Placement and Intake Screen and Matching Tool. 2. Child placing supervisor will assist case manager with the gathering of documentation of completing the tool. Child placing supervisor will provide oversight on the interpretation of documents received as well as assisting the case manage with implementing pertinent information gathered with the Pre- Placement and Intake Screening and Matching Tool. 3. Child Placing supervisor will complete a review on the first draft of the Pre-Placement and Intake Screening Matching Tool to ensure information is concise, sequenced and relevant to the child?s emotional and psychological needs. 4. RCI?s Quality Assurance Reviewer will review the Pre-Placement and Intake Screening and Matching Tool?s first draft and submit the final draft to Child placing supervisor and Program Director for final approval and filing in child?s record. Person (s) Responsible Child Placing Supervisor Case Manager Quality Assurance Reviewer Program Director
Standard #:	22VAC40-131-250-N
Description:	Violation: Based on a review of the "Pre- Placement and Intake Screening and Matching Tool" for FC-1 and an interview with an agency representative (AR-1), the agency failed to docu- ment asummary of the child's (FC-1) preplace- ment interview and the results of the preplace-ment visit in the file. Evidence: 1) The "Pre-Placement and Intake Screening and Matching Tool" for FC-1 documents that a pre- placement visit was conducted. 2) The "Pre-Placement and Intake Screening and Matching Tool" for FC-1 does not document a summary of the preplacement interview and the results of the preplacement visit as required. 3) In an exit interview of 6/3/21, AR-1 acknowl- edged that asummary of the preplacement interview was not documented.
Plan of Correction:	RCI will ensure that a summary of the preplacement interview and the result of the preplacement visit is documented in the child?s file. RCI has developed a tool that has become a permanent part of the file called ?Summary of Preplacement to ensure that the results of interview and visit are documented in the child file. Person(s) responsible Case manager, Child Placement Supervisor
Standard #:	22VAC40-131-250-O
Description:	Violation: Based on a review of "Pre-Placement and Intake Screening and Matching Tool" for FC-1 and an interview with an agency represen- tative (AR-1), the agency failed to complete a written assessment of FC-1 that contains all required elementsspecified in 22VAC40-131-250.G within 30 days of placement. Evidence: 1) The "Pre-Placement and Intake Screening and Matching Tool" completed for FC-1 was dated more than 30 daysafter the placement of FC-1. 2) In an exit interview on 6/03/21, AR-1 acknowledged that the intake assessment was not completed within the required timeframe.
Plan of Correction:	RCI will set up a grid to carefully ensure that the 30-day time frame is adhere to for the elements requested in 22VAC-131-250-G. 1. RCI case manager will provide to the Child Placement Supervisor on the 25 day the completed elements required in the ?Pre-Placement and Intake Screening and Matching Tool.? 2. The grid will have the timetable required for each new FC placement to ensure that within 30 days all elements have been completed as specified in 2VAC40-131-250 G. Person(s) Responsible Case Manager, Child Placing Supervisor and Program Director
Standard #:	22VAC40-131-260-A
Description:	Violation: Based on a review of the "Social History" submitted for a foster child (FC-1) and an interview with an agency representative (AR-1), the agency failed to complete the social history within 45 days of the date of FC-1's placement. Evidence: 1) The "Social History" for FC-1 was dated more than 45 daysafter the date of FC-1's placement. 2) In an exit interview on 6/03/21, AR-1 acknowledged that the social history was not completed within the required timeframe.
Plan of Correction:	RCI will ensure that the social history on each child within 45 days of the date child?s placement. RCI will ensure that the social history on each child within 45 days of the date child?s placement. 1. RCI Quality Assurance Reviewer will require that the case manager provide to the Child Placing Supervisor the first draft of the Social History to be completed 40 days of the date of the child?s placement. 2. Once the Home Study is finalized the Quality Assurance Reviewer will work directly with the case manager and Child Placing Supervisor to ensure that the Home Study is accurate and completed within 45 days of the date of child?s placement. Person (s) Responsible Case Manager Child Placing Supervisor Quality Assurance Supervisor
Standard #:	22VAC40-131-260-B
Description:	Violation: Based on a review of the "Social History" submitted for a foster child (FC-1) and an interview with an agency representative (AR-1), the agency failed to include required ele- ments in the social history report for FC-1. Evidence: 1) 260.B.3 The social history report does not include the services needed to reach the child's permanency goal. 2) 260.B.4 The social history report does not include information on FC-1's family structure, relationships, and involvement with the child. 3) 260.B.5 The social history report does not include datesand names of previous place- mentsand caretakers for FC-1. 4) 260.B.6 The social history report does not include the educational history for FC-1. 5) 260.B.6 The social history for FC-1 does not include namesand addresses of providers of medical treatment. 6) 260.B.7 The social history for FC-1 does not include FC-1's history of abuse and neglect. 7) 260.B.8 The social history for FC-1 does not include the education and occupation of the child's parents, siblings, aunts, uncles, and grandparents. 8) 260.B.10 The social history for FC-1 does not include emotional and psychological problems the child has experienced within the last 13 months. 9) In an exit interview on 6/03/21, AR-1 acknowledged that the agency failed to include required elements in the social history.
Plan of Correction:	RCI will update the Social History for FC-1 in the following manner: 1. Will accurately outline services need to reach the youth?s permanency goal. 2. Will address the child?s biological family structure, relationships and interaction and involvement with child. 3. The updated Social History will include the dates and names of previous placements and caretakers. The social history report will also include names and addresses of medical providers. 4. The new social history will now include the child?s history of abuse and neglect and will also include the education and occupation of the child?s parents, siblings, aunts, uncles and grandparents. 5. The social history will be updated to include the child?s emotional and psychological issues endured within the last 13 months. RCI will ensure the case worker gathers pertinent documentation, such psychological assessments, court service plan, discharge summaries, psychiatric notes for review prior to initiating the development of Social History. RCI?s child placement supervisor will provide training including essential elements in the Social History to address abuse and neglect, emotional as well as psychological needs of the child. RCI?s case manager will be required to submit the first draft of the Social History within the first 10 days of placement to ensure sufficient time to complete the document with all required elements. Person (s) responsible RCI?s Case Manager Child Placing Supervisor Quality Assurance Reviewer Program Director
Standard #:	22VAC40-131-290-K-2
Description:	Violation: Based on a review of the "Health Statement of Permanent Member of Foster Family Household" for a foster family (FH-1) and an interview with an agency representative (AR-1), the agency failed to include the tubercu- losisscreening/test date for FH-1 on the form. Evidence: 1) The "Health Statement of Permanent Member of Foster Family Household" form for FH-1 included the type of test/screening and the results but it did not include the date as required. 2) In an exit interview on 6/03/21, AR-1 acknowledged that the date of the test/screening was not documented as required.
Plan of Correction:	RCI will ensure that all household members who come into contact with the children will submit to tuberculosis screening or tests and provide documentation. 1. RCI case manager will provide place, time and locations where foster home can receive the tuberculosis screening or test and request a copy of the scheduled appointment time. 2. RCI case manager will follow up with the foster home members to ensure that the test has been taken and proof of the results will be filed. Person (s) Responsible Case Manager Child Placing Supervisor
Standard #:	22VAC40-131-340-E
Description:	Violation: Based on a review of the "Comprehensive Treatment and Service Plan" and an interview with an agency representative, the agency did not include required elements in FC-1's service plan. Evidence: 1) 340.E.1 The "Comprehensive Treatment and Service Plan" does not include a comprehensive assessment of FC-1's emotional, social, behav ioral, educational, nutritional, medical, psychiat- ric, or dental needs. 2) 340.E.2 The "Comprehensive Treatment and Service Plan" does not include the nature pf the placement to be provided to the child. 3) 340.E.3 The "Comprehensive Treatment and Service Plan" does not include goals and objec tives to meet FC-1's emotional needs, social needs, behavioral needs, educational needs, nutritional needs, developmental needs, or psy- chiatric needs. 4) 340.E.4 The "Comprehensive Treatment and Service Plan" does not include target dates for the accomplishment of the permanency plan- ning goal, the emotional goal, the behavioral goal, the educational goal, the medical goal, or the Independent Living goal. 5) 340.E.5.a The "Comprehensive Treatment and Service Plan" does not include a description of how the licensee plans to work with related community resources, including the child's pri- mary care physician, to provide continuity to the child. 6) 340.E.5.b The "Comprehensive Treatment and Service Plan" does not include the services and supports to be offered to the child's parents. 7) 340.E.5.c The "Comprehensive Treatment and Service Plan" does not include a description of the participation sought from the parent. 8) 340.E.5.d The "Comprehensive Treatment and Service Plan" does not include visitation between the child and parentsand siblings. 9) 340.E.5.e The "Comprehensive Treatment and Service Plan" does not include independent living services to be provided. 10) 340.E.6 The "Comprehensive Treatment and Service Plan" does not include discharge goals and objectives. 11) 340.E.7 The "Comprehensive Treatment and Service Plan" does not include a description of programs and services to assist the youth in transition from foster care to independent living. 12) In an exit interview on 6/03/20, AR-1 acknowledged that the service plan did not contain required elements.
Plan of Correction:	RCI will update the Comprehensive Treatment Plan of FC-1 in the following manner: 1. will ensure the plan is inclusive of all elements addressing emotional, social, behavioral medical, psychiatric or dental needs. 2. The updated plan will clearly outline the nature of placement as well as the goals and objectives will accurately address the FC-1 emotional needs, social needs, behavioral needs, educational needs, nutritional needs, development and psychiatric needs. 3. Plan will include accurate target dates of each goal outlined on the plan. 4. The updated plan will clearly outline plans on how the agency will work with the department as well as community resources in providing continuity of care for the youth. 5. The updated plan will address Independent Living Plan and services and assessments to assist youth with transitioning out of foster. 6. The updated plan will also address biological visits as contacts between you and biological family. RCI will ensure the case worker gathers pertinent documentation, such as psychological assessments, court service plan, discharge summaries, psychiatric notes for review prior to initiating development of the Comprehensive Treatment and Service Plan. RCI?s child placing supervisor and quality assurance reviewer will review documentation with case manager to identify specifics goals and objective that will accurately address, emotion needs, socials needs, behavioral needs, educational needs, nutritional needs, developmental needs or psychiatric needs. RCI will consult with department?s social worker, therapist, psychiatrist, mentor or other community supports to assist with the development of Comprehensive Treatment and Service Plan. RCI?s Quality Assurance Reviewer and Program Director will review the final draft of the Comprehensive Treatment and Service Plan prior to approval. Person(s) responsible Case Manager Child Placing Supervisor Quality Assurance Reviewer
Standard #:	22VAC40-131-340-K
Description:	Violation: Based on a review of the "Comprehensive Treatment and Service Plan" for a child (FC-1) and an interview with an agency representative (AR-1) the agency failed to provide a copy of the plan to the custodial placing agency, the foster parents, and the parent. Evidence: 1) There was no documentation that copies of the service plan were provided to the custodial placing agency, the foster parents, or the parent. 2) In asecond exit interview with AR-1 on 6/03/21, AR-1 acknowledged there was no way to verify whether the custodial placing agency, the foster parents, or the parent received a copy.
Plan of Correction:	RCI will provide a confidential copy of the child?s service plan to the custodial placing agency, foster parent and biological family members. 1. Proof of delivery of copy by email, regular mail or in person signed document. 2. RCI case manager will request a return response from the recipient within 10 calendar days. 3. All correspondence with the recipients will be in the plan and filed in the folder. Person(s) Responsible Case manager Child Placement Supervisor
Standard #:	22VAC40-131-340-M
Description:	Violation: Based on a review of the "Comprehensive Treatment and Service Plan" for a child (FC-1) the Department of Social Services (DSS) Plan for a child (FC-1) and an interview with an agency representative (AR-1), the agency did not develop a plan that was compatible with the goals in the plan sent to the court. Evidence: 1) The "Comprehensive Treatment and Service Plan" for FC-1 did not document a permanency planning goal but did document that the per- manency planning goal had been achieved. 2) The DSS plan for FC-1 documented a perma- nency planning goal of Relative Placement with a concurrent goal of Return Home. 3) In an exit interview on 6/03/20, AR-1 acknowledged that the goals were not compatible.
Plan of Correction:	RCI has updated the service plan to ensure that it is compatible with the goals in the plan sent to the court RCI case manager and Child Placement Supervisor will ensure that the permanency planning goal is clearly stated and that the ?Comprehensive Treatment and Service Plan? are being reviewed by the inhouse quality assurance team 24 hours prior to submission.