VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Extra Special Parents, Inc.
1527 Huguenot Rd
Ste. 101
Midlothian, VA 23113
(804) 714-1776

Current Inspector: Dawn Espelage (540) 759-8852

Inspection Date: April 2, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-131-1-GENERAL PROVISIONS/63.2 (1) GENERAL PROVISIONS 22VAC40-131 PERSONNEL 22VAC40-131 PROGRAM STATEMENT 22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN'S SERVICES 22VAC40-191 BACKGROUND CHECKS FOR CHILD WELFARE

Technical Assistance:

22VAC40-131-350 - The fourth quarter summary report should clearly identify that the licensee is evaluating and updated the comprehensive treatment and service plan for the upcoming year. 22VAC40-131-200 - Technical assistance was provided regarding ensuring certificate of approvals are for 36 months and any noted addendums should be added to the approval certificates.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/25/2024 from 11:00a.m. to 4.00 p.m. and on 3/26/2024 from 10:00 to 3:45 p.m. The exit meeting was held on 3/26/2023. The Licensing Inspector met with the President to initiate the inspection and concluded an exit with the team of Administrative Supervisor, Lead Family Services Specialist, Clinical Supervisor, and the Director of Services. Number of approved provider homes: (80) Number of children in care: (62) Number of Foster Home records reviewed (12) Number of children?s records reviewed: (6). Observations by licensing inspector: posting of the license and inspection documents was observed. An exit meeting was conducted on the following date of the inspection. There were no major changes made to the policies or procedures since the last inspection. Technical assistance was provided regarding ensuring certificate of approvals are 36 months and any noted addendums added to the certificates. Technical assistance was provided regarding clearly identifying the 4th quarter progress summary as an evaluation and update for the next year?s comprehensive service plan. The evidence gathered during the inspection determined (4) violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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, Irvin D. Goode, Licensing Inspector at 804-543-5188 or by email at Irvin.Goode@dss.virginia.gov

Violations:

Standard #:	22VAC40-131-290-C-5
Description:	Violation: Based on the record review for FC-4, the agency failed to demonstrate that visual acuity was addressed on the medical examination report as recommended by the physician report signed and dated on 4/9/2024. Findings: 1. Physical examination documentation dated 4/9/2024 in the record for FC-4 did not document a follow-up as the individual failed the eye test. 2. The findings were discussed during the preliminary findings and exit review.
Plan of Correction:	1. The ESP physical form provided to the parents to take to appointments will be amended as of 4/1/2024 by Director of Treatment Foster Care. It will include a box for the doctor to check that indicates no concerns. We are hoping that will avoid the doctor?s inclination to write N/A. 2. Foster parents have training on 4/16 and 4/18. The topic will address the requirements for all areas of the form to be filled out thoroughly by the doctor when they are at the appointment. It will also include training on the importance and requirement of a follow-up appointment as soon as possible if concerns are noted during a medical or dental examination. Suppose this continues to be an issue after the training. In that case, CS may need to accompany the foster parents to the medical appointment to ensure documents are filled out correctly and they are aware of any required follow-up appointments. A follow up email will be sent to the foster parents who did not attend training within five days of training.
Standard #:	22VAC40-131-290-C-6
Description:	Violation: Based on the record review for FC-3, the agency failed to demonstrate auditory acuity was addressed on the medical examination report signed and dated on 4/17/2023. Findings: 1. Physical examination documentation dated 4/17/2023 in the record for FC-3 did not address auditory acuity. The auditory acuity section on the medical examination form stated ?N/A? in the space provided. 2. The findings were discussed during the preliminary findings and exit review.
Plan of Correction:	1. The ESP physical form provided to the parents to take to appointments will be amended as of 4/1/2024 by Director of Treatment Foster Care. It will include a box for the doctor to check that indicates no concerns. We are hoping that will avoid the doctor?s inclination to write N/A. 2. Foster parents have training on 4/16 and 4/18. The topic will address the requirements for all areas of the form to be filled out thoroughly by the doctor when they are at the appointment. It will also include training on the importance and requirement of a follow-up appointment as soon as possible if concerns are noted during a medical or dental examination. Suppose this continues to be an issue after the training. In that case, CS may need to accompany the foster parents to the medical appointment to ensure documents are filled out correctly and they are aware of any required follow-up appointments. A follow up email will be sent to the foster parents who did not attend training within five days of training.
Standard #:	22VAC40-131-290-F
Description:	Violation: Based on the record review for FC-5, the agency failed to demonstrate that follow-up for dental restoration was addressed from the dental examination report signed and dated on 10/02/2023. Findings: 1. Dental examination documentation dated 10/2/2023 in the record for FC-5 addressed the need for follow-up dental care. 2. The licensing specialist requested the dental examination follow-up documentation. 3. The findings were discussed during the preliminary findings and exit review.
Plan of Correction:	Foster parents have training on 4/16 and 4/18. The topic will address the requirements for all areas of the form to be filled out thoroughly by the doctor when they are at the appointment. It will also include training on the importance and requirement of a follow-up appointment as soon as possible if concerns are noted during a medical or dental examination. Suppose this continues to be an issue after the training. In that case, CS may need to accompany the foster parents to the medical appointment to ensure documents are filled out correctly and they are aware of any required follow-up appointments. An email will be sent to all foster parents who did not attend training within 5 days of training.
Standard #:	22VAC40-131-340-B-1
Description:	Violation: Based on the record review for FC-1, the agency failed to demonstrate that individualized measurable objectives and strategies were described in the treatment plan dated 2/12/2024. Findings: 1. Individual treatment plan documentation dated 2/12/2024 in the record for FC-1 did not contain measurable goals and objectives. Excerpt: FC-1: ?will learn budgeting and saving skills to build financial literacy?. This documentation did not list measurable outcomes and strategies. 2. The findings were discussed during the preliminary findings and exit review
Plan of Correction:	(Director of Treatment Foster Care) will meet with (Editor), the reviewer, to address the requirement of measurable goals and ensure that she checks those thoroughly. This meeting will occur by 4/12/2024. 2. Director of Treatment Foster Care and the leads will also meet with and train the clinical staff in measurable goal development to ensure they are well aware of what miserable goals are and what they need to look like. This meeting will occur on 4/3/2024.