VIRGINIA DEPARTMENT OF SOCIAL SERVICES

SKILL BUILDERS
1400 18th Street
Chesapeake, VA 23324
(757) 233-2896

Current Inspector: Sherry Woodard (757) 987-0839

Inspection Date: May 18, 2022 , May 19, 2022 and June 16, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-131 PERSONNEL 22VAC40-131 ADDITIONAL REQUIREMENTS FOR SPECIFIC PROGRAMS 22VAC40-80 THE LICENSE 22VAC40-191 BACKGROUND CHECKS FOR CHILD WELFARE AGENCIES

Technical Assistance:

Discussed what the records of each staff person should include as noted in the ?Standards for Licensed Child Placing Agencies? - 22VAC40-131-160.B.1-10. Discussed the date of separation for each position held as noted in the ?Standards for Licensed Child Placing Agencies? - 22VAC40-131-160.B.1-10. Discussed the results of the life skills assessment completed within the last 90 days as noted in the ?Standards for Licensed Child Placing Agencies? - 22VAC40-131-440.C.4. Discussed counseling needs as it pertains to the individualized service plan as noted in the ?Standards for Licensed Child Placing Agencies? - 22VAC40-131-440.J.1.

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/18/22 from 12:27 p.m. to 6:04 p.m. and 5/19/22 from 9:50 a.m. to 6:15 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of children in care: 4 The licensing inspector completed a tour of the physical plant that included the office setting and conditions. Number of children?s records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with staff: 2 Additional Comments/Discussion: An entrance conference was held on 5/18/22. On each date of the inspection, the Executive Director and the Senior Case Manager were available and accessible during the inspection. On 5/19/22, these staff members were interviewed in order to seek clarification about several elements. Preliminary findings were also discussed on the same date. 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 Michele Freeman, Licensing Inspector at (804) 662-7062 or by email at michele.freeman@dss.virginia.gov

Violations:

Standard #:	22VAC40-131-440-E
Description:	Violation: Based on an interview with staff and review of foster youth?s, FY1?s, record, the agency failed to Include all of the elements as it pertains to the written agreement for participation in the arrangement with the youth, his guardian, and as appropriate, his family. Findings: 1) Staff, S3, was interviewed about the form used for the written agreement for participation in arrangement with the youth, his guardian, and as appropriate, his family. S3 mentioned the agency?s ?Agreement between the Agency and Resident? is used for this purpose. 2) 440.E.1 ? The timeframe for completing the program is missing from the agency?s written agreement for participation. 3) 440.E.6 ? Information pertaining to the physical setting arrangements and requirements that all arrangements must be approved is missing from the agency?s written agreement for participation. 4) S3 was unable to show where these elements existed in the ?Agreement between the Agency and Resident.?
Plan of Correction:	The agency will update its ?Agreement Between the Agency and Resident? form to discuss the purpose of the youth?s placement within the independent living arrangement, with a timeframe for completing the program. The update will also include information pertaining to the physical setting arrangement and requirements that all arrangements must be approved by the licensee. The executive director will be responsible to ensure updates are made to the agreement.
Standard #:	22VAC40-131-440-F
Description:	Violation: Based on interviews with staff and review of foster youth?s, FY1?s, record, the agency failed to comply with the written participation agreement as it pertains to it being signed by a representative of the licensee, the youth, and as appropriate, the legal guardian. Findings: 1) The ?Agreement between the Agency and Resident,? is the written participation agreement for this agency. It was not signed by the representative of the licensee. 2) Staff, S3, and staff, S4, were interviewed about the missing signature. 3) S4 acknowledged the signature was missing because she was supposed to sign this agreement.
Plan of Correction:	To comply with the state standards, the written participation agreement shall be signed by a representative of the licensee, the youth, and as appropriate, the legal guardian. The signatures required on the participation agreement by licensee representatives will be witnessed by a second employee of the agency to ensure all documents are completed thoroughly. The executive director and assigned staff members will be responsible for reviewing signed documents.
Standard #:	22VAC40-131-440-K
Description:	Violation: Based on interviews with staff and review of foster youth?s, FY1?s, record, the agency failed to conduct a 90-day review within a 90-day period. Findings: 1) Upon review of FY1?s record, the youth was admitted on 10/8/21. 2) The beginning date for this report is 10/8/21 and the ending date is 1/11/22. 3) This report also has a section titled, ?Date Completed,? which also is dated for 1/11/22. 4) This report should have been completed by 1/6/22. 5) Staff, S3, and staff, S4, were interviewed about this report. Both acknowledged the ending date and the date it was completed exceeded the 90 day period.
Plan of Correction:	The agency will conduct a review of each individualize service plan and the progress of each youth towards meeting the goals and objectives identified in the plan. The first review will take place within 90 days of the admission date and within each 90-day period thereafter. To correct the noncompliance a tracking mechanism to pinpoint due dates on all required documents will be implemented to ensure that all individualized service plans are completed within the 90-day period. The executive director and assigned staff members will be responsible for implementing and monitoring the new tracking system.
Standard #:	22VAC40-191-40-D-1-c
Description:	Violation: Based on an interview with staff and review of personnel records, the facility failed to comply with the requirements for background checks before three years since the date of the last sworn statement or affirmation, most recent central registry finding and most recent criminal history record check report. Findings: 1) Upon review of staff, S1?s, personnel record, the following was found- a. The received dates on the sworn statement, central registry finding and the criminal history record check reports confirms the current reports were not obtained before three years since the date of the previous reports. b. Staff, S3, was not able to provide a background check conducted before three years since the date of the last sworn statement, most recent central registry finding and most recent criminal history record check report. c. Staff, S3, was interviewed about S2?s background checks. S3 acknowledged the findings in regard to the background checks. 2) Upon review of staff, S2?s, personnel record, the following was found- a. The received date on the sworn statement or affirmation form confirms the current form was not obtained before three years since the date of the previous form. b. A current central registry finding was missing from the record. The latest central registry finding in the record is dated for September 2018. c. The received date on the criminal history record confirms the current report was not obtained before three years since the date of the previous report. d. Staff, S3, was unable to provide background checks conducted before three years for the last sworn statement or affirmation and the last criminal history record check. Also, S3 was unable to provide a current central registry finding, which was missing from the record. e. Staff, S3, was interviewed about S2?s background checks. S3 acknowledged the findings in regard to the background checks.
Plan of Correction:	The agency will comply with the state standards by making sure that sworn statements, central registry findings, and the criminal history record check reports are entered into the employee?s personnel file prior to the three years compliance date. To correct the noncompliance a tracking mechanism to alert 3 months prior to the due date will be implemented to ensure that all documents are sent to each required agency within a manageable timeframe to receive each document before the three-year compliance date. The executive director and an assigned staff member will be responsible for implementing the new tracking system.