VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Impact Living Services
316 Brook Park PL
Suite A1
Forest, VA 24551
(434) 533-1088

Current Inspector: Dawn Espelage (540) 759-8852

Inspection Date: June 12, 2024

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

Technical Assistance:

22VAC40-131-200.E Discussion regarding provider home written notice of approval status. 22VAC40-131-370.R.2 Discussion regarding the filing timeline.

Comments:

Type of inspection: Monitoring A monitoring inspection was initiated on 6/12/24 and concluded on 6/13/24. The program manager was contacted by telephone to initiate the inspection. The program manager reported that the current census was 29. The inspector emailed the program manager a list of items required to complete the inspection. The inspector reviewed 2 resident records, 2 provider home records and 3 staff records submitted by the facility to ensure documentation was complete. An exit interview was conducted with State Coordinator and Foster Care Director on 6/13/24, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. 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 #:	22VAC40-131-350-A
Description:	Violation: Based on record review and interview, the agency failed to complete quarterly progress reports every 90 days for Foster Child (FC) 1. Findings: 1) FC 1 was placed on 4/22/22 and discharged from care on 3/21/24. 2) The record contained a quarterly review dated 4/17/23. 3) The licensing specialist did not locate quarterly reviews for July 2023, October 2023, or January 2024. 4) The licensing specialist provided additional time for the agency to try to locate additional quarterly reviews; the agency was unable to do so. 5) Findings were discussed and acknowledged at the exit meeting on 6/13/24.
Plan of Correction:	The Agency identified and corrected a programming error in the Electronic Health Record (EHR) system that was causing delays in quarterly updates. The issue has been resolved, and all future quarterlies will now trigger and be completed on their due dates.