VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Intercept Youth Services operating as Intercept Health
245 Garrisonville Road
Suite 201
Stafford, VA 22554
(540) 318-4740

Current Inspector: Kevin Lassiter (804) 241-2093

Inspection Date: Nov. 6, 2019 and Nov. 7, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-131 Personnel 22VAC40-131 Provider Homes 22VAC40-131 Children's Services 63.2 General Provisions

Technical Assistance:

During the inspection, several anomalies occurred with the electronic record system. Specifically, user names and dates and times of access were questioned. The agency is asked to review the requirements of 22 VAC 40-131-370-B and C regarding electronic records and signatures. Technical assistance provided regarding standard #22VAC40-230.E.1, documenting interviews with the foster home during the reevaluation process. Regarding standard #22VAC40-180.H, the licensee agreed to work with their IT team to upload their ?inquiry forms? into the electronic records.

Comments:

An unannounced monitoring inspection was completed on November 6, 2019 from 08:45 am to 4:00 pm and on November 7, 2019 from 8:00 am to 3:15 pm at Intercept Health located at 2712 Jefferson Davis Highway, Stafford, Virginia 22554. The licensee reports a total of twenty-one (21) children receiving therapeutic foster care services and twenty-four (24) approved foster care provider homes. During this inspection, the following actions were taken: 1.Reviewed three (3) children records. 2.Reviewed three (3) provider home records. 3.Reviewed one (1) additional newly approved provider home record (background only). 4.Reviewed five (5) new employee records. 5.Background checks and references for all board officers will be reviewed at a later date as a part of an inspection for another location. 6.Policy and Procedures were reviewed. 7.A physical plant inspection was conducted. 8.Interviews were conducted. The Director of Treatment Foster Care and Regional Program Supervisor were present for the inspection and exit interview at 1:45 pm on November 7, 2019. An Acknowledgement of Inspection form was signed by the Director of Treatment Foster Care on November 7, 2019. There were nine (9) citations for violations of the Standards for Licensed Child-Placing Agencies. One was a key health and safety standard. Upon receipt of the Violation Notice, the licensee should develop a plan of correction to include 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 noncompliance will be corrected. The licensee has five business days from receipt of the inspection documents to complete the section entitled "Plan of Correction", sign each page of the inspection documents and return to the Licensing Office. The licensee should retain a copy to be posted at the facility. Results of the inspection are subject to public disclosure and will be posted on the Virginia Department of Social Services public web site within five business days, regardless of whether or not the Plan of Correction is completed.

Violations:

Standard #:	22VAC40-131-140-F-2
Description:	22VAC40-131-140.F.2.C Violation: Based on the review of the staff record (S5) and based on an interview with agency representatives, the licensee failed to ensure that this staff had two years of experience in providing casework services to children and families. Evidence: (1)Based on the review of the staff record (S5), the application completed by S5 as well as the resume located in the staff record documented 12 months of experience providing casework services to children and families with no additional evidence of any additional casework experience providing casework to children and families. (2)During an interview, AR3 confirmed that S5 had 12 months of documented experience in providing casework services to children and families with no additional documented experience in providing casework to children and families. (3)During the exit interview, AR2 acknowledged that this employee did not have any additionally documented casework experience.
Plan of Correction:	This violation was corrected on 11/12/19. A revised job description for (S5) was signed and filed in the employee file noting the employee?s job description as a Family Services Specialist Trainee. In addition, a Family Services Trainee Agreement form was created, signed and filed in the employee record 11/12/19 indicating on-going documented experience to be obtained throughout the staff?s first 12 months of employment with Intercept providing casework to children and families.
Standard #:	22VAC40-131-290-C-12
Description:	22VAC40-131-290.C.12 Violation: Based on the review of the record for FC1 and based on an interview with agency representatives, the licensee failed to obtain and maintain a copy of the record of immunizations that FC1 received since his last examination. Evidence: (1)The hard copy and electronic record for FC1 did not contain documentation of a copy of the record of immunizations that FC1 received since his last examination. (2)During an interview, AR2 and AR5 thoroughly reviewed both the hard copy and electronic copy record for FC1 and neither was able to locate a copy of the immunization record for FC1.
Plan of Correction:	Since the licensing visit on 11/7/19 the licensee has completed a 2nd request to obtain FC1?s immunization records on 11/8/19. The assigned FC will continue to request a copy of the records to ensure this violation will be corrected. If FC1?s immunization records are not received per the 2nd request, a copy of the immunization records will be obtained during FC1?s next scheduled physical on 2/28/20.
Standard #:	22VAC40-131-290-C-8
Description:	22VAC40-131-290.C.8 Violation: Based on the review of the record for FC1 and based on an interview with agency representatives, the licensee failed to obtain a medical examination report for FC1 that included evidence of freedom from communicable diseases, including tuberculosis. Evidence: (1)The medical examination report located in the record for FC1 did not contain evidence of freedom from communicable diseases, including tuberculosis. At the time of the inspection, this section was left blank on the medical examination form that was located in the record. (2)During an interview, AR2 and AR5 reviewed the electronic record as well as the hard copy record and acknowledged that there was no medical examination for FC1 that contained evidence that this child was free from communicable diseases, including tuberculosis.
Plan of Correction:	In addressing FC1 violation for LCPA regulation 22VAC40-131-(6)-290-C-8 the licensee acknowledged that the medical examination form was left blank by the physician however it is noted that FC1 was given a TB test on 2/28/19 and results were read on 3/3/19. In an attempt to correct the violation the assigned FC requested on 11/8/19 that the physician address the prompt noted ?free from communicable disease? on the physical form conducted 2/28/19. The licensee reports that the TB test documentation was placed in the record on 11/08/2019.
Standard #:	22VAC40-131-290-E-1
Description:	22VAC40-131-290.E.1 Violation: Based on the review of the record for FC1 and based on an interview with agency representatives, the licensee failed to ensure that a dental examination was completed for FC1 within 60 days following the date of placement. Evidence: (1)The dental examination located in the file for FC1 was completed, as evidence by the dentist signature date after 60 days of placement. (2)During an interview, AR2 and AR5 reported that there was a delay in obtaining FC1?s dental examination due to an insurance issue. AR2 and AR5 reported that they were required to pay for the dental exam due to it not being covered by the insurance which resulted in the dental examination being completed after 60 days following the date of placement.
Plan of Correction:	This violation will be corrected within 30days. A request for authorization to FC1 medical insurer has been requested by the DSS (Department of Social Services) worker to obtain information regarding the previous dental provider. Moving forward the licensee will require DSS (Department of Social Services) representatives to complete an authorization form, at the time of admissions, in order to request contact names of all prior dental (and medical) providers byway of insurance carriers whom provided above mentioned services to admitted youth. In doing so, Intercept will be able to be provided with documentation of prior medical services received.
Standard #:	22VAC40-131-290-K
Description:	22VAC40-131-290.K Violation: Based on the review of the record for FH1, the licensee failed to obtain documentation of a tuberculosis screening or tests for Other Household Member 1 (OHM1). Evidence: (1)There was no documentation in the record for FH1 of a tuberculosis screening or test for OHM1. Based on the documentation, OHM1 is in contact with the children placed in this home. (2)During an interview, AR2 and AR5 thoroughly reviewed both the hard copy records and electronic copy records for FH1 and neither was able to locate evidence of OHM1 receiving a tuberculosis screening or test.
Plan of Correction:	This violation was corrected at the end of the day on 11/07/19. The licensee acknowledged that the tuberculous test form was not present in either the hard copy and or the electronic records however a copy of the paperwork, verifying that the tuberculous test was conducted, was presented to the reviewer at the exit interview. It is also noted that the final results of the TB test has since been uploaded in the system verifying the final results of the conducted tuberculosis for the OHM1.
Standard #:	22VAC40-131-330-G-2
Description:	22VAC40-131-330.G.2 Violation: Based on the review of the foster child record (FC1) and based on an interview with agency representatives, there was no documentation of a face-to-face contact in the foster home during the month of January 2019 and May 2019. Evidence: (1)The review of the record for FC1 documented no face to face contacts in the foster home during the month of January 2019 and May 2019. (2)During an interview with AR2 and AR5, they carefully reviewed several sections of the record and were not able to locate face to face contacts in the foster home during the month of January 2019 and May 2019. (3)During the exit interview, AR2 acknowledged that there were 3 contact notes, including emails and other documentation however, there was no documentation of face to face contacts in the home for the month of January 2019.
Plan of Correction:	This violation cannot be corrected. Following the completion of the licensing review on 11/7/19 the licensee representative (AR1) will provide a state-wide training to all TFC East Family Consultants within 30 days of this violation as to address LCPA regulation 22VAC40-131-(6)-330-G-2 pertaining to the documentation of face to face visits conducted within the foster home.
Standard #:	22VAC40-131-340-F-1
Description:	22VAC40-131-340.F.1 Violation: Based on the review of the foster child record (FC1) and based on an interview with agency representatives, there was no evidence that the birth parents of the child were involved in developing the child?s individualized service plan, child?s treatment plan as appropriate and the child?s quarterly progress reports. Evidence: (1)The review of the record for FC1 documented that the involvement of the birth parents was appropriate and that the birth parents were visiting as well as maintaining contact with the child. (2)The review of the record for FC1 did not contain any evidence that the birth parents of the child were involved in developing the child?s individualized service plan, child?s treatment plan as appropriate and the child?s quarterly progress reports. (3)During the exit interview, AR5 reviewed the record and determined that while there was a box on the most recent quarterly that stated that the birth parents were provided with a copy of the quarterly, she acknowledged that there was no evidence that the birth parents of the child were involved in developing the child?s individualized service plan, child?s treatment plan as appropriate and the child?s quarterly progress reports.
Plan of Correction:	This violation was unable to be corrected. Following the completion of the licensing review on 11/7/19 the licensee representative (AR1) will provide a state-wide training to all TFC East Family Consultants within 30 days of this violation as to address LCPA regulation 22VAC40-131-(6)-340-F-1. In providing this state-wide training the importance of having the bio parent?s involvement in developing the child?s individualized service plan, treatment plan and quarterly progress will be reiterated.
Standard #:	22VAC40-131-350-A
Description:	22VAC40-131-350.A Violation: Based on a review of the record for FC1, at the time of the review, the licensee failed to document a review of progress and report that occurred no later than 90 days from the date of the child?s placement and subsequent progress review. Evidence: (1)At the time of the review, the last quarterly report that was documented in the record was dated, 06/28/2019; there was no subsequent progress review no later than 90 days from 06/28/2019. At the time of the review, the electronic record contained a blank document dated 09/28/2019. (2)During the exit interview, AR2 and AR5 acknowledged that following the inspectors review of the record, AR1 reviewed and approved the document which resulted in the document being added following the review of the record. (This violation was corrected while on site). (3)During the exit interview, AR5 acknowledged that there is a ?technical glitch? in the system which placed the incorrect date on the report that was added to the record which they report that they are planning to address with their IT department.
Plan of Correction:	The violation was corrected on site. At the time of the interview the quarterly report was provided for review. During the exit interview it was discovered that due to a system glitch the reviewer was unable to see the completed version of the report. In communicating the reviewers concerns regarding a variety of system glitches the licensee relayed the agencies discussions with IT and the plan of researching other possible EMR systems that would have the ability to fully support the agency?s record keeping.
Standard #:	22VAC40-131-370-M-12
Description:	22VAC40-131-370.M.12 Violation: Based on the review of the record for foster home (FH1) and based on an interview with agency representatives, the licensee failed to document the relationship of each member in the provider?s home on the face sheet. Evidence: (1)Based on the review of the foster home provider record (FH1), the face sheet located in the record did not include the relationship of other household member (OHM1). (2)Based on an interview with AR5, their electronic system does not provide and option for OHM1?s relationship status to FH1. AR5 reports that they will send a notice to their IT department to have this matter resolved.
Plan of Correction:	In response to the 22VAC40-131-(6)-370-M-12 violation, Documentation Supervisor notified the System Administrator and an option for OHM1?s relationship status was added to FH1?s face sheet.