VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Youth for Tomorrow New Life Center, Inc.
11835 Hazel Circle
Bristow, VA 20136
(703) 368-7995

Current Inspector: Kevin Lassiter (804) 241-2093

Inspection Date: July 6, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-131 ORGANIZATION AND ADMINISTRATION 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 renewal inspection was initiated on 7/06/2020. The inspection was concluded on 7/20/2020. The Director of Foster Care Services was contacted by telephone to initiate the inspection. The agency reports 11 children in care and 32 approved provider homes. The inspector emailed the Director of Foster Care Services a list of items required to complete the inspection. The inspector reviewed documents from 4 provider home records, 2 children's records, and 6 personnel records submitted by the agency. Background checks for 4 corporate officers and 2 agent empowered to act on behalf of the corporation were reviewed in compliance with regulations regarding license renewals. An exit interview was conducted on 7/20/20 with the Director of Foster Care Services, Director of Quality Assurance, Immigrant Foster Care Case Manager, Quality Assurance Coordinator, Assistant Vice President of Programs, the Vice President of Programs, and the Director of Human Resources. 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 #:	22VAC40-131-290-C
Description:	Violation: Based on a review of the medical examination report for a child receiving foster care services (FC-2) and an interview with agency representatives, the agency failed to obtain a medical examination for the child that included required elements. Evidence: 1) The medical examination in the record for FC-2 did not contain the signature and title of the examiner, the current physical condition of the child, the growth and development of the child, the nutritional status of the child, or evidence of freedom from communicable disease, including tuberculosis. 2) In an interview with agency representatives (AR-1, AR-2, AR-3, AR-4, AR-5, AR-6, and AR-7) on 7/20/20, this licensing specialist noted that the medical examination report in the child's record did not contain the required elements. Additional documentation was not provided to dispute the violation. AR-6 stated that the agency will coordinate the exams themselves rather than relying on medical information provided by the custodian prior to placement. Following the exit interview on 7/20/20, AR-2 emailed this licensing specialist a copy of a TB test completed for FC--2 from the previous placement through the Office of Refugee Resettlement. FC-2 was screened for TB prior to the current foster care placement.
Plan of Correction:	Assistant TFC Supervisor will review the medical examination paperwork on a weekly basis in collaboration with the Department of Quality Assurance for evidence of regulated services being rendered.
Standard #:	22VAC40-131-340-E
Description:	Violation: Based on a review of the service plan for a child receiving foster care services (FC-1) and an interview with agency representatives, the agency failed to include required elements in the child's individualized service plan. Evidence: 1) The service plan in the record for FC-1 did not include an assessment of the child's educational needs as required by 22VAC40-131-340.E.1 2) The service plan for FC-1 did not include specific independent living services to be provided to assist the child in meeting his goals as required by 22VAC40-131-340.E.3.a. 3) The service plan for FC-1 did not include goals and objectives to meet identified medical, dental, developmental, or psychiatric goals as required by 22VAC40-131-340.E.3. 4) The service plan for FC-1 did not include the participation and conduct sought from the child's parents or the visitation between the child and his parents as required by 22VAC40-131-340.E.5.c. and d. 5) In an interview on 7/16/20 with agency representatives (AR-1, AR-2 and AR-3), AR-1 acknowledged that required elements were not addressed in the service plan.
Plan of Correction:	Assistant TFC Supervisor will review the foster care service plan with the Director of Foster Care Services and the Department of Quality Assurance after completion to confirm that all areas have been addressed to include the needs of the child with goals assigned. In addition, to providing clear information related to the parents level of participation in the plan. Independent Living objectives will be clear in description of how relevant independent living skills are measured.
Standard #:	22VAC40-131-340-F
Description:	Violation: Based on a review of the child's file for FC-1, the agency failed to document the involvement of the birth parents in the development of the child's individualized service plan. Evidence: 1) There was no documentation in the file that the birth parents were involved in the development of the individualized service plan for FC-1. 2) The individualized service plan for FC-1 had a goal of return home. 3) In an interview with agency representatives (AR-1, AR-2, and AR-3) on 7/16/20, AR-1 acknowledged that the birth parents were not involved in the development of the plan.
Plan of Correction:	Assistant TFC Supervisor will confirm documentation of birth parents involvement in collaboration with the Director of Foster Care Services and the Department of Quality Assurance as evidenced by weekly review of the files.
Standard #:	22VAC40-131-340-K
Description:	Violation: Based on a review of the child's file for FC-1, the agency failed to provide a copy of the child's individualized service plan to the biological parents and to the foster parents. Evidence: 1) There was no documentation in the file that the birth parents received a copy of the service plan for FC-1. The service plan for FC-1 had a permanency goal of return home. 2) There was no documentation in the file that the foster parents received a copy of the service plan for FC-1. 3) In an interview with agency representatives (AR-1, AR-2, and AR-3) on 7/16/20, AR-1 acknowledged that the agency did not provide a copy of the service plan to the birth parents or the foster parents as required.
Plan of Correction:	Assistant TFC Supervisor will confirm documentation of birth parents involvement in collaboration with the Director of Foster Care Services and the Department of Quality Assurance as evidenced by weekly review of the files.
Standard #:	22VAC40-191-40-D-1-a
Description:	Violation: Based on a review of the required attachments for the renewal application and an interview with agency representatives, the agency failed to obtain background checks for a corporate officer before the end of 30 days after his appointment. Evidence: 1) Corporate officer (CO-3) was appointed on 11/22/19. 2) No criminal history record check results for (CO-3) were sent for review when required attachments to the renewal application were requested by the licensing specialist. 3) This licensing specialist noted that the background check results for CO-3 were not sent along with the other requested documents in an exit interview on 7/20/20 with AR-1, AR-2, AR-3, AR-4, AR-5, AR-6, and AR-7. 4) In a phone interview on 7/21/20, AR-7 acknowledged that they had sent in a request but never received the results.
Plan of Correction:	HR Director has established a quality assurance process with the Executive Assistant for the CEO to track due dates for Board of Trustee background checks.
Standard #:	22VAC40-191-40-D-1-c
Description:	Violation: Based on a review of the required attachments for the renewal application and an interview with agency representatives, the agency failed to obtain background checks for corporate officers and an agent before three years since the dates of their last background checks. Evidence: 1) The criminal history record check for CO-1 was dated 1/11/17. The sworn disclosure statement for CO-1 was dated 1/24/17. 2) The criminal history record check for CO-2 was dated 5/05/17. The central registry search for CO-2 was dated 4/19/17. The sworn disclosure statement was dated 2/09/17. 3) The criminal history record check for A-2 was dated 1/11/17. The central registry search was dated 12/02/16. 4) This licensing specialist noted that the background checks for corporate officers and an agent were outdated in an interview with agency representatives (ART-1, AR-2, AR-3, AR-4, AR-5, AR-6, AR-7) on 7/20/20. 5) In a phone interview with AR-7 on 7/21/20, AR-7 acknowledged that the background checks are outdated.
Plan of Correction:	HR Director has established a quality assurance process with the Executive Assistant for the CEO to track due dates for Board of Trustee background checks.