VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Bair Foundation of Virginia
184 Business Park Drive
Suite 200
Virginia beach, VA 23462
(757) 424-2861

Current Inspector: Sherry Woodard (757) 987-0839

Inspection Date: Nov. 30, 2020 and Dec. 9, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-131 PERSONNEL 22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN'S SERVICES 63.2 General Provisions. 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 November 30, 2020 and concluded on December 09, 2020. The Therapeutic Foster Care Program Director was contacted by email to initiate the inspection. The agency reported 44 children in care, and 49 approved provider homes. The agency reports 2 new staff since the last inspection. Board Officer Records were reviewed. The inspector emailed the Program Director a list of items required to complete the inspection. The inspector reviewed 4 complete children records, 5 complete provider home records, and 4 staff records submitted by the agency to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the agency. 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 website within five business days, regardless of whether or not the Plan of Correction is completed.

Violations:

Standard #:	22VAC40-131-230-I-4
Description:	Violation: Based on the review of the records presented for Foster Home (FH)-4, the licensee failed to document the following in an addendum dated 11/17/2020: (a) circumstances and issues that lead to the suspension, (b) actions taken by the licensee as a result of becoming aware of the circumstances and issues, (c) actions taken by the provider to address each circumstance and issues and (d) the license?s response and disposition of whether the home warranted removal from suspension. Evidence: (1)According to documentation presented for review, the most recent addendum dated 11/17/2020 for FH-4, a suspended home did not document (a) circumstances and issues that lead to the suspension, (b) actions taken by the licensee as a result of becoming aware of the circumstances and issues, (c) actions taken by the provider to address each circumstance and issues and (d) the license?s response and disposition of whether the home warranted removal from suspension. (2)During the exit interview, AR1 and AR2 reviewed the information located in the record and confirmed that the most recent addendum dated 11/17/2020 did not document (a) circumstances and issues that lead to the suspension, (b) actions taken by the licensee as a result of becoming aware of the circumstances and issues, (c) actions taken by the provider to address each circumstance and issues and (d) the license?s response and disposition of whether the home warranted removal from suspension.
Plan of Correction:	All home suspension addendums will specify the reason for home suspension as well as the attempts that were made to prevent suspension. Supervisor will review suspension addendums and ensure that the required documentation is included. Foster parents with any physical limitations or disabilities developed after certification will require a plan for care surrounding their limitation included in the home study addendum. PERSON(S) RESPONSIBLE: Family Certification Specialist, Program Supervisors, Family Certification Specialist
Standard #:	22VAC40-131-250-M
Description:	Based on the review of the records presented for Foster Child (FC)-2 and based on an interview with agency representatives (AR), the licensee failed to prepare FC-2 for placement and arrange a preplacement visit for the child in the prospective home. Evidence (1)Based on the review of the documents presented for FC-2, the ?Prep for Placement? form dated 07/13/2020 documented that the child completed a pre-placement visit at a group home. (2)There was no documentation of a preplacement visit conducted in the prospective home. There was no documentation of why there was not a preplacement visit conducted in the prospective home. (3)During the exit interview, AR1 and AR3 reviewed the record and determined that there was no documentation of a preplacement visit in the prospective home and no documentation of why the preplacement visit did not take place in the prospective home.
Plan of Correction:	All pre-placements will be advocated to occur in the home. Documentation of the advocacy will be included in the Prep for Placement form. If a pre-placement did not occur in the home, the reason for pre-placement not occurring will also be included in the Prep for Placement form. PERSON(S) RESPONSIBLE: Program Supervisors and Intake Coordinator
Standard #:	22VAC40-131-290-F
Description:	According to the review of the documentation presented for FC-3 and based on an interview with agency representatives, the licensee failed to arrange follow up care for FC-3. Evidence: (1)Based on the review of the Foster Child (FC)-3?s records, a physical exam presented at the time of placement recommended that the youth follow up with an ENT and endocrinologist. (2)During an exit interview, AR1 and AR2 reviewed records and determined that there was no evidence of arrangements of recommended for the recommended follow-up medical care.
Plan of Correction:	All medical documentation will be thoroughly reviewed upon receipt to identify any follow-ups that are needed. Supervisors will review all child medical records for existing placements and create plan of action for medical follow-ups that are needed. All follow-up appointments will be scheduled upon notification that follow-up is needed. PERSON(S) RESPONSIBLE: Case Managers, Program Supervisors, Case Managers and Foster Parents
Standard #:	22VAC40-131-330-G-3
Description:	Based on the review of the Foster Child (FC) record for FC-1, FC-2 and FC-3 and based on an interview with agency representatives (AR), the licensee failed to document contacts that documented the training and guidance provided to foster parents. Evidence: (1)The documents presented, specifically, the ?VA Coaching Form? located in the records for FC-1, FC-2 and FC-3 documented behaviors and areas of training needs however, the documentation failed to document the training and guidance provided to the foster parents. (2)During the exit interview, AR1, AR-2 and AR-3 reviewed the VA Coaching Form and additional documents located in the record and acknowledged that there was no documentation of contacts that included documentation of training and guidance provided to foster parents.
Plan of Correction:	All Visit Coaching forms for current placements will detail specifically what interventions were provided to the foster parent from the case manager. Supervisors will monitor that the coaching is documented concisely in the visit coaching forms. Refresher training on visit coaching forms will be provided to all staff to encourage improvement with the use of this document. PERSON(S) RESPONSIBLE: Case Managers, Program Supervisors, Program Supervisors.
Standard #:	22VAC40-191-40-D-1-c
Description:	Violation: Based on the review of the personnel records presented for Board Officer 4 (BO), based on an interview with agency representatives (AR) and based on an email from AR-1; the licensee failed to obtain a sworn statement and criminal history record check before three years since the dates of the last. Evidence: (1)According to documentation presented for review, the date of the last criminal history record check was beyond three years since the last. (2) According to documentation presented for review, the date of the last sworn statement was beyond three years since the last. (3) During the exit interview, AR4 reviewed records and reached out to the cooperate office and was not able to provide documentation of a sworn statement or criminal history completed before three years since the last dated documentation. (4) In an email, AR1 acknowledged the absence of a sworn statement or criminal history completed before three years since the last dated documentation.
Plan of Correction:	Board member records will be tracked at the National office and maintained for timeliness. Board member records will be sent to the local offices prior to expiration. PERSON(S) RESPONSIBLE: National Director for Performance and Quality Assurance, Executive Assistant