VIRGINIA DEPARTMENT OF SOCIAL SERVICES

StepStone Family & Youth Services
207 West Main Street
Suite B-6
Christiansburg, VA 24073
(540) 394-7110

Current Inspector: Jamie Morgan (276) 525-5656

Inspection Date: Nov. 19, 2019

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:

Licensing Inspector provided technical assistance as to how the agency can demonstrate compliance with 22VAC40-131-160.2 (requirement for educational background of employees in the personnel record).

Comments:

An unannounced monitoring inspection was conducted on November 19, 2019 from 10:00 AM - 2:30 PM. Braley and Thompson reports a total of 10 provider homes and 8 foster children in placement. During this inspection, one provider home record, one foster child record, and one personnel record was reviewed. Two personnel were interviewed during the inspection. An exit interview was conducted at the conclusion of the inspection with the TFC Program Manager and Team Leader to review preliminary inspection findings. An acknowledgement form was signed. There were four violations. Upon the receipt of the violation notice, the licensee should identify the necessary corrective action and develop a plan of correction for each violation. The plan of correction should include the following: The steps to correct noncompliance with the standard(s); measures to prevent re-occurrence of noncompliance; person(s) responsible for implementation and monitoring of preventative measure(s); and date by which noncompliance will be corrected. The licensee has five (5) calendar days from receipt of the inspection documentation to complete the section titled Plan of Correction, sign each page of the documentation and return it to the Licensing Office. The licensee should retain a copy to be posted at the facility. Results of the inspection documentation are subject to public disclosure and will be posted on the VDSS web site within 5 days, regardless of whether the Plan of Correction is completed.

Violations:

Standard #:	22VAC40-131-230-E-4
Description:	Violation: Based on a review of the record for a Provider Home (PH1) and interview with personnel (S3), the licensee failed to obtain the results of a new tuberculosis screening for other household members (OHM). Evidence: 1. According to the re-evaluation for PH1 in the record of PH1, OHM1, OHM2, OHM3, OHM4 and OHM5 come in contact with children as described in 22VAC40-131-290-K. 2. The re-evaluation process for PH1 did not include obtaining the results of a new tuberculosis screening documenting the absence of tuberculosis in a communicable form for OHM1, OHM2, OHM3, OHM4, and OHM5. 2. During the exit interview S3 was asked if tuberculosis screenings were completed for household members during the re-evaluation. Personnel, S3, stated that this was her first re-evaluation completed and she did not obtain results of a TB assessment for OHM1, OHM2, OHM3, OHM4, and OHM5 as part of the re-evaluation processing for approving PH1.
Plan of Correction:	All staff will receive training on the Standard addressing certification and recertification of foster homes, including all components of the original home study, being present and up-to-date in the recertification process. Compliance Coordinator will work with the Team Leader in this office on the usage of the database tool to audit files monthly.
Standard #:	22VAC40-131-340-B-2
Description:	Violation: Based on a review of the record for Foster Child (FC1) and interview with personnel (S2), the licensee failed to develop an individualized service plan for the child. Evidence: 1. FC1 was placed with the licensee 162 days prior to the date of inspection and placed at the treatment level. 2. At the time of review, the record for FC1 failed to document an individualized treatment plan. 3. When asked about the individualized service plan during the exit interview, S2 looked for the individualized service plan. S2 acknowledged that she was unable to locate a completed individualized service plan for FC1.
Plan of Correction:	Service Plan for FC1 has been placed in the file. Compliance Coordinator will work with the Team Leader in this office on the usage of the database tool to audit files monthly.
Standard #:	22VAC40-131-350-A
Description:	Violation: Based on a review of the record for FC1 and interview with personnel (S2), the licensee failed to complete the report of progress no later than 90 days from the child's date of placement. Evidence: 1. The record for FC1 was reviewed. FC1 was placed 162 days prior to the date of the inspection. 2. The first progress report was due within 90 days of placement. 3. The record for FC1 did not contain a progress report. 4. During an interview with personnel (S2), S2 looked for the progress report and acknowledged that she was unable to locate a quarterly progress summary for FC1.
Plan of Correction:	Progress Report for FC1 has been placed in the file. Compliance Coordinator will work with the Team Leader in this office on the usage of the database tool to audit files monthly.
Standard #:	22VAC40-191-40-D-1-b
Description:	Violation: Based on a review of the personnel file for an employee (S1) and interview with personnel (S3), the central registry search for S1 was not received before 30 days of employment at the facility ended. Evidence: 1. The central registry search report for S1 was dated 57 days after the employee's date of hire. 2. During the exit interview, S2 was asked about the date of the report. S2 acknowledged that the central registry search report for S1 was dated more than 30 days after S1's date of hire and that criteria for an exception to this violation as described in 22VAC40-191-60.D was not met.
Plan of Correction:	If by day 30 of the new employee's date of hire, The Background checks from OBI have not been received for said staff member, the State Trainer will request an update via email to OBI within four days of the 30th day of hire. If OBI does not respond, B&T will contact VADSS Licensing and continue to contact OBI for information.