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. 17, 2023

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

Technical Assistance:

22VAC40-131-260.B.4, 8, and 9 Discussion regarding completion of all social history elements and/or documentation of efforts to obtain the information.

Comments:

Type of inspection: Monitoring An unannounced monitoring inspection was held on 11/17/2023 from 10:40 a.m. to 4:10 p.m. The Acknowledgement of Inspection form was signed and left at the facility on the date of the inspection. A preliminary findings review was held on the same date. Number of children in care: 15 Number of approved provider homes: 9 The licensing inspector completed a tour of the physical plant that included the office setting and conditions. Number of children?s records reviewed: 2 Number of provider homes reviewed: 3 Number of interviews conducted with staff: 1 Number of staff records reviewed: 2 An exit meeting was conducted on 11/27/23 to review the inspection findings. 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 #:	22VAC40-131-130-B
Description:	Violation: Based on record review and interview, the agency failed to provide a copy of the job description to Staff 2 (S2) at the time of employment. Findings: 1) S2 was hired on 6/26/23. 2) S2?s personnel record contained a job description dated 9/5/23. 3) The agency was provided an opportunity to obtain the missing document and provide to the licensing specialist by the following business day. 4) No job description from the time of employment was provided to the licensing specialist.
Plan of Correction:	HR- will review new staff orientation check list for compliance and timely documentation. AED and HR to review mainstream of new hires
Standard #:	22VAC40-131-180-N
Description:	Violation: Based on record review and interview, the agency failed to complete an addendum to Provider Home 1 (PH1) home study documenting a new adult household member. Findings: 1) PH1 was approved on 6/27/23. 2) PH1?s application documented no other household members. 3) The record contained a criminal history for Household Member 1 (HM1) dated 9/14/23. 4) The record contained a central registry background check for HM1 dated 10/4/23. 5) The licensing specialist did not find any documentation regarding a new household member in PH1?s record. 6) S1 confirmed that there was a new adult household member as of 9/15/23. 7) S1 reviewed the file as well and was unable to find additional documentation. 8) S1 acknowledged the finding.
Plan of Correction:	QAM-will monitor for changes in home upon monthly reviews for addendum completion Program Managers- to review home files weekly w/staff for chances and appropriate documentation needed for changes AED- review weekly w/PM client and home files for changes to be documented.
Standard #:	22VAC40-131-290-K
Description:	Violation: Based on record review and interview, the agency failed to obtain a tuberculosis screening or test regarding HM1. Findings: 1) The licensing specialist did not locate a completed tuberculosis screening/test for HM1 in PH1?s record. 2) S1 reviewed the file as well and was unable to find additional documentation. 3) S1 provided documentation on 11/20/23 of a tuberculosis screening of HM1 completed on 11/20/23.
Plan of Correction:	QAM-will monitor for changes in home upon monthly reviews for addendum completion Program Managers- to review home files weekly w/staff for chances AED- review weekly w/PM client and home files for changes to be documented.
Standard #:	22VAC40-191-40-D-4-a
Description:	Violation: Based on record review and interview, the agency failed to obtain a Sworn Statement from HM1 within 30 days of the move in date of 9/15/23. Findings: 1) PH1?s record contained two background checks regarding a new household member (HM1). 2) The licensing specialist did not find a Sworn Statement for HM1 in PH1?s record. 3) S1 reviewed the file as well and was unable to locate a Sworn Statement. 4) S1 acknowledged the finding. 5) S1 provided a signed Sworn Statement by HM1 dated 11/17/23.
Plan of Correction:	AED- will provide Licensing Standard training to all Program Managers for compliance. Program Managers to provide training to CM for licensure compliance QAM- monthly monitoring for Background checks for all individuals in the home are completed in a timely manner