VIRGINIA DEPARTMENT OF SOCIAL SERVICES

StepStone Family & Youth Services operated by Braley & Thompson
2701 Emerywood Parkway
Suite 102
Richmond, VA 23228
(804) 756-3561

Current Inspector: Dawn Espelage (540) 759-8852

Inspection Date: Sept. 3, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN'S SERVICES 22VAC40-131 ADDITIONAL REQUIREMENTS FOR SPECIFIC PROGRAMS 22VAC40-80 THE LICENSE.

Comments:

An unannounced monitoring inspection was completed on September 3, 2019 from 1:30 p.m. to 4:45 p.m. The licensee reports 15 children in foster care and 12 approved provider homes. During this inspection, two children records and two provider home records were reviewed. The program manager and case manager were available for the inspection. The program manager participated in the exit interview which commenced at 4:00 p.m. on September 3, 2019. The state director participated in the exit interview via telephone. An acknowledgment form was signed by the program manager and left at the end of the inspection. There were eight citations for violations of the Standards for Child-Placing Agencies. See the violation notice on the Department's public web site for violations of the Standards. 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 #:	22VAC40-131-210-D
Description:	Violation: Based on a review of the record for Foster Home (FH) FH1 and interview with the program manager, the licensee failed to ensure the providers completed annual training. Findings: FH1's initial approval was on 9/23/15. At the time of review the record for FH1 documented the most recent training as being on 8/29/17. During an interview with the program manager, it was acknowledged that the required annual training was not documented as being completed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-250-O
Description:	Violation: Based on a review of the record for Foster Child (FC) FC1 and interview with the program manager, the licensee failed to ensure the written assessment contained all of the elements required by 22VAC40-131-250-G. Findings: FC1 was placed with the licensee on 2/22/19. The record for FC1 documents a written assessment dated 3/21/19. The written assessment fails to document the names of the individuals involved in staffing FC1's case and FC1's adjustment to school. During an interview with the program manager, it was acknowledged that the written assessment was missing the required information.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-290-D
Description:	Violation: Based on a review of the record for FC1 and interview with the program manager, the licensee failed to ensure a copy of the medical examination was documented in the record. Findings: FC1 was placed with the licensee on 2/22/19. The record for FC1 documents a Commonwealth of Virginia Client Health Information Form that states the last medical examination completed for FC1 was on 1/3/19. However, a copy of the medical examination was not documented in the record. During an interview with the program manager, it was acknowledged that the medical examination was not in the record at the time of review.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-290-J
Description:	Violation: Based on a review of the record for FC1 and interview with the program manager, the licensee failed to ensure the child's record documented the prescribed medications intended effects and adverse reactions. Findings: FC1 was placed on 2/22/19. FC1's record documents prescribed psychotropic medications. However, the record failed to document the prescribed medications intended effects and adverse reactions experienced by the child. During an interview with the program manager, it was acknowledged that the record failed to document the required information.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-330-G
Description:	Violation: Based on a review of the record for Foster Child (FC) FC1 and interview with the program manager, the licensee failed to ensure the contacts with FC1 documented training and guidance provided to the foster parents, and private interview with the child as least once a month. Findings: The contact notes reviewed for FC1 failed to document training and guidance provided to the foster parents. Contact notes for the months of April-July 2019 failed to document at least one private interview with the child monthly. During an interview with the program manager it was acknowledged that the contact notes were out of compliance.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-330-J
Description:	Violation: Based on a review of the record for Foster Child (FC) FC1 and interview with the program manager, the licensee failed to ensure the contacts made with the child included the signature of the staff person who made the contact. Findings: The contact notes documenting contact made with FC1 on; 3/4, 4/7, 4/13, 5/15, 5/20, 6/15, and 7/19/19 failed to include the signature of the staff person who made the contact. During an interview with the program manager, the contacts provided to the licensing inspector by the case manager were discussed and it was acknowledged that the contacts were out of compliance.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-340-B-2
Description:	Violation: Based on a review of the record for FC1 and interviews with the case manager and program manager, the licensee failed to develop an individualized service plan for the child. Findings: FC1 was placed with the agency on 2/22/19. At the time of review, the record failed to document an individualized service plan. During an interview with the case manager and program manager, it was acknowledged that the individualized service plan had not been completed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-350-B
Description:	Violation: Based on a review of the record for FC1 and interview with the program manager, the licensee failed to document the progress reviews in written summaries. Findings: FC1 was placed with the licensee on 2/22/19. At the time of review the record failed to document any written quarterly progress reviews. During an interview with the program manager, it was acknowledged that the required reports were not completed.
Plan of Correction:	Not available online. Contact Inspector for more information.