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: Nov. 6, 2020

Complaint Related: No

Areas Reviewed:

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. An announced renewal inspection was initiated on 11/6/2020 and concluded on 11/16/2020. The program director was contacted by telephone to initiate the inspection. The agency reported 13 children in care, and 12 approved provider homes. The inspector emailed the program manager a list of items required to complete the inspection. The inspector reviewed 2 children records and 2 provider home records. The agency previously submitted COVID-19 policies and procedures. An exit interview was conducted by telephone on 11/12/2020 at approximately 2:30 pm with the program manager. An additional interview was conducted on 11/16/2020 at approximately 10:10 am with the program manager. 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. There were 6 citations for violation of the Standards for Child-Placing Agencies. 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 #:	22VAC40-131-180-I
Description:	Violation: Based on review of the record for Foster Home (FH) FH1 and interview with AR2, the licensee failed to include information received in the file. Findings: 1. The home study for FH1 documents previous approval with another child placing agency. 2. The record documents a signed authorization to release information for the previous agency. 3. At the time of review, the record for FH1 failed to document information received from the previous agency. 4. During an interview, AR2 acknowledged the information was not in the record.
Plan of Correction:	PM has retrained case management staff to ensure that ALL required documentation is acquired and documented in the home study. Facility currently has a compliance officer that reviews all foster
Standard #:	22VAC40-131-180-M
Description:	Violation: Based on review of the home study for Foster Home (FH) FH2 and interview with AR2, the licensee failed to consider all information received prior to making a decision to approve. Findings: 1.Provider (P) P1 resides in FH2. 2.The sworn disclosure for P1 documents "public intoxication". 3.The home study for FH2 fails to document the "public intoxication" was addressed prior to approving FH2. 4.During an interview with AR2, it was acknowledged that the information on P1's sworn disclosure was not documented as being considered prior to approval of FH2.
Plan of Correction:	Public intoxication is not listed as a barrier crime preventing individuals from becoming foster parents. However, all staff (CM, PM, TFP trainer) will be retrained to treat all disclosures as if they were potential barrier crimes and document due diligence within the home studies of incoming foster parents.
Standard #:	22VAC40-131-250-O
Description:	Violation: Based on review of the record for FC1 and interview with AR2, the licensee failed to include in the written assessment the names of individuals involved in staffing FC1's case . Findings: 1.The written assessment completed for FC1 failed to include the names of the individuals involved in staffing the case as required by 22VAC40-131-250-G. 2.During an interview with AR2 it was acknowledged that the names of agency staff were not documented.
Plan of Correction:	PM will provide Licensing Standards training to all case managers with clear focus on documentation processes (to include expectations of documentation for assessments, home studies, and case notes, etc). The written assessment for FC1 will be addended to include the names of agency staff that were involved in the staffing of FC1?s case.
Standard #:	22VAC40-131-290-F
Description:	Violation: Based on review of the record for Foster Child (FC1) and interview with Agency Representative (AR2), the licensee failed to ensure FC1 received recommended medical care follow-up. Findings: 1. FC1's record documents a medical examination dated, 11/22/19, with recommended follow up to see a cardiologist. 2. At the time of review, documentation of the recommended medical care for FC1, from the 11/22/19 medical visit was not in the record. 3. During an interview with AR2, it was acknowledged that FC1's record did not document receipt of recommended medical care follow up.
Plan of Correction:	Documentation of FC1 receiving medical follow-up on 1/8/20 was received from the local DSS, confirming that FC1 is in good health and no further follow-up for her condition was necessary. All medical appointments and issues occurred prior to FC1 being placed with this agency. PM will retrain all staff to carefully read over medical documents and to follow-up on any current or past recommendations that were made.
Standard #:	22VAC40-131-340-E-1
Description:	Violation: Based on review of the record for FC1 and interview with AR2, the licensee failed to include a comprehensive assessment of FC1's medical needs. Findings: 1.The record for FC1 documents a medical examination dated,11/22/19 that was received by the licensee on 3/5/20. 2.The medical examination documents medical needs and recommended follow up. 3. The record for FC1 contains the individualized service plan completed for FC1 dated, 4/15/20. 4. The service plan fails to include the medical needs from the 11/22/19 medical visit. 5. A comprehensive assessment of FC1's medical needs was not included in the service plan 6. During an interview, AR2 acknowledged the service plan was out of compliance.
Plan of Correction:	PM shall retrain staff about including all disclosed medical information and follow-ups on the Individualized Services Plans, as well as ensuring follow-ups and results, if applicable, are documented on all Comprehensive Individualized Services Plans. An addendum will be added to FC1?s ISP regarding follow-up documentation of FC1?s medical visit that took place prior to FC1 being placed with this agency.
Standard #:	22VAC40-131-350-B-14
Description:	Violation: Based on review of the record for FC1 and interview with AR2, the licensee failed to include the dates of progress covered for the review. Findings: 1.The record for FC1 documents a progress review dated, 9/14/20. 2.The progress review fails to include the dates the progress review covers. 3. During an interview with AR2, it was acknowledged that the progress review failed to document coverage dates.
Plan of Correction:	PM has retrained all staff regarding the requirement to provide completed information on documents per the Licensing Standards. The quarterly report reviewed for this violation has been revised to include the dates of progress covered for the quarterly review.