VIRGINIA DEPARTMENT OF SOCIAL SERVICES

StepStone Family & Youth Services
2201 Graves Mill Road
Suite D
Forest, VA 24551
(434) 832-1326

Current Inspector: Dawn Espelage (540) 759-8852

Inspection Date: Sept. 22, 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:

22VAC40-131-360 Discussion regarding clarity in the Discharge Summary regarding progress, condition of child, and ?discharged to.?

Comments:

Type of inspection: Monitoring An unannounced monitoring inspection was held 9/22/23 from 10:50 a.m. to 5:00 p.m. An entrance conference and preliminary findings review were held on this date. The Acknowledgement of Inspection form was signed, and a copy left at the facility. Number of children in care: 31 Number of approved provider homes: 16 The licensing inspector completed a tour of the physical plant that included the office setting and conditions. Number of children?s records reviewed: 4 Number of provider home records reviewed: 2 Number of staff records reviewed: 1 Number of staff interviewed: 1 An exit meeting was held on 9/26/23 with the Executive Director, Associate Executive Director, and Program Manager. 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 #:	22VAC40-131-180-M
Description:	Violation: Based on record review and interview, the agency failed to document consideration of all information received prior to approval of provider home one (PH1). Findings: 1) PH1 was approved 5/5/23. 2) PH1?s driving record reflected a negative point balance. 3) The home study did not address the negative DMV point balance. 4) No other documentation was found in the record to indicate there had been a discussion regarding the driving record. 5) S3 acknowledged that PH1?s driving record was not discussed during the home study. 6) S3 acknowledged the finding.
Plan of Correction:	Training around the standard of "assessing all information" prior to HS approval will be provided to all licensing specialists and supervisors involved in the home study and home assessment and approval process. Staff approving foster homes will review all information gathered and ensure each piece of information obtained was fully assessed prior to approving the home study.
Standard #:	22VAC40-131-250-O
Description:	Violation: Based on record reviews and interview, the agency failed to complete and file written assessments within 30 days of placement. Findings: 1) Foster Child (FC)1 was placed on 8/10/23. 2) On the date of the inspection (9/22/23), the written assessment was not located in the record. 3) Agency staff was given an opportunity to locate and provide the written assessment by the following business day in case it had been overlooked in the record. 4) S3 provided an assessment on 9/25/23, dated 9/15/23 and signed by the supervisor on 9/23/23. 5) Agency staff acknowledged the finding at exit.
Plan of Correction:	Executive Director will ensure case workers and supervisors are aware of the written assessment due date Executive Director will check extended reach to ensure due date triggers are accurate. Quality Assurance Manager will ensure Written Assessments are tracked and completed by date due.
Standard #:	22VAC40-131-290-F
Description:	Violation: Based on record review, the agency failed to document follow up for additional dental needs regarding FC3. Findings: 1) FC3 had a dental checkup and cleaning on 5/4/23. 2) The dental exam form noted many cavities with a recommendation for a follow-up with a pediatric dentist. 3) Information regarding additional dental appointments was not found in the case record. 4) Agency staff was given an opportunity to determine if there was additional information regarding a follow-up dental appointment with a pediatric dentist. 5) Upon interview of the case worker, then foster parent, a follow up appointment was scheduled on 12/6/23 and child placed on a cancellation list for a sooner appointment. 6) Staff acknowledged the finding during the exit review.
Plan of Correction:	Program manager will review medical and dental records to ensure follow up of recommendations is clearly documented. Executive Director will provide training to case managers around how and where to document compliance with recommended dental follow-up. Quality Assurance Coordinator will review records monthly, ensuring recommendations for dental follow-up are documented clearly.
Standard #:	22VAC40-131-370-Q-2
Description:	Violation: Based on record review, the agency failed to maintain narrative case notes addressing all elements of the chapter regarding private contacts with FC3. Findings: 1) FC3 had two visits in August 2023 ? 8/16/23 and 8/31/23. 2) Both contacts documented conversations and observation during the home visit. 3) Neither case note reflected that FC3 was spoken to privately. 4) Agency staff was given an opportunity to see if other contacts were made but not documented in the case record. 5) A monthly report was provided dated 9/5/23 that referenced a private interview was held in August (no date or details) and did not indicate any concerns 6) Agency staff acknowledged the finding during the exit review.
Plan of Correction:	Executive Director will review documentation forms to ensure they accurately capture information regarding the required monthly private interview. Executive Director will provide training to staff regarding the purpose and expected content of the required contact and how to accurately document to reflect compliance and interaction with child. Quality Assurance Coordinator will assess documentation around individual contacts monthly and ensure a detailed report of all contacts is present in the case notes.