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: March 4, 2024 and March 5, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-131 GENERAL PROVISIONS 22VAC40-131 ORGANIZATION AND ADMINISTRATION 22VAC40-131 PERSONNEL 22VAC40-131 PROGRAM STATEMENT 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:

22VAC40-131-140.D.3 Discussion regarding accurate job description.

Comments:

Type of inspection: Renewal An unannounced monitoring inspection was held on-site 3/4/24 from 11:00 a.m. to 4:25 p.m. and virtually for staff records on 3/5/24. An entrance conference and preliminary findings review were held on 3/4/24. The Acknowledgement of Inspection form was signed, and a copy left at the facility. Number of children in care: 27 Number of approved provider homes: 17 The licensing inspector completed a tour of the physical plant that included the office setting and conditions. Number of children?s records reviewed: 3 Number of provider home records reviewed: 2 Number of staff records reviewed: 6 Number of staff interviewed: 2 An exit meeting was conducted 3/13/24. 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 #:	22VAC40-131-250-O
Description:	Violation: Based on record reviews and interview, the agency failed to complete and file a written assessment within 30 days of placement. Findings: 1) Foster Child (FC) 3 was placed on 12/27/23. 2) On the date of the inspection (3/4/24), 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) The licensing inspector did not receive additional documentation. 5) Preliminary findings were discussed on 3/4/24.
Plan of Correction:	Weekly supervisions with staff to include monitoring of client files for compliance. Quality Assurance Manager will Monitor 10% of client files for ooeration. Treatment Dr .will meet weekly with Program Manager to review files for compliance over the next 6 months.
Standard #:	22VAC40-131-280-A
Description:	Violation: Based on record review, the agency failed to obtain a Foster Home Agreement for FC3. Findings: 1) FC3 was placed 12/27/23. 2) The file did not contain documentation of a signed foster home agreement. 3) The agency was provided with additional time to locate documentation. 4) The licensing inspector did not receive additional documentation. 5) Preliminary findings were discussed on 3/4/24.
Plan of Correction:	Weekly supervisions with staff to include monitoring of client files for compliance. Quality Assurance Manager will Monitor 10% of client files for operation. Treatment Dr .will meet weekly with Program Manager to review files for compliance over the next 6 months.
Standard #:	22VAC40-131-290-C-12
Description:	Violation: Based on record review, the agency failed to obtain immunization records within 60 days for the medical report. Findings: 1) FC3 was placed 12/27/23. 2) The file contained documentation of a physical exam dated 1/27/24. 3) The file did not contain FC3?s immunization record. 4) The licensing inspector did not find additional documented efforts to obtain the immunization record. 5) The agency was provided with additional time to locate documentation. 6) The licensing inspector did not receive additional documentation. 7) Preliminary findings were discussed on 3/4/24.
Plan of Correction:	Weekly supervisions with staff to include monitoring of client files for compliance. Quality Assurance Manager will Monitor 10% of client files for operation. Treatment Dr .will meet weekly with Program Manager to review files for compliance over the next 6 months.
Standard #:	22VAC40-191-40-D-1-b
Description:	Violation: Based on record review and interview, the agency failed to obtain required background checks within 30 days of employment for Staff (S) 1 and 6. Findings: 1) S1 was hired on 1/16/2024. 2) S1?s record did not contain a Central Registry. 3) S7 acknowledged the Central Registry had not been completed. 4) S6 was hired on 1/12/24. 5) S6?s record did not contain the Central Registry. 6) S7 acknowledged that the Central Registry had not been completed.
Plan of Correction:	HR Manager will maintain a compliance checklist for each new hire and completed prior to a staff start date
Standard #:	22VAC40-191-40-D-1-c
Description:	Violation: Based on record review and interview, the agency failed to obtain required background checks within 3 years from the prior background checks for Board member 2 (B2). Findings: 1) B2?s initial Central Registry was dated 3/4/20. 2) The licensing specialist requested the most recent Central Registry. 3) S7 forwarded the request to another HR office. 4) At the time of this writing, the licensing specialist has not received an updated Central Registry.
Plan of Correction:	ED will notify HR manager of any new board member changes. HR manager will review dates of background checks for compliance
Standard #:	22VAC40-191-40-D-1-f
Description:	22VAC40-191.40.D.1.e e. Foster parent approved by a Sworn statement Before three years since licensed child-placing agency, or affirmation, the dates of the last sworn in an independent foster home, search of central statement or affirmation, or an adoptive parent registry, and most recent central approved by a licensed child- criminal history registry finding, and most placing agency, until the record check recent criminal history adoption is final record check report or national criminal background check Violation: Based on record review, the agency failed to obtain required background checks within three years from the prior background checks and prior to re-approval for Provider Home 2 (PH2). Findings: 1) PH2 was re-approved on 10/5/23. 2) PH2?s file did not contain an updated Criminal History. 3) The agency completed and obtained a new criminal history for PH2 on 3/5/24. 4) Preliminary findings were discussed on 3/4/24.
Plan of Correction:	Weekly supervisions with staff to include monitoring of client files for compliance. Quality Assurance Manager will Monitor 10% of client files for operation. Treatment Dr .will meet weekly with Program Manager to review files for compliance over the next 6 months.
Standard #:	22VAC40-191-40-D-1-g
Description:	Violation: Based on record review, the agency failed to obtain required background checks within three years from the prior background checks and prior to re-approval of Household Member 1 (HM1) for PH2. Findings: 1) PH2 was re-approved on 10/5/23. 2) PH2?s file did not contain an updated Criminal History for HM1. 3) The agency completed and obtained a new criminal history HM1 on 3/5/24. 4) Preliminary findings were discussed on 3/4/24.
Plan of Correction:	Weekly supervisions with staff to include moniloring of client files for compliance. Quality Assurance Manager will Monitor 10% of client files for operation. Treatment Dr .will meet weekly with Program Manager to review files for compliance over the next 6 months.