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: Aug. 8, 2024 and Aug. 9, 2024

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:

22VAC40-131-200.G.3 Discussion ? capacity should match on the approval letter and certificate of approval.

Comments:

Type of inspection: Monitoring An unannounced monitoring inspection was held 8/8/24 from12:30 to 4:00 p.m. and 8/9/24 from 12:30 to 5:30 p.m. An entrance conference was held with the treatment director. The Acknowledgement of Inspection form was signed, and a copy left at the facility on 8/8/24. A preliminary findings review was held on 8/13/24. The exit was held via e-mail 8/16/24 after drafts were reviewed. Number of children in care: 24 Number of approved provider homes: 22 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: 3 Number of staff records reviewed: 3 Number of staff interviewed: 1 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 #:	22VAC40-131-160-B-3
Description:	Violation: Based on record review, the agency failed to obtain required references for S2 and S3. Findings: 1) S2 was hired on 3/18/24. 2) S2?s file did not contain references. 3) S3 was hired 3/21/24. 4) The record did not contain references. 5) The agency was provided additional time to find the documentation. 6) S1 acknowledged the finding.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-230-C
Description:	Violation: Based on record review, the agency failed to complete all elements of the re-evaluation of PH3. Findings: 1) A re-evaluation was completed on 9/11/23. 2) The case worker signed and dated the update on 9/11/23. 3) The director/designee signature line was blank (E.8). 4) The agency failed to document a consultation with the supervisor for the approval (G). 5) The agency failed to address the relationships between each child, other children in the home, and family members (F.3). 6) The agency failed to provide a reason for discharge for each former placement in the provider home (F.3). 7) Agency staff acknowledged the finding during the preliminary findings review.
Plan of Correction:	TD reviwed with PM and Quality 8/13/24 Assurance Manager the need for documentaiton review prior to approvl
Standard #:	22VAC40-131-250-M
Description:	Violation: Based on record review and interview, the agency failed to complete pre-placement activities with FC1. Findings: 1) The file contained a referral dated 4/22/24, with placement needed by 5/2/24. 2) Per the written assessment, placement was made on 5/2/24 and no pre-placement occurred due to an ?emergency? placement. 3) No other documentation was located in the record describing efforts to complete pre-placement. 4) Agency staff acknowledged the finding at exit.
Plan of Correction:	TD reviewed w/PM Placement guidelines and for emergencey and planned placement needs and documentation
Standard #:	22VAC40-131-260-A
Description:	Violation: Based on record review, the agency failed to complete a social history within 45 days of placement for FC3. Findings: 1) FC3 was placed on12/27/03. 2) The record contained a social history dated 3/27/24, beyond the 45-day requirement. 3) Agency staff acknowledged the finding during the exit review.
Plan of Correction:	Quality Assurance Manager will run 30 day reports and send to PM and CM' to stay ahead of late documenation
Standard #:	22VAC40-131-260-B
Description:	22VAC40-131-260.B4, 7 & 8 Violation: Based on record review, the agency failed to complete all elements of the social history for FC3. Findings: 1) The record contained a social history dated 3/27/24. 2) Information regarding pre-natal history, family structure and relationships, and family educational and vocational history was not completed. 3) The record did not contain documented efforts to obtain this information. 4) The record did contain documentation that the case manager had met and spoken with FC3?s mother at least on 7/9/24. 5) The documentation did not indicate that additional social history information was gathered. 6) S1 acknowledged the finding.
Plan of Correction:	review of violation w/ Staff to correct documenation errors
Standard #:	22VAC40-131-290-C-12
Description:	Violation: Based on record review, the agency did not have an immunization record for FC1. Findings: 1) FC1 had a physical exam dated 4/1/24, prior to placement with this agency. 2) The physical exam form left the immunization record blank with a statement that there were no records. 3) The file did not have any documented efforts to obtain an updated immunization record. 4) Agency staff was given an opportunity to determine if there was additional information. 5) Staff acknowledged the finding during the exit review. 6) Staff received the immunization records on 8/13/24.
Plan of Correction:	TD reviwed w/all PM and Quality Assurance Manager- Guidelines for client physicals and review of records prior to documentation approval
Standard #:	22VAC40-131-320-E
Description:	Violation: Based on record review, the agency failed to provide a serious incident report within 24 hours to licensing for a serious incident regarding FC2 dated 5/12/24. Findings: 1) The record contained an incident report dated 5/12/24. 2) The incident resulted in hospitalization of FC2. 3) The licensing inspector did not find a notification to licensing of the incident. 4) The agency was provided an opportunity to provide documentation of the licensing notification. 5) S1 stated there was no further information. 6) Agency staff acknowledged the finding during the exit review.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-330-G-1
Description:	Violation: Based on record review, the agency failed to complete face to face contact twice in January 2024 and June 2024 for FC3. Findings: 1) Case narrative reflected one face to face of FC3. 2) A second home visit had been scheduled for 1/19/24 but was canceled due to inclement weather. 3) Phone contact was made with the foster father on 1/19/24 for an update of FC3?s progress. 4) A face to face with FC3 was not re-scheduled. 5) Case narrative documented one home visit in June 2024. 6) A second visit was completed at FC3?s daycare. 7) The case narrative did not document if the child was seen during the community visit, observations of the child?s condition, or any other indication that FC3 was at the daycare at the time of the contact with the daycare teacher. 8) Agency staff acknowledged the finding during the exit review.
Plan of Correction:	TD reviwed w/staff 8/13/24 violation and the need to maintain appropriate level documentaion and PM need for through review
Standard #:	22VAC40-191-40-D-1-b
Description:	Violation: Based on record review, the agency failed to obtain required background checks within the allowed timeframe for S2 and S3. Findings: 1) S2 was hired on 3/18/24. 2) S2?s file did not contain a Sworn Statement of Affirmation. 3) S3 was hired 3/21/24. 4) The Central Registry background check was dated 8/8/24. 5) The agency was provided time to find the Sworn Statement as well as additional documentation regarding the late Central Registry. 6) S1 acknowledged the finding.
Plan of Correction:	TD reviewed w/ED HR Findings ED will review with new HR coordintar Compliance regulations