VIRGINIA DEPARTMENT OF SOCIAL SERVICES

StepStone Family & Youth Services
3045 J Ordway Drive
Roanoke, VA 24017
(540) 400-0717

Current Inspector: Dawn Espelage (540) 759-8852

Inspection Date: May 29, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-131 ORGANIZATION AND ADMINISTRATION 22VAC40-131 PERSONNEL 22VAC40-131 CHILDREN?S SERVICES 22VAC40-131 ADDITIONAL REQUIREMENTS FOR SPECIFIC PROGRAMS 22VAC40-191 BACKGROUND CHECKS FOR CHILD WELFARE AGENCIES

Comments:

Type of inspection: Monitoring A monitoring inspection was initiated on 5/29/24 and concluded on 5/30/24. The Treatment Director was contacted by telephone to initiate the inspection. The Treatment Director reported that the current census was 5. The inspector emailed the Treatment Director a list of items required to complete the inspection. The inspector reviewed 1 resident record and 2 staff records submitted by the facility to ensure documentation was complete. An exit interview was conducted with the Treatment Director and Program Manager on 5/30/24, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. 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 #:	22VAC40-131-130-A
Description:	Violation: Based on record review, the agency failed to provide a written job description for Staff 2 (S2). Findings: 1) S2?s position was changed to Program Manager on 3/12/24. 2) The job description in the record was on a ?Rescare Community Living? form. 3) The job responsibilities reference ?group home;? such as ?service individuals in a group home,? ?serve as on call support for group homes,? and ?oversee accounts payable for the group homes.? 4) The job qualifications included a requirement of two years? experience working with the elderly and developmentally disabled population. 5) The finding was discussed at the exit.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-440-C-4
Description:	Violation: Based on record review, the agency failed to obtain a life skills assessment during the evaluation process. Findings: 1)Youth 1 (Y1) was admitted to the program on 2/21/24. 2)The record did not contain a life skills assessment. 3) The licensing inspector asked the agency if there was a life skills assessment that was not in the file. 3) Staff 2 provided a life skills assessment dated 5/29/24, the date of the inspection. 4) The finding was discussed at the exit on 5/30/24.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-440-D
Description:	Violation: Based on record review, the agency failed to document an orientation on the day of Y1?s admission: Findings: 1) Y1 was admitted on 2/21/24. 2) The orientation checklist in the record was signed on 4/17/24. 3) The finding was discussed at the exit on 5/30/24.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-440-D-4
Description:	Violation: Based on record review, the agency failed to develop an emergency preparedness and response plan at the time of admission for Y1. Findings: 1) Y1 was admitted on 2/21/24. 2) The record contained an emergency preparedness plan dated 3/29/24. 3) The finding was discussed at the exit on 5/30/24.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-440-H
Description:	Violation: Based on record review, the agency failed to complete an Individual Service Plan for Y1 within 30 days of the 2/21/24 admission. Findings: 1) The licensing inspector did not find an Individual Service Plan in the record. 2) Finding discussed at the exit on 5/30/24.
Plan of Correction:	Not available online. Contact Inspector for more information.