VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The PICF Training Institute, LLC
23 West Broad Street
Suite 402
Richmond, VA 23220
(804) 385-4171

Current Inspector: Sherry Woodard (757) 987-0839

Inspection Date: Oct. 1, 2019 , Oct. 2, 2019 , Oct. 15, 2019 , Oct. 22, 2019 and Oct. 24, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-131 ORGANIZATION AND ADMINISTRATION 22VAC40-131 PERSONNEL 22VAC40-131 ADDITIONAL REQUIREMENTS FOR SPECIFIC PROGRAMS 22VAC40-191 Background Checks for Child Welfare Agencies

Comments:

An unannounced monitoring inspection was conducted on October 1, 2019 from 11:15 a.m. to 4:25 p.m. and on October 2, 2019 from 9:34 a.m. to 2:00 p.m. The agency reports a total of fourteen youth in placement. There have been ten staff hired since the last inspection. Additional documentation was reviewed during a desk review on October 15, 2019 and October 22, 2019. During this inspection, one staff interview was conducted, two youth records were reviewed, and ten personnel records were reviewed (two personnel records were reviewed entirely and eight personnel records were reviewed for background investigations information only). Preliminary inspection findings were reviewed at the conclusion of the inspection with the Executive Director. An acknowledgement form was signed. A telephone exit meeting was held with the Executive Director on October 24, 2019. Upon the receipt of the violation notice, the licensee should identify the necessary corrective action and develop a plan of correction for each violation. The plan of correction should include the following: The steps to correct noncompliance with the standard(s); measures to prevent re-occurrence of noncompliance; position(s) responsible for implementation and monitoring of preventative measure(s); and date by which noncompliance will be corrected. The licensee has five (5) calendar days from receipt of the inspection documentation to complete the section titled Plan of Correction, sign each page of the documentation and return it to the Licensing Office. The licensee should retain a copy to be posted at the facility. Results of the inspection documentation are subject to public disclosure and will be posted on the VDSS web site within 5 days, regardless of whether the Plan of Correction is completed.

Violations:

Standard #:	22VAC40-131-150-B
Description:	Violation: Based on review of the personnel records for Staff S1 and Staff S2 and interview with the Executive Director, the agency failed to document all of the required initial orientation in the personnel records. Findings: 1. The personnel records for Staff S1 and Staff S2 did not document required initial orientation in the licensee's policies regarding discipline and behavior management and the licensee's emergency preparedness and response plan. 2. During the inspection, when the Licensing Specialist asked about the training, the Executive Director acknowledged that this required training had not been completed by Staff S1 and Staff S2.
Plan of Correction:	The New Hire Training Orientation has been revamped to include the Emergency Preparedness portion in the Agency Policy & Procedures section of orientation. In addition, the Behavior Management Training has been added to the Agency Policy & Procedures section of orientation.
Standard #:	22VAC40-131-370-Q-2
Description:	Violation Based on review of the record for a youth placed in an independent living arrangement, Youth1, and interview with the Executive Director, there was no documentation of a face-to-face visit with the youth during the month of May 2019. Findings: 1. A face-to-face visit with the youth was not documented for the month of May 2019. 2. During the inspection, the Executive Director was asked about the missing case notes, the Executive Director reported that the electronic record documentation for May had been deleted.
Plan of Correction:	The program has secured a comprehensive IT Firm to manage and provide security to all electronic devices and electronic records. The IT Firm secures data from breaches and provides a secure back up to all client records including electronic records to ensure that documents or entries into the electronic record can be deleted without proper authorization. In addition to the inception of the IT Firm?s services, we have implemented a CQI Team, comprised of the Operations Manager, Child Placing Supervisor, Resource Coordinator, and Executive Director to review all records quarterly for quality assurance measures.
Standard #:	22VAC40-191-40-D-1-b
Description:	Violation: Based on review of the personnel record for Staff S2 and interview with the Executive Director, the licensee failed to ensure the background checks were completed before 30 days of employment ended. Findings: 1. The Child Protective Services Central Registry Search result and criminal history record check were not completed before 30 days of employment ended. 2. During the exit meeting, the Executive Director acknowledged that, based on the date of hire that was documented in the personnel record at the time of the inspection, the background checks were not completed before 30 days of employment ended.
Plan of Correction:	The PICF Hiring Practice and Procedure has been revised to outline timeframes and start dates to assure that no newly hired individuals are working without proper background checks beyond the 30-day mark of hire. The Operations Manager will oversee this process. In addition, we will follow the procedures outlined in the Background Checks for Child Welfare Agencies.