VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The PICF Training Institute, LLC
1435 Hull Street
Richmond, VA 23224
(804) 385-4171

Current Inspector: Sherry Woodard (757) 987-0839

Inspection Date: Feb. 11, 2020 and Feb. 12, 2020

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 renewal inspection was conducted on February 11, 2020 from 9:45 a.m. to 4:07 p.m. A desk audit to review additional documentation was conducted on February 12, 2020. The agency reports a total of 6 youth in independent living arrangement placements. There has been 2 staff hired since the last inspection. During this inspection, two staff interviews were conducted and personnel and youth records were reviewed for six staff and two youth (1 current in care and 1 discharge). Preliminary inspection findings were reviewed at the conclusion of the inspection with Staff S1 and Staff S7. An acknowledgement form was signed. An exit meeting was held via telephone with Staff S1 on February 12, 2020. 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; person(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 #:	22VAC40-131-40-B
Description:	Violation: Based on review of the record for a youth placed in an independent living arrangement, Youth 1, and interview with Staff S1, the licensee failed to comply with its own policies and procedures. Findings: 1. Review of the licensee's policies and procedures manual revealed "all youth participants must have a completed application packet before being admitted to the program". 2. An application was not located in the record for Youth 1. 3. During an interview with the Licensing Specialist, S1 stated that an application had been requested but had not been received prior to Youth 1's admission into the program.
Plan of Correction:	The CEO and Child Placing Supervisor will assure that the youth application is completed during the referral process. In instances where the youth has difficulty with completing the application on their own, PICF staff will support the youth with its completion and the CEO or Operations Manager will consult with Licensing for support and guidance.
Standard #:	22VAC40-131-150-B-1
Description:	Violation: Based on a review of the personnel (staff) record for Staff S5 and interview with Staff S1 and Staff S7, the licensee failed to ensure the required orientation was completed. Findings: 1. The personnel record for S5 documents initial orientation, however, fails to document initial orientation as required by 22VAC40-131-(3)-150-B.1.b. 2. During an interview with the Licensing Specialist, S7 acknowledged that orientation in S5's applicable position job description was not documented (this was marked "N/A").
Plan of Correction:	The CEO and Operations Manager will assure that all staff complete orientation within 30 days of hire regardless of type of position. All required trainings will be completed within the first 30 days of hire. The CEO will perform an audit of the personnel record prior to the end of the first 30 days to assure compliance.
Standard #:	22VAC40-131-160-B-10
Description:	Violation: Based on a review of the personnel (staff) record for Staff S5 and interview with Staff S7, the agency failed to ensure a job description was included in the personnel (staff) record. Findings: 1. The personnel (staff) record did not include a job description for S5. 2. During an interview with the Licensing Specialist, Staff S7 acknowledged that a job description was not included in the personnel (staff) record for S5.
Plan of Correction:	The CEO and Operations Manager will assure that all staff sign a job description within the 30 days of hire regardless of type of position. The CEO will perform an audit of the personnel record prior to the end of the first 30 days to assure compliance.
Standard #:	22VAC40-131-160-B-5
Description:	Violation : Based on review of the personnel (staff) records for Staff S1, Staff S2, and Staff S3, annual performance evaluations were not documented in the personnel records. Findings: 1. Annual performance evaluations were not documented in the personnel records, as required by this standard, for S1, S2, or S3. 2. During an interview with the Licensing Specialist, Staff S1 and S7 reported that evaluations had been completed for S2 and S3 but the evaluations were not located in the personnel records during the inspection. 3. During an interview with the Licensing Specialist, S1 reported that an annual performance evaluation had not been completed.
Plan of Correction:	The agency's policy for annual performance evaluations will be revised to indicate that all staff will be evaluated during the month of February each year in conjunction with the Annual Staff Training and Retreat.