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: Nov. 10, 2020 and Nov. 20, 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:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on November 10, 2020 and concluded on November 20, 2020. The Executive Director was contacted by telephone to initiate the inspection. The Executive Director reported there were 8 youth in placement. There have been two staff hired since the last inspection. The inspector emailed the Executive Director a list of items required to complete the inspection. The inspector reviewed two youth records and two staff records submitted by the agency to ensure documentation was complete. Exit meeting was held with the Executive Director on November 20, 2020. The agency submitted their COVID-19 policies and procedures. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the agency. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return to the Licensing Office within 5 business days from receipt of the inspection documentation. You will need to specify how the deficient practice will be or has been corrected (merely writing the word corrected is not acceptable). Your plan of correction must contain the steps to correct the noncompliance with the standard(s), the measures to prevent the noncompliance from occurring again; and the position responsible for implementing each step and/or monitoring any preventive measure(s). 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 #:	22VAC40-131-440-C-3
Description:	Violation: Based on review of Document 1 and Report 1, and interview with agency representative AR1, the agency failed to demonstrate evaluation of the youth?s readiness for placement by accepting a youth (Youth 1) for placement in an independent living arrangement. Youth 1?s history did not demonstrate maturity and emotional stability and failed to consistently maintain behavioral stability in prior placements. Findings: 1. The record for Youth 1 contained a document, Document 1, dated 09/09/2020. The information in Document 1 was provided to the licensee by the legal guardian prior to placement. Review of Document 1 revealed: ?(Youth 1) will say she knows how to live independently but she needs help in understanding what goes into providing for herself?. ?(Youth 1) can get easily agitated.? ?(Youth 1) has a hard time processing ?No?. ?(Youth 1) has a history of AWOL.? 2. The record for Youth 1 contained a residential treatment report, Report 1, dated 08/06/2020. Report 1 is date stamped received by the agency on 09/09/2020. Review of Report 1 revealed: ?(Youth 1) exhibits a history of self-harm, suicide attempts (client reports over 50), property destruction, anxiety, impulsivity, elopement, verbal and physical aggression, substance use, academic decline, lack of social supports.? ?(Youth 1) has proven unmanageable in the community?. ?(Youth 1) has shown significant decompensation this review period?. ?(Youth 1) has engaged in extensive property damage, as well as physical aggression toward peers and staff?. ?(Youth 1) has begun endorsing suicidal ideation and thoughts of self-harm?. 3. According to Report 1, ?(Youth 1) has received an administrative discharge due to lack of investment in her treatment and safety concerns?. Youth 1 was discharged from residential treatment on 09/29/2020 and placed into the independent living arrangement by the licensee on this same date.
Plan of Correction:	The CEO and/or placement staff will assure a thorough review and evaluation of youth?s maturity and appropriateness of youth interviewed for placement. CEO will staff cases with Licensing Specialist when specific questions or concerns arise prior to acceptance of such youth with difficult determinations.
Standard #:	22VAC40-131-440-F
Description:	Violation: Based on review of the youth?s record and interview with agency representative AR1, the agency failed to have the legal guardian of Youth 1, placed in the independent living arrangement, sign the written participation agreement. Findings: 1. According to the face sheet, Youth 1, is a child at age 17, whose legal guardian is a local department of social services. 2. The written placement agreement/IL agreement between Youth 1 and the agency was not signed by the legal guardian of the youth.
Plan of Correction:	For localities where authorized representatives are not present to sign the Placement Agreement, the Placement Agreement will be sent electronically for signature prior to the day of placement and received by PICF prior to the placement of any youth. CEO and/or Placement Coordinator will assure that localities are educated on the acceptance of electronic signatures.