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: Jan. 26, 2023 and May 16, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-131 Organization and Administration 22VAC40-131 Personnel 22VAC40-131 Additional Requirements for Specific Programs 22VAC40-80 The License 22VAC40-191 Background Checks for Child Welfare Agencies

Technical Assistance:

Discussed personnel records as noted in the ?Standards for Licensed Child Placing Agencies? ? VAC 40-131-160.A. Discussed the purpose of the independent living arrangement, with timeframe for completing the program in relation to the written agreement for participation in the arrangement as noted in the ?Standards for Licensed Child Placing Agencies? ? VAC 40-131-440.E.1. Discussed the information pertaining to the physical setting arrangements in relation to the written agreement for participation in the arrangement as noted in the ?Standards for Licensed Child Placing Agencies? ? VAC 40-131-440.E.6.

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/26/23 from 10:55 AM ? 5:23 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of youth in care: 5 The licensing inspector completed a tour of the physical plant that included the office setting and conditions. Number of youth records reviewed: 1 Number of interviews conducted with staff: 2 Additional Comments/Discussion: An entrance conference was held at the agency on 1/26/23. Also, on the same date, a youth?s record and staff records were reviewed at the agency. The Executive Director and the Operations Manager were available and accessible during the inspection. These individuals were also interviewed on the same date to address questions about various documents reviewed in the youth?s record. The Executive Director was interviewed on 1/29/23 and 2/13/23 to address additional questions about documents reviewed in the youth?s record. An exit meeting was conducted on 5/16/23 to review the inspection findings. 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 Michele Freeman, Licensing Inspector at (804) 662-7062 or by email at michele.freeman@dss.virginia.gov

Violations:

Standard #:	22VAC40-131-440-C
Description:	Violation: Based on interviews with staff and review of foster youth?s, FY1?s, record, the facility failed to consider elements in the evaluation prior to accepting a youth for an independent living arrangement and prior to making an arrangement for the youth. Findings: 1. During the interview on 2/13/23, staff, S3, specifically stated ?I admit the documentation is not there? when asked which document(s) in FY1?s record support the following elements: *440.C.3.a - Consistently maintains behavioral stability conforming to acceptable societal norms and he does not demonstrate behaviors dangerous to himself or other persons. *440.C.3.b - Is not involved in high risk behaviors such as delinquent or criminal activities or substance use and abuse. 2. The facility?s lack of documentation for the above-mentioned elements as acknowledged by S3 confirms they were not considered in the evaluation for FY1.
Plan of Correction:	Staff will be re-trained on the assessment and admission criteria. Each admission is staffed with the Clinical Director and CEO prior to admission.