VIRGINIA DEPARTMENT OF SOCIAL SERVICES

United Methodist Family Services
6935 Columbia Pike
Annandale, VA 22003
(703) 941-9008

Current Inspector: Kevin Lassiter (804) 241-2093

Inspection Date: Oct. 29, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-131 ORGANIZATION AND ADMINISTRATION 22VAC40-131 PERSONNEL 22VAC40-131 PROVIDER HOMES 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 An unannounced monitoring inspection was conducted on 10-28-2024 from 3:30 pm to 5:00 pm and 10-29-2024 from11:00 am to 4:00 p.m. The preliminary findings review took place on 10-29-2024 with the Assistant Director. An Acknowledgement of the Inspection form was signed and provided to the Assistant Director. The exit review was held on 10-31-2024. Number of children in care: 9 Number of approved provider homes: 11 Number of children?s records reviewed: 1 Number of provider home records reviewed: 2 Number of staff records reviewed: 1 Staff interview: 2 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 Kevin Lassiter, Licensing Inspector at 804-241-2093 or by email at kevin.lassiter@dss.virginia.gov

Violations:

Standard #:	22VAC40-131-150-B-1
Description:	Violation: Based on a record review of S#4 (hire date 03-11-2024) the initial orientation appeared to not have been completed within 30 days of the date of employment. Findings: 1. In review of S#4?s record on the day of the inspection, 10-29-2024. LS was unable to determine full compliance, from the document titled ?TFC On-boarding Checklist?. The checklist did contain an affirmation statement that ?signers are affirming that all TFC licensure requirements were reviewed and completed within 30 days of hire?; however, the document did not contain the date of employment nor did the document have a date of completion for S#4. 2. In further observation of the ?TFC On-boarding Checklist?, the document also contained a line item for the ?observer?s name and observer?s date. The date indicated for the observer was reflected as, ?05-03-2024. This date was beyond 30 days for this signer. 3. Agency representative acknowledged the findings during a preliminary review on 10-30-2024 and again on 10-31-2024 during the exit review.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-250-O
Description:	Violation: Based on a record review FC-#1?s record, the agency failed to complete a written assessment within 30 days of the placement for FC-#1. Findings: 1) In review of FC-#1?s record during an inspection on 10-28-2024 with a placement date of 08-02-2024, the written intake assessment observed on file was not completed until 09-20-2024 and signed on 10-29-2024, which placed this intake assessment out of compliance. 2) Agency representative acknowledged the findings during the preliminary review on 10-29-2024 and again on 10-31-2024 during the exit review.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-260-A
Description:	Based on a record review of FC-#1?s file, the agency failed to include an accurate placement date on the Social History document. Findings: 1. In review of FC-#1?s record, with placement date of 08-02-2024 and as observed on the placement agreement, the Social History on file was observed to have and inaccurate placement date of 02-21-2020. 2. Agency representative acknowledged the findings during the preliminary review on 10-29-2024 and again on 10-31-2024 during the exit review.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-290-A
Description:	Violation: Based on a record review of FC-#1?s file, the agency failed to show evidence of the date of the medical examination conducted by or under the direction of a licensed physician for FC-#1. Findings: 1) In review of FC1?s record, with a placement date of 08-02-2024, though a copy of the medical examination was on file, the Licensing Inspector (LS) was unable to determine full compliance of this document because the date of the medical examination was not included on the document nor was the document signed to indicate whether or not the medical examination was conducted by or under the direction of a licensed physician. Likewise, LS was unable to identify the location of the medical examination based the view of the report on file. 2) Agency representative(s) acknowledged the findings during the preliminary review on 10-29-2024 and again on 10-31-2024 during the exit review.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-340-E-3
Description:	Violation: Based on a record review of FC-#1?s file, the agency failed to provide accurate information pertaining the FC-#?1 service plan, ?Area of Treatment #6? and based on FC-#1?s current placement date. Findings: 1) In review of FC-#1?s record, with a placement date of 08-02-2024, the ?Area of Treatment #6? in the service plan, appeared to be information pertaining to a prior provider home placement for FC-#1. Likewise, the placement date affixed to the current service plan also appeared to be inaccurate (02-21-2020). The LS did however, observed the start date of the plan to be accurate. 2) Agency representative acknowledged the findings during the preliminary review on 10-29-2024, and indicated that the section? ?Area of Treatment #6? had not been updated from FC-#1 last placement (02-21-2020), and acknowledged that the placement date on the service plan was inaccurate. Agency representatives also acknowledged the findings again on 10-31-2024 during the exit review.
Plan of Correction:	Not available online. Contact Inspector for more information.