VIRGINIA DEPARTMENT OF SOCIAL SERVICES

United Methodist Family Services
815 Baker Road
Virginia beach, VA 23462
(757) 490-9791

Current Inspector: Sherry Woodard (757) 987-0839

Inspection Date: Dec. 2, 2020

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

Comments:

This inspection was conducted using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. This announced focused inspection was conducted in response to an agency self-report. The inspection was initiated on 12/2/2020 and concluded on 12/17/2020. The regional director was contacted by telephone to initiate the inspection. The agency reported 16 children in care, and 17 approved provider homes. Standards for provider homes and children services were reviewed for compliance. One child record and one provider home record was reviewed. Two staff were interviewed regarding treatment and services provided to the child and the provider home where the child was residing. The licensee?s policies and procedures on Medication Administration, Medical, Dental and Mental Health Services, Center Specific Intake Procedure, and Placement Assessment were reviewed. The regional director was available for questions throughout the inspection. An exit interview was conducted by telephone on 12/15/2020 from approximately 3:00 pm to 4:00 pm with the vice president of programs, regional director, community based services supervisor and assistant director of quality improvement and risk management to discuss inspection findings. A second exit interview was conducted on 12/17/2020 from approximately 9:55 am to 10:20 am with the regional director, community based services supervisor, and case manager to discuss additional documentation provided on 12/16/20. Information gathered during the inspection determined non-compliance with applicable standards or laws, and violations were documented on the violation notice issued to the agency. There were 6 citations for violations of the Standards for Child-Placing Agencies. Upon receipt of the Violation Notice, the licensee should develop a plan of correction to include the steps to correct non-compliance with the standard(s); measures to prevent re-occurrence of non-compliance; person(s) responsible for implementation and monitoring of preventative measure(s); and date by which noncompliance will be corrected. The licensee has five business days from receipt of the inspection documents to complete the section entitled "Plan of Correction", sign each page of the inspection documents and return to the Licensing Office. The licensee should retain a copy to be posted at the facility. Results of the inspection are subject to public disclosure and will be posted on the Virginia Department of Social Services public web site within five business days, regardless of whether or not the Plan of Correction is completed.

Violations:

Standard #:	22VAC40-131-40-B
Description:	Violation: Based on review of FC1?s record and the licensee?s ?Center Specific Intake Procedure?, the licensee failed to follow its own policies and procedures. Findings: 1. The record for FC1 documents a discharge summary received by the licensee on 8/3/20 from the previous placement provider. The discharge summary documents a specific suicide plan as a reason for referral to the previous placement provider. 2. The licensee?s Center Specific Intake Procedure states, ?Information, which includes identification of suicidal ideation or history of suicide, attempts, and aggressive, dangerous self-destruction for psychotic behavior should be documented in the assessment information.? 3. The TFC placement assessment completed by AR2 on 8/12/20 does not include the specific suicide plan documented in the discharge summary received by the licensee on 8/3/20 from the previous placement provider.
Plan of Correction:	1.The Intake Worker will review all discharge summaries and provider reports to obtain insight into child?s needs, past history and current behaviors so that this information may be documented in the Placement Assessment by date: 2.Prior to placement, a staffing meeting will take place to discuss any and all information related to the child?s needs, past history and current behaviors by date: Measure to prevent re-occurrence: supervisory review Person/s responsible for implementing and monitoring: Director, CBSS/intake worker and FSC
Standard #:	22VAC40-131-40-M
Description:	Violation: Based on review of the record for FC1 and interview with AR1, the licensee failed to provide interventions and follow up services necessary. Findings: 1. The record for FC1 documents a contact note completed by ARI on 9/11/20 that states an email was received by AR1 from the foster mother in FH1, on 9/11/20 documenting FC1 had difficulty contracting for safety. At the time of review, the record for FC1 did not document interventions taken by the licensee to address FC1 having difficulty contracting for safety. 2. The record for FC1 documents an email received by AR1 on 10/23/20 from the foster mother in FH, documenting events that took place on 10/22/20 with FC1 which includes increased treatment needs. 3. During an interview with AR1 on 12/14/20, AR1 was asked what interventions were taken by the licensee to address FC1 having difficulty contracting for safety on 9/10/20. ARI stated, the licensee did not complete a safety plan as an intervention. 4. During an interview with AR2 on 12/14/20 when asked what interventions were provided by the licensee, AR2 stated ?AR1 would go over safety planning during home visits in a loose way and in hindsight a safety plan should have been done.? 5. At the time of review, the record for FC1 did not document a safety plan completed after FC1's 7/21/20 treatment foster care placement with the licensee as an intervention to address FC1's ongoing treatment needs.
Plan of Correction:	1.Develop and implement a written safety plan that is completed initially for any youth who has a history of or currently presents with suicidal ideation/prior attempts and/or self-harm by 2-28-21 2.Develop procedures for updating written safety plans by 2-28-21 3.Train staff on expectations and best practices regarding safety plans to include the importance of revisiting the safety plan with the resource parents and youth, by 2-28-21 Measure to prevent re-occurrence: written safety plans will be on file for any child with a history or currently presenting with suicidal ideation/prior attempts and/or self-harm. Person/s responsible for implementing and monitoring: Assistant Director, Quality Improvement and Risk Management (ADQIRM), Director and CBSS.
Standard #:	22VAC40-131-210-B
Description:	Violation: Based on review of the record for FH1, interviews with AR1 and AR2, the licensee failed to ensure the providers in FH1 received training relevant to the needs of children and families. Findings: 1. FH1 was approved by the licensee on 12/18/2018. 2. An annual home study was completed on 1/3/2020 for FH1's continued approval. 3. The record for FH1 documents an ?Acceptance of a Child?s Behavior/Issues Checklist? for the providers in FH1 that was received by the licensee on 1/3/20. 4. The checklist documents the ?level of ability to parent (knowledge/skills/resources)? to support a child who has suicidal thoughts/attempts and self-mutilation/self-harm as ?With Assistance Needs Skill Dev?. 5. FH1?s record does not document training relevant to the needs of children with suicidal ideation or history of self-harm. 6. During separate interviews with AR1 and AR2 on 12/14/20, when asked what training was provided to FH1, AR1 and AR2 both stated, the licensee did not provide FH1 with pre-service training or ongoing training addressing suicidal ideation or self-harm.
Plan of Correction:	1.Initial pre-service training for all resource parents will include training on parenting youth with a history of suicidal ideation/attempts and/or self-harm. a. A virtual training will be identified by 3-31-21 b. All current resource parents will take the virtual training by 3-31-21 c. Initial training will be incorporated into UMFS ImPACT training for new families by 3-31-21 Measure to prevent re-occurrence: training records Person/s responsible for implementing and monitoring: FSC 2.Ongoing training for all resource parents will include training on parenting youth with a history of suicidal ideation/attempt and/or self-harm. a. A virtual ongoing training will be identified by: 3-31-21 b. All current resource parents will take the virtual training by: 3-31-21 c. A library of resources and training material will be created so that resource parents may be assigned additional training and guidance around suicidal ideation/attempt and/or self-harm as appropriate and as needs arise, by: 3-31-21 Measure to prevent re-occurrence: training records Person/s responsible for implementing and monitoring: FSC 3.The Child?s Behavior/Issues Checklist will be revisited with each potential placement to ensure the resource parents receive additional support when identified as needed. Implementation date: 2-1-21 Measure to prevent re-occurrence: reviewed at the time of match. Person/s responsible for implementing and monitoring: FSC
Standard #:	22VAC40-131-260-B-3
Description:	Violation: Based on review of the social history completed for FC1, the licensee failed to include services needed to reach the child?s permanency goal in the social history. Findings: The social history for FC1 was completed on 9/2/20 by AR1 and failed to include services needed to reach permanency.
Plan of Correction:	1. All TFC staff will be trained within 45 days of employment regarding the requirements to complete social histories. All social histories will be reviewed to ensure the child?s permanency goal is addressed by the supervisor of the case prior to signature. Measure to prevent re-occurrence: via initial child case file review form Person/s responsible for implementing and monitoring: Mary Davies, CBSS
Standard #:	22VAC40-131-370-Q
Description:	Violation: Based on review of the record for FC1 and interview with AR2, the licensee failed to ensure narrative case notes were current within 30 days. Findings: 1. FC1?s record was reviewed 12/3/20-12/7/20. At the time of review, the record documented one contact note for 7/21/20, which was completed by AR2. 2. AR3 provided a copy of FC1?s quarterly progress review (QPR) covering 7/21/20 to 9/30/20 on 12/16/20 as requested by this inspector on 12/16/20. The QPR was completed by AR1 and documents contact notes covering 7/21/20 to 9/30/20. 3. The QPR provided, documented one contact note for 7/21/20 completed by AR2 that was different from the 7/21/20 contact note initially reviewed in FC1's record. 4. During an interview on 12/17/20 with AR2, when asked why the 7/21/20 contact note initially reviewed in the record was different from the 7/21/20 contact note documented in the QPR provided on 12/16/20, AR2 stated she updated the 7/21/20 contact note.
Plan of Correction:	1.Case notes for each TFC case will be completed on a weekly basis and reviewed by the assigned supervisor of the case. Training will be provided regarding documentation as it relates to revisions of contact notes. Measure to prevent re-occurrence: supervisory review Person/s responsible for implementing and monitoring: ADQIRM and CBSS
Standard #:	22VAC40-131-460-D
Description:	Violation: Based on review of the record for Foster Child (FC) FC1, Foster Home (FH) FH1, and interview with Agency Representative (AR) AR1, the licensee failed to provide training and guidance to the providers in FH1 in implementing the treatment and service plan for FC1. Findings: 1. FC1 was placed into Foster Home (FH) FH1 by the licensee on 7/21/20 for treatment foster care. 2. The contact notes in the records for FC1 and FH1 failed to document ongoing training and guidance provided by the licensee that addressed FC1's ongoing treatment needs regarding suicidal ideation, hopelessness and depression while residing in FH1 from 7/21/20 to 11/16/20. 3. The record for FC1 documents a contact note completed by ARI on 9/11/20 that states an email was received by AR1 from the foster mother in FH1, on 9/11/20 detailing FC1?s increased treatment needs. The records for FC1 and FH1 failed to document training and guidance provided by the licensee addressing FC1?s increased treatment needs. 4. The record for FC1 documents an email received by AR1 on 10/23/20 from the foster mother in FH1, documenting events that took place with FC1 on 10/22/20. The records for FC1 and FH1 failed to document training and guidance provided by the licensee addressing treatments needs based on events that occurred on 10/22/20. 5. FC1's record documents an email received by ARI on 11/13/20 from FC1's foster mother documenting concerns shared by FC1's teacher. The records for FC1 and FH1 failed to document training and guidance provided by the licensee addressing the teacher?s concerns. 6. During an interview with AR1 on 12/14/20, when asked what training was provided by the licensee to FH1, AR1 stated, she was not familiar with pre-service training provided by the licensee but suicidal ideation is not a part of the training. No additional information was provided regarding training provided to FH1 by the licensee that addressed FC1's treatment needs, including suicidal ideation.
Plan of Correction:	1.All TFC staff will be trained on how to effectively provide ongoing training and guidance to resource parents specific to the child?s needs and as related to supporting the goals and objectives as outlined in the treatment plan. Date: 2-28-21 Measure to prevent re-occurrence: documentation in contact notes & treatment plan progress sections verified via file reviews. Person/s responsible for implementation and monitoring: Director and Community Based Services Supervisor (CBSS) 2.Initial pre-service training for all resource parents will include training on parenting youth with a history of suicidal ideation/attempts and/or self-harm. a. A virtual training will be identified 3-31-21 b. All current resource parents will take the virtual training by 3-31-21 c. Initial training will be incorporated into UMFS ImPACT training for new families by 3-31-21 Measure to prevent re-occurrence: training records Person/s responsible for implementing and monitoring: Family Systems Coordinator 3.Ongoing training for all resource parents will include training on parenting youth with a history of suicidal ideation/attempt and/or self-harm. a. A virtual ongoing training will be identified by 3-31-2021 b. All current resource parents will take the virtual training by 3-31-21 c. A library of resources and training material will be created so that resource parents may be assigned additional training and guidance around suicidal ideation/attempt and/or self-harm as appropriate and as needs arise, by 3-31-21 Measure to prevent re-occurrence: training records Person/s responsible for implementing and monitoring: Family Systems Coordinator(FSC)