VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Impact Living Services
1454 Mexico Way NE
Roanoke, VA 24012
(434) 533-1088

Current Inspector: Dawn Espelage (540) 759-8852

Inspection Date: Aug. 14, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-131 ORGANIZATION AND ADMINISTRATION 22VAC40-131 ADDITIONAL REQUIREMENTS FOR SPECIFIC PROGRAMS

Comments:

An unannounced monitoring inspection was conducted on August 14, 2019 from 11:50 a.m. to 4:32 p.m. The agency reported eight youth in placements. No new staff have been hired since the last inspection. During this inspection, four youth records were reviewed (3 current in care and 1 discharged youth record). The Program Director was present and available to respond to questions during the inspection. Preliminary inspection findings were reviewed at the conclusion of the inspection with the Program Director and an acknowledgement form was signed. 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; position(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 #:	22VAC40-131-440-H
Description:	Violation: Based on review of the record for a youth placed in an independent living arrangement, Youth2, the initial service plan was not completed within 30 days of the date of admission to the independent living arrangement as required. Findings: 1. The initial service plan in the record for Youth2 was due by July 7, 2019 but was completed July 22, 2019. 2. The Program Director confirmed that the initial service plan was not completed within 30 days of the youth's date of admission.
Plan of Correction:	Program Director changed electronic record to alert staff to complete ISP within 30 days of admission. Previously it was alerting at 45 days due to an electronic record set up error.