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: Dec. 29, 2020 and Jan. 15, 2021

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:

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 December 29, 2020 and concluded on January 15, 2021. The Executive Director was contacted by telephone to initiate the inspection. The Executive Director reported there were six youth in independent living arrangements, four children in care and four approved foster homes. The inspector emailed the Executive Director a list of items required to complete the inspection. The inspector reviewed one personnel record, one volunteer record, one child?s record, one foster home record, and two youth's records submitted by the agency to ensure documentation was complete. Exit meeting was held with the Executive Director on January 15, 2021. The agency reported they are following COVID-19 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 agency. Please do not post the Supplemental form. 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 #:	22VAC40-131-110
Description:	Violation: Based on review of the record for Youth 2 and interview with agency representative AR1, the licensee failed to ensure all materials and information received by the licensee indicated the date received. Findings: 1. Review of several documents in the youth's record did not indicate the date received. 2. During an interview, AR1 acknowledged that the date received was not indicated.
Plan of Correction:	ILS Program Manager will provide date stamps to all locations and provide training to case workers to ensure they date all received materials.
Standard #:	22VAC40-131-440-C-4
Description:	Violation: Based on review of the record for Youth 2 and interview with agency representative AR1, the licensee failed to complete the life skills assessment within the last 90 days prior to accepting the youth for an independent living arrangement. Findings: 1. A life skills assessment was not completed within the last 90 days prior to accepting Youth 2 for an independent living arrangement. 2. During an interview, AR1 confirmed that the life skills assessment had not been completed within the last 90 days prior to the youth's acceptance.
Plan of Correction:	ILS Program Manager will complete individual supervision with Case Workers to ensure preadmission assessments are completed within 90 days of admission.