VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Impact Living Services
1411 German School Road
Apt. 203
Richmond, VA 23225
(434) 533-1088

Current Inspector: Kevin Lassiter (804) 241-2093

Inspection Date: April 25, 2022 and May 3, 2022

Complaint Related: No

Areas Reviewed:

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

Technical Assistance:

None

Comments:

An unannounced renewal inspection was completed by the Licensing Specialist on 4/25/22 from 9:31 a.m. to 5:12 p.m. and 4/26/22 from 9:42 a.m. to 1:11 p.m. The current census is twelve (12) youth. The following is a listing of the activities for this inspection: Two youth records were reviewed. Three staff records were reviewed. The background checks for the Board Officer were reviewed. On 4/25/22, the Program Manager/Child Placing Supervisor for the Fairfax location, the Program Manager/Child Placing Supervisor for this location, and the Site Supervisor were available and accessible during the inspection. On 4/26/22, the Program Manager/Child Placing Supervisor for this location and the Site Supervisor were available and accessible during the inspection. The Program Manager/Child Placing Supervisor for this location and the Site Supervisor were interviewed on-site on 4/26/22 in regard to the youth records. The Human Resources Manager was interviewed on 4/26/22 by phone in regard to the staff records. The Acknowledgment of Inspection form was signed and left at the agency on both dates. Upon receipt of this violation notice, a plan of correction is requested for the violations. The Plan of Correction should include, as appropriate: - steps to correct noncompliance of a regulation, - measures to prevent reoccurrence of noncompliance, - person(s) responsible for implementing each step and/or monitoring any preventive measure(s), and - the date by which the noncompliance will be corrected. Be advised that the Violation Notice, including the Plan of Correction and this Summary page will be posted on the VDSS web page and available for review by the general public. Do not write any names or other confidential information into your plan of correction. The licensee should retain a copy of this document to be posted at the facility. The results of the inspection are subject to public disclosure and will be posted on the Virginia Department of Social Services? website within 5 business days.

Violations:

Standard #:	22VAC40-131-160-B-3
Description:	Violation: Based on an interview with staff and review of staff?s, S1?s, record, the agency failed to comply with maintaining a staff record with at least two written references. Findings: 1) Upon review of the electronic staff record for S1, it only contained one written reference. 2) Staff, S6, was interviewed about the need for at least two written references. A second written reference was not provided for review during the interview period.
Plan of Correction:	HR Manager will ensure that all hard copy references are uploaded into electronic health record system.
Standard #:	22VAC40-131-440-D
Description:	Violation: Based on an interview with staff and review of foster youth?s, FY2?s, record, the agency failed to comply with providing the youth at the time of admission, an orientation to the independent living arrangement program. Findings: 1) FY2 was admitted to this agency?s independent living arrangement program on 2/16/22. 2) Upon review of the ?Program Orientation? form in FY2?s record, it lists all of the elements required for orientation. 3) The date on the ?Program Orientation? form by the agency?s staff member?s signature states 2/17/22. 4) Staff, S3, and staff, S5, were interviewed about the date on FY2?s ?Program Orientation? form. S5 shared the orientation was conducted the day after FY2 was admitted into the program.
Plan of Correction:	Regional Manager will communicate with site supervisor the need to complete orientation prior to admission rather than the day after admission
Standard #:	22VAC40-131-440-E-1
Description:	Violation: Based on an interview with staff and review of the foster youths? records, the agency failed to comply with maintaining at the time of admission, the written agreement for participation in the arrangement as it pertains to the timeframe for completing the program. Findings: 1) The agency?s ?Participation Agreement? form is used as the written agreement for participation in the arrangement with the youth, his guardian and as appropriate, his family. 2) Upon review of foster youth?s, FY1?s, record and foster youth?s, FY2?s, record, the timeframe for completing the program on the ?Participation Agreement? for each youth is incomplete. There is a start date, but there is no end date. 3) Staff, S3, and staff, S5, were interviewed about the ?Participation Agreement? for each youth. Both acknowledged the timeframe for the completing the program on this form is incomplete for each youth.
Plan of Correction:	Regional Manager will communicate with site supervisor the need to complete participation agreement prior to admission rather than the day after admission.