VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Impact Living Services
10519 Braddock Road
Unit A & B
Fairfax, VA 22032
(434) 533-1088

Current Inspector: Kevin Lassiter (804) 241-2093

Inspection Date: July 21, 2020 , July 22, 2020 and July 27, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-131 ORGANIZATION AND ADMINISTRATION 22VAC40-131 PERSONNEL 22VAC40-131 PROGRAM STATEMENT 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 63.2 General Provisions. 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. An initial inspection was initiated on July 21, 2020 and concluded on July 27, 2020. This inspection was conducted in response to a new application for licensure and the agency is not yet in operation. The Executive Director was contacted by telephone to initiate the inspection. Inspection activities included reviewing ten personnel records, to include background checks for corporate board officers and agents of the corporation, and policies and procedures, to ensure documentation was complete. Agency office inspection was conducted remotely by video. Exit meeting was held with the Executive Director on July 27, 2020. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the agency. 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; person(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 #:	22VAC40-131-150-D-1
Description:	Violation: Based on review of personnel records for Staff S4, S7, S8, S9 and S10, and an interview with Staff S9, the agency failed to ensure that annual training was completed for each professional staff person. Findings: 1. The agency maintains personnel records using an electronic records system. The personnel information in the electronic records system for S4, S7, S8, S9, and S10 did not include documentation of annual training completed in the past 13 months and applicable to the staff person?s job duties and responsibilities. 2. During an interview with the Licensing Specialist on 07/27/2020, these findings were discussed with Staff S9. S9 acknowledged that annual training had not been completed.
Plan of Correction:	Executive Director met with COO and HR Manager to devise a plan in which the HR Manager will be responsible for coordinating training for all non program administrative staff