VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Pentecostal Children's Home DBA Appalachian Foster Care Alliance
308 Coeburn Ave SW
Norton, VA 24273
(276) 437-0170

Current Inspector: Jamie Morgan (276) 525-5656

Inspection Date: Jan. 4, 2021 , Jan. 5, 2021 , Jan. 11, 2021 , Jan. 20, 2021 , Jan. 29, 2021 , Feb. 19, 2021 , Feb. 23, 2021 and March 19, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-131 ORGANIZATION AND ADMINISTRATION 22VAC40-131 PERSONNEL 22VAC40-131 PROGRAM STATEMENT 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. An announced initial inspection was initiated on 1/4/2021 and concluded on 3/19/2021 in response to a new application for licensure; this agency is not currently operating in Virginia. The applicant?s policies and procedures were inspected by desk review. A site inspection was completed on 2/19/2021. Background check results were requested for board officers, agents, and employees and were not returned at the time this inspection concluded. Preliminary findings from the inspection were discussed during an exit interview on 3/19/2021 with the Executive Vice President. There were seventeen citations for Violations of the Standards for Licensed Child Placing Agencies. See the violation notice on the Department?s public web site for violations of the Standards. 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 #:	22VAC40-131-100-A
Description:	Violation: Based on a review of policies and procedures submitted by the applicant, the applicant failed to develop a written plan to monitor the quality and effectiveness of its program and services. Findings: 1) Following submission of policies and procedures with the initial application, the applicant revised policies and procedures. The last revision was submitted to the Licensing Specialist on 2/23/2021. 2) The findings were discussed during the exit interview. Staff 1 (S1) acknowledged the findings.
Plan of Correction:	This policy has been added to the ACH Policy and Procedure Manual. The heading for this section is ?Program Evaluation and Improvement?. (See the GREEN highlighted area beginning on page 64) to review the new policy.
Standard #:	22VAC40-131-90-A
Description:	Violation: Based on review of policies and procedures, the applicant failed to develop written policies and procedures that address all required elements of 22VAC40-131-90.A Findings: 1) Following submission of policies and procedures with the initial application, the applicant revised policies and procedures. The last revision was submitted to the Licensing Specialist on 2/23/2021. 2) The revised policies and procedures did not include: a. procedures governing plans for active and closed cases b. procedures related to the disposition of children in placement at the time of cessation, including procedures for assisting placing agencies in placing children c. procedures for notification to the placing agency, legal guardian, and the department of the d. procedures for disposing and storing active cases consistent with requirements for local governments contained in the Library of Virginia?s Record Retention and Disposition Schedule General Schedule No. 15. 3) The findings were discussed during the exit interview. S1 acknowledged the findings.
Plan of Correction:	The ?Closed Cases as a Result of CPA Closing? section of the ACH Policy and Procedure Manual on page ## will be deleted (See Strike Through Text highlighted in GRAY). A new version of this policy has been added directly below the previous version. The new heading for this section is ?Procedures for Discharge Due to Program Closing?. (See the GREEN highlighted area beginning on page 84) to review the new policy. A policy has also been added to address 2) a & d.. The heading for this section is ?Records Management Policy?. (See the GREEN highlighted area beginning on page 67) to review the new policy.
Standard #:	22VAC40-131-90-B-2
Description:	Violation: Based on review of policies and procedures, the applicant failed to develop written admission policies and procedures that address all required elements of 22VAC40-131-90.B.2. Findings: 1) Following submission of policies and procedures with the initial application, the applicant revised policies and procedures. The last revision was submitted to the Licensing Specialist on 2/23/2021. 2) The revised policies and procedures did not include decision-making procedures for acceptance, matching, placement and discharge from care. 3) The findings were discussed during the exit interview. S1 acknowledged the findings.
Plan of Correction:	The ?Placement? section of the ACH Policy and Procedure Manual on page ## will be deleted (See Strike Through Text highlighted in GRAY on page 49). A new version of this policy has been added directly below the previous version. The new heading for this section is ?Intake, Matching and Initial Placement Procedures?. (See the GREEN highlighted area beginning on page 50) to review the new policy.
Standard #:	22VAC40-131-90-D
Description:	Violation: Based on review of policies and procedures, the applicant failed to develop written policies and procedures that address all requirements of 22VAC40-131-90.D. Findings: 1) Following submission of policies and procedures with the initial application, the applicant revised policies and procedures. The last revision was submitted to the Licensing Specialist on 2/23/2021. 2) The revised policies and procedures did not include policies or procedures for: a. ensuring that children are not subjected to physical, mental, or sexual abuse; verbal abuse or remakes that belittle or ridicule the child or his family; physical neglect or denied essential program or treatment services, meals, clothing, bedding, sleep or personal care products; or any humiliating, degrading, or abused actions; b. investigating and responding to allegations of misconduct toward children c. implementing the child?s detailed back-up emergency care plan when the child?s placement disrupts d. procedures for assigning designated casework staff to be available on call to foster parents 24 hours a day, 365 days a year 3) The findings were discussed during the exit interview. S1 acknowledged the findings.
Plan of Correction:	The ?Corporal Punishment? (p. 56) and ?Foster Parents as Mandated Reporters? (p. 72) sections of the ACH Policy and Procedure Manual will be deleted ((See Strike Through Text highlighted in GRAY on the respective pages)A new version of these policies have been added directly below the previous version to address findings 2) a. and b. These sections will be combined and the new heading will be ?Reporting Suspicion of Abuse and Neglect of a Child?. (See the GREEN highlighted area beginning on page 56) to review the new policy. There were two policies added to address finding 2) c. ?Placement Moves? (p. 75) and ?Provision of STFC? (p. 73) both of which play a very important role in the backup emergency plan of a child experiencing any kid of crisis in a foster home. (See the GREEN highlighted area beginning on page on the respective pages for each policy listed above) In addition to the previous two additions, the ?Discharge from Care? section of the ACH Policy and Procedure Manual on page 76 will be deleted (See Strike Through Text highlighted in GRAY). A new version of this policy has been added directly below the previous version to address finding 2) c. The new heading for this section is ?Discharge from Services and Placement Disruptions?. (See the GREEN highlighted area beginning on page 76) to review the new policy. An additional policy has been added to address finding 2) d. The heading for this section is ?Designation of On Call Staff?. (See the GREEN highlighted area beginning on page 70) to review the new policy.
Standard #:	22VAC40-131-90-E
Description:	Violation: Based on review of the policies and procedures, the applicant failed to develop written policies and procedures addressing all required elements of 22VAC40-131-90.E. Findings: 1) Following submission of policies and procedures with the initial application, the applicant revised policies and procedures. The last revision was submitted to the Licensing Specialist on 2/23/2021. 2) The revised policies and procedures did not include procedures for: a. management of written and electronic record describing confidentiality, accessibility, security, and retention of records pertaining to the files of children, applicants for home provider, and approved home providers. 3) The findings were discussed during the exit interview. S1 acknowledged the findings.
Plan of Correction:	The ?Confidentiality Policy and Management of Records? section of the ACH Policy and Procedure Manual on page 66 will be deleted (See Strike Through Text highlighted in GRAY)This section has been divided into 2 new sections and these have been added directly below the previous version. The new heading for these sections are ?Confidentiality? (p. 66) and ?Records Management Policy? (p. 67). (See the GREEN highlighted area beginning on the respective pages list above) to review the new policy.
Standard #:	22VAC40-131-90-F
Description:	Violation Based on review of the policies and procedures, the applicant failed to develop written policies and procedures addressing all required elements of 22VAC40-131-90.F. Findings: 1) Following submission of policies and procedures with the initial application, the applicant revised policies and procedures. The last revision was submitted to the Licensing Specialist on 2/23/2021. 2) The revised policies and procedures did not include written procedures governing children?s planned and emergency discharges from the licensee?s program and services. 3) The findings were discussed during the exit interview. S1 acknowledged the findings.
Plan of Correction:	The ?Discharge from Care? section of the ACH Policy and Procedure Manual on page 76 will be deleted (See Strike Through Text highlighted in GRAY) A new version of this policy has been added directly below the previous version to address finding 2) c. The new heading for this section is ?Discharge from Services?. (See the GREEN highlighted area beginning on page 76) to review the new policy.
Standard #:	22VAC40-131-90-G
Description:	Violation: Based on review of the policies and procedures, the applicant failed to develop written policies and procedures that addressed all required elements for the foster parent?s use of physical restraint in 22VAC40-131-90.G. Findings: 1) Following submission of policies and procedures with the initial application, the applicant revised policies and procedures. The last revision was submitted to the Licensing Specialist on 2/23/2021. 2) The applicant stated in the policies and procedures the agency will allow use of restraints by foster parents. 3) The policies regarding the use of physical restraint did not include: a. a description of less intrusive behavior support and crisis management techniques approved by the licensee for use by foster parents b. a description of methods of restraint approved by the licensee c. a description of training required to be completed prior to the use of each method of physical restraint d. a description of the licensee?s method for determining that the foster care parent has the ability to apply the licensee?s approved methods of physical restraint and crisis intervention e. a statement prohibiting the use of seclusion of a child in a room or area secured by a door that is locked or held shut or secured by individuals physically blocking the door or using other physical or verbal means to block the door so that the child cannot leave the room or area 4) The findings were discussed during the exit interview. S1 acknowledged the findings.
Plan of Correction:	The ?Restraint and Behavior Control? section of the ACH Policy and Procedure Manual on page 59 will be deleted (See Strike Through Text highlighted in GRAY). A new version of this policy has been added directly below the previous version. The new heading for this section is ?Behavior Support and Management?. (See the GREEN highlighted area beginning on page 59) to review the new policy. Please not the change in this policy to completely prohibit the use of restraints in any way.
Standard #:	22VAC40-131-90-H
Description:	Violation: Based on review of the policies and procedures, the applicant failed to develop written policies and procedures addressing all required elements related to behavior support and control in 22VAC40-131-90.H. Findings: 1) Following submission of policies and procedures with the initial application, the applicant revised policies and procedures. The last revision was submitted to the Licensing Specialist on 2/23/2021. 2) The policies and procedures did not include: a. acceptable methods of behavior support b. specific unacceptable methods for behavior control and discipline 3) The findings were discussed during the exit interview. S1 acknowledged the findings.
Plan of Correction:	The ?Restraint and Behavior Control? section of the ACH Policy and Procedure Manual on page 59 will be deleted (See Strike Through Text highlighted in GRAY). A new version of this policy has been added directly below the previous version. The new heading for this section is ?Behavior Support and Management?. (See the GREEN highlighted area beginning on page 59) to review the new policy.
Standard #:	22VAC40-131-90-I
Description:	Violation: Based on review of the policies and procedures, the applicant failed to develop written personnel policies and procedures required by 22VAC40-131-90.I. Findings: 1) Following submission of policies and procedures with the initial application, the applicant revised policies and procedures. The last revision was submitted to the Licensing Specialist on 2/23/2021. 2) The policies and procedures did not include personnel policies and procedures, including procedures to assure that persons employed in or designated to assume the responsibility of each position possess the education, experience, knowledge, skills, and abilities specified in the job description for the position. 3) The findings were discussed during the exit interview. S1 acknowledged the findings.
Plan of Correction:	The ACH Foster Care Norton Personnel Policy and Procedure Manual is attached. The verification of all requirements for a position are included in the ?Human Resources Employment Reference Checks? section of the manual and can be found on page 28 of the policy. (See the GREEN highlighted area on page 28) to review the new policy.
Standard #:	22VAC40-131-130-A-3
Description:	Violation: Based on a review of job descriptions submitted, all required elements were not addressed in the job descriptions. Findings: 1) The applicant submitted job descriptions for the Executive Director, Program Director, Child-Placing Supervisor, and Caseworker. 2) The job descriptions for the Program Director, Child-Placing Supervisor, and Caseworker positions did not identify the job title of the position?s immediate supervisor. 3) The findings were discussed during the exit interview. S1 acknowledged the findings
Plan of Correction:	The previously submitted job descriptions have been updated to address the missing elements of the standard. The Job Descriptions are now a part of the Personnel Policy and Procedure Manual. See the highlighted area in Green on each job description on page 6-10 to review the updates.
Standard #:	22VAC40-131-140-D
Description:	Based on a review of resumes, the applicant failed to identify a qualified individual to serve as the Program Director for a Licensed Child Placing Agency. Findings: 1) The Initial Application for Child Placing Agency Licensure indicated the Program Director was ?TBD.? 2) During inspection, the applicant provided resumes for three (3) candidates for consideration to serve at the Program Director. 3) The candidates did not meet the minimum qualifications for Program Director. 4) The applicant submitted an allowable variance request for an individual to serve at the Program Director. The request was denied on 3/4/2021. 5) The findings were discussed during the exit interview. S1 acknowledged the findings and stated the agency is recruiting for a qualified Program Director.
Plan of Correction:	ACH has made an offer to a qualified individual who has worked as a foster care Program Director for the past 8 years with another LCPA Provider. This individual has accepted the Program Director position and will be working out a notice within the organization he is currently employed with and will concurrently begin completion of all references and required background checks for this position. Upon being hired, ACH will forward all of the individual?s references and background checks to the designated licensing specialist for review. (see attached resume)
Standard #:	22VAC40-131-170-A
Description:	Violation: Based on a review of the Program Statement and Description and consultation with the applicant, the applicant failed to address all required elements. Findings: 1) The applicant included a Program Statement and Description with the initial application. The Program Statement and Description did not address all required elements. 2) S1 submitted a final revised Program Statement and Description on 2/23/2021. 3) The Program Statement and Description summary included a reference to Independent Living Arrangements. There were no policies and procedures for Independent Living Arrangements. 4) The Program Statement and Description did not address: a) Whether the licensee intends to serve youth 18 to 21 years of age in approved foster homes. b) Procedures consistent with 22VAC40-131-180 for conducting the home study and the decision-making process for approval and selection of families to receive children. c) Procedures for placement of children and discharge from care or services consistent with Part VI. 22VAC40-131. d) Orientation and training the licensee provides to families consistent with 22VAC40-131-210, 22VAC40-131-220, and 22VAC40-131-460.D. e) Procedures for accepting emergency and short-term foster care placements. 5) The findings were discussed during the exit interview. Saff 1 (S1) acknowledged the findings.
Plan of Correction:	The following policies were added to address IL Arrangements and Services: ?Independent Living Arrangement Eligibility and Assessment?, ?Independent Living Orientation and Pre-placement The ?Closed Cases as a Result of CPA Closing? section of the ACH Policy and Procedure Manual on page 83 will be deleted (See Strike Through Text highlighted in GRAY). A new version of this policy has been added directly below the previous version. The new heading for this section is ?Procedures for Discharge Due to Program Closing?. (See the GREEN highlighted area beginning on page 84) to review the new policy. Procedures?, ?Independent Living Services?, and ?Discharge from Independent Living Program? (See the GREEN highlighted area beginning on page 78) It is the intent of the ACH to serve youth 18-21 in approved foster homes. All required policies have been added to the revised version of the current policy manual regarding Independent Living Arrangements and Independent Living Services. These policies are highlighted in green and can found on pages 78-83. The ?Home Study? section of the ACH Policy and Procedure Manual on page 44 will be deleted (See Strike Through Text highlighted in GRAY). A new version of this policy has been added directly below the previous version. The new heading for this section is ?Home Study Requirements?. (See the GREEN highlighted area beginning on page 46) to review the new policy.
Standard #:	22VAC40-131-370-C
Description:	Violation: Based on a review of the policies and procedures submitted by the applicant, the applicant failed to address all required elements for use of electronic signatures. Findings: 1) Following submission of policies and procedures with the initial application, the applicant revised policies and procedures. The last revision was submitted to the Licensing Specialist on 2/23/2021. 2) The revised policies and procedures stated ?ACH does allow the use of electronic signatures. The foster parent may agree to use an electronic signature with the following understanding by both parties: each electronic signature identifies the individual signing the document by name and title; the documentation cannot be altered after signature has been affixed.? 3) The policy statement did not include procedures or address all elements required. 4) The findings were discussed during the exit interview. Staff 1 (S1) acknowledged the findings.
Plan of Correction:	The Electronic Signatures section of the ACH Policy and Procedure Manual on page 69 was updated to address the missing elements of the standard. See the highlighted area in green (4,5,6) of this section to review the updates.
Standard #:	22VAC40-131-460-B
Description:	Violation: Based on review of policies and procedures, the applicant failed to address all required elements for providing Treatment Foster Care. Findings: 1) The applicant applied to provide Treatment Foster Care services. 2) Following submission of Program Statement and Description and policies and procedures with the initial application, the applicant revised the Program Statement and Description and policies and procedures. The last revision was submitted to the Licensing Specialist on 2/23/2021. 3) The revised Program Description and policies and procedures did not provide a comprehensive description of: a. specific treatment techniques the licensee plans to use with children and families b. specific behavioral management strategies the licensee will allow foster parents to use with placed children; and c. the staffing pattern that: i. provides for the intensity of services required in treatment foster care ii. describes the treatment team, treatment plans, and credentials of professional staff responsible for treatment services iii. provide for at least one full-time professional staff or part-time staff whose hours are equivalent to a full-time position; and iv. designates a qualified individual responsible for overseeing the program 4) The findings were discussed during the exit interview. Staff 1 (S1) acknowledged the findings.
Plan of Correction:	The Program Description has been revised to include the missing required elements pursuant to 22VAC40-131-(7)-460-B. These revisions are highlighted in green and can found on pages 14-22 and pages 33-37.
Standard #:	22VAC40-191-40-C-1-a
Description:	Violation: Based on review of the application, application attachments, and interview the applicant failed to obtain required background checks for all board officers. Findings: 1) During the initial inspection, background check results were not returned for all board officers. 2) The finding was discussed during the exit interview. Staff 1 (S1) stated background check requests have been submitted and are pending return. 3) S1 acknowledged the findings.
Plan of Correction:	The results of the required background checks and references for al board officers are pending and will be forwarded to Licensing Specialist upon arrival.
Standard #:	22VAC40-191-40-C-1-b
Description:	Violation: Based on review of the application, application attachments, and interview the applicant failed to obtain required background checks for all employees. Findings: 1) During the initial inspection, background check results were not returned for all employees. 2) The finding was discussed during the exit interview. Staff 1 (S1) stated background check requests have been submitted and are pending return. 3) S1 acknowledged the findings.
Plan of Correction:	The results of the required background checks and references for all employees are pending and will be forwarded to Licensing Specialist upon arrival.