VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Patrick Henry Family Services Operations, Inc.
1056 Vista Park Dr.
Ste. C
Forest, VA 24551
(434) 376-2006

Current Inspector: Dawn Espelage (540) 759-8852

Inspection Date: June 27, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-131 ORGANIZATION AND ADMINISTRATION 22VAC40-131 PROVIDER HOMES 22VAC40-191 BACKGROUND CHECKS FOR CHILD WELFARE AGENCIES

Comments:

Type of inspection: Monitoring An unannounced monitoring inspection was held on 6/27/23 from 11:20 a.m. to 3:35 p.m. A preliminary findings review was held on the same date. The Acknowledgement of Inspection form was provided and signed. Number of children in care: 0 Number of approved provider homes: 5 The licensing inspector completed a tour of the physical plant that included the office setting and conditions. Number of children?s records reviewed: 0 Number of provider records reviewed: 1 An exit meeting was held on 7/7/23 to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Dawn Espelage, Licensing Inspector at 540-759-8852 or by email at dawn.espelage@dss.virginia.gov

Violations:

Standard #:	22VAC40-131-290-L-1
Description:	Violation: Based on the record review of Provider Home 1 (PH1), the agency failed to obtain medical examination results that included written examiner comments that address the applicant's or caretaker's mental and physical condition in relation to his ability to take care of a child. Findings: 1) The file contained documentation of medical examinations for both Applicant 1 and 2 that included a request for any physical or mental conditions that would jeopardize a normal parental role. 2) The physical exam forms were missing the required language as the examiner did not address the question, only writing in ?denies?. 3) Staff 1 (S1) and S2 were provided an opportunity to locate additional medical exams and/or documentation requesting the form be completed correctly. 4) The findings were discussed during the preliminary findings review and staff acknowledged the finding.
Plan of Correction:	1. We have emailed the family to share the notice from the inspection. They are reaching out to their doctor to share the expectation and waiting for a written response. Once a full statement regarding the applicants? physical and mental states (in relation to their abilities to parent) has been received, their file will be updated. We will update our policies and procedures manual to specifically address the review of this physical exam document to ensure that comments are completed in full sentences to accurately address the needs identified by the LCPA guidelines for Virginia. 3. All staff will receive documented re-training on documentation review to outline LCPA guidelines and specifically highlight this update to our policies and procedures. 1.It is difficult to predict exactly how long the doctor will take to respond. Our hope is to have this fully resolved within 1 week, by 7/10/23.. 2. We will review our P&P by 7/5/23 and anticipate that the update to our policies and procedures will be completed by 7/12/23. The retraining of staff will occur within 1 week of updates to our P&P, no later than 7/19/23.
Standard #:	22VAC40-191-40-D-6
Description:	Violation: Based on record review, the agency failed to obtain background checks within the specified time frame of no more than 90 days prior to the provider home approval. Findings: 1) Provider Home 1 (PH1) file, approved 1/27/23, contained central registry results of applicant 1 (A1) and applicant 2 dated 4/5/22. 2) PH1 record contained central registry results for household member 1 (HM1) dated 5/25/22. 3)The PH1 record did not contain documentation of more recent central registry searches. 4) The file contained a national criminal background check of A1 and A2 dated 8/26/22. 4) Staff 1 and 2 were provided an opportunity to locate updated criminal history checks. 5) The findings were discussed during the preliminary findings review and staff acknowledged the finding.
Plan of Correction:	We cannot make any corrections to the provider home file to provide a report that falls within the required 90 day range - so there is no immediate remedy for the provider home in question. However, we will update our policies and procedures manual to specifically outline a checks and balances review of the background documents to address the needs identified by the LCPA guidelines for Virginia. In addition, we will implement increased review of electronic records by a secondary reviewer.2. All staff will receive documented re-training on documentation review to outline LCPA guidelines and specifically highlight this update to our policies and procedures. 1. We will review our P&P by 7/5/23 and anticipate that the update to our policies and procedures will be completed by 7/12/23. 2. The retraining of staff will occur within 1 week of updates to our P&P, no later than 7/19/23.