VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Pinnacle Family Services
14 W. Queens Way
Hampton, VA 23669
(757) 846-6953

Current Inspector: Dawn Espelage (540) 759-8852

Inspection Date: June 28, 2021 and July 1, 2021

Complaint Related: No

Areas Reviewed:

63.2 (1) General Provisions 22VAC40-131-2 Organization and Administration 22VAC40-131-3 Personnel 22VAC40-131-4 Program Statement 22VAC40-131-5 Provider Homes 22VAC40-131-6 Children's Services 22VAC40-131-7 Additional Requirements for Specific Programs 22VAC40-191 (BC) Background Checks for Child Welfare Agencies

Comments:

An initial inspection was initiated on June 28, 2021 and concluded on July 1, 2021. The President was contacted by telephone to initiate the inspection. The President reported that there were 3 current employees. The inspector emailed the President a list of items required to complete the remote documentation review portion of the inspection. The inspector conducted a remote physical plant inspection, reviewed (3) staff records, reviewed policies and procedures and reviewed additional information submitted by the facility to ensure documentation was complete. An exit interview was conducted with the CEO/Executive Officer and President on 07/01/2021, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-131-70-F
Description:	Based on the review of the documentation presented, the applicant failed to submit evidence of sufficient funds to ensure operation in compliance with regulatory standards. Findings: There was no documentation of sufficient funds to ensure compliance submitted with the review documents.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-70-F
Description:	Based on the review of the documentation presented, the applicant failed to submit evidence of sufficient funds to ensure operation in compliance with regulatory standards. Findings: There was no documentation of sufficient funds to ensure compliance submitted with the review documents.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-90-A
Description:	Based on the review of the documentation submitted, the licensee failed to develop written policy and procedures governing the plans for active and closed cases. Findings: 1. Based on the review of the documents submitted, titled "policies and procedures," the document did not contain actual policies or procedures. This document was a restatement of the regulatory standards. 2. Based on the documentation submitted there were no written procedures governing the plans for active and closed cases.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-90-B
Description:	Based on the review of the documentation submitted, the licensee failed to develop written policies and procedures for child-placing activities for each program for which they submitted an application. Findings: 1. Based on the review of the documents submitted, titled "policies and procedures," the document did not contain actual policies or procedures. This document was a restatement of the regulatory standards. 2. Based on the documentation submitted there were no written procedures for child-placing activities for each program for which they submitted an application.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-90-C
Description:	Based on the review of the documentation submitted, the licensee failed to develop written policies and procedures governing the licensee's responsibility to monitor the administration of medication by foster parents. Findings: 1. Based on the review of the documents submitted, titled "policies and procedures," the document did not contain actual policies or procedures. This document was a restatement of the regulatory standards. 2. Based on the documentation submitted there were no written policies and procedures governing the licensee's responsibility to monitor the administration of medication by foster parents.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-90-D
Description:	Based on the review of the documentation submitted, the licensee failed to develop written policies and procedures for prohibiting corporal punishment, chemical and mechanical restrains, and seclusion. The licensee failed to develop written policies and procedures covering standards 22VAC40-131-90.D 1-5. Findings: 1. Based on the review of the document submitted as the facilities policies and procedures, the document did not contain policies or procedures, the document was a copy of the regulatory standards. 2. Based on the documentation submitted there were no written procedures for prohibiting corporal punishment, chemical and mechanical restrains, and seclusion. The licensee failed to develop written policies and procedures covering standards 22VAC40-131-90.D 1-5.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-90-F
Description:	Based on the review of the documentation, the licensee failed to submit policies and procedures with written procedures governing children's planned and emergency discharges from the licensee's program and services. Findings: 1. The documentation submitted for review contained references to the regulatory standards and did not document a policy or procedure. 2. The documentation submitted did not demonstrate the development of procedures governing children's planned and emergency discharges from the licensee's program and services.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-90-G
Description:	Based on the review of the documentation, the licensee failed to submit policies and procedures with written procedures governing foster parent's use of physical restraint. Findings: 1. The documentation submitted for review contained references to the regulatory standards and did not document a policy or procedure. 2. The documentation submitted did not demonstrate the development of procedures governing foster parent's use of physical restraint.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-90-H
Description:	Based on the review of the documentation, the licensee failed to submit policies and procedures with written procedures addressing acceptable methods of behavior supports and unacceptable methods for behavior control and discipline. Findings: 1. The documentation submitted for review contained references to the regulatory standards and did not document a policy or procedure. 2. The documentation submitted did not demonstrate the development of procedures procedures addressing acceptable methods of behavior supports and unacceptable methods for behavior control and discipline.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-90-I
Description:	Based on the review of the documentation, the licensee failed to submit policies and procedures with written personnel procedures. Findings: 1. The documentation submitted for review contained references to the regulatory standards and did not document a policy or procedure. 2. The documentation submitted did not demonstrate the development of personnel procedures.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-130-A
Description:	Based on the information submitted for review, the licensee failed to submit job descriptions for Staff (S)1, 2 and 3. Findings: The staff records submitted did not contain job descriptions for S-1, S-2, and S-3.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-140-E
Description:	Based on the review of the documentation submitted, the licensee failed to develop written policies and procedures for management of all records, written and electronic. Findings: 1. Based on the review of the document submitted as the facilities policies and procedures, the document did not contain policies or procedures. The document was a copy of the regulatory standards. 2. Based on the documentation submitted there were no written procedures for management of all records, written and electronic.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-150-B-1
Description:	Based on the documents presented for review and based on an exit interview with agency representatives (AR), the licensee failed to submit documentation of the required initial orientation for Staff (S) 1, 2 and 3. Findings: 1. The documentation presented for review did not contain documentation initial orientation for S1, S2 and S3. 2. During the exit interview, AR-1 reviewed the presented information and acknowledged the missing information.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-160-B-2
Description:	Based on the documents presented for review and based on an exit interview with agency representatives (AR), the licensee failed to submit a personnel record that contained documentation of Staff (S) S-1, S-2, and S-3's educational background. Findings: 1. The documentation presented for review did not contain documentation of educational backgrounds as described in this standard. 2. During the exit interview, AR-1 reviewed the presented information and acknowledged the missing information.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-160-B-3
Description:	Based on the documents presented for review and based on an exit interview with agency representatives (AR), the licensee failed to submit a personnel record that contained documentation of at least two written references for Staff (S) S-2. Findings: 1. The documentation presented for review did not contain documentation of at least two written references for Staff (S) S-2. 2. During the exit interview, AR-1 reviewed the presented information and acknowledged the missing information.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-191-40-C-1-a
Description:	Based on the review of the documentation presented for review and based on an interview with agency representatives (AR), the licensee failed to submit background checks (sworn statement or affirmation, search of central registry, and criminal history record check) at the time of initial application for the applicant and agents involved in the day-to-day operations of the child welfare agency. Findings: 1. The documentation did not contain evidence of background checks (sworn statement or affirmation, search of central registry, and criminal history record check) for S-1, S-2 or S-3, all of whom are listed as either applicants or agents involved in the day-to-day operations of the child welfare agency. 2. During the exit interview AR-1 reviewed the documentation and acknowledged the absence of the required information.
Plan of Correction:	Not available online. Contact Inspector for more information.