VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Sherry Woodard (757) 987-0839

Inspection Date: Aug. 30, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-131-1-GENERAL PROVISIONS/63.2 (1) GENERAL PROVISIONS 22VAC40-131 ORGANIZATION AND ADMINISTRATION 22VAC40-131 PERSONNEL 22VAC40-131 PROGRAM STATEMENT 22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN'S SERVICES 22VAC40-131 ADDITIONAL REQUIREMENTS FOR SPECIFIC PROGRAMS 22VAC40-80 THE LICENSE 22VAC40-191 BACKGROUND CHECKS FOR CHILD WELFARE AGENCIES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/30/2022 from 10:00a.m. to 4:00 p.m. The Licensing Inspector met with the Case Manager at the site to initiate the inspection. The Licensing contacted the Program Director to advise of the inspection by telephone. Number of approved provider homes: (2) Number of children in care: (2) Number of children?s records reviewed: (1). Number of provider home records reviewed: (1). Number of staff records reviewed: (1). Observations by licensing inspector: posting of the license and inspection documents was observed. An exit meeting was conducted on the date of inspection with the Program Director and the Case Manager. There were no major changes made to the policies or procedures since the last inspection. The evidence gathered during the inspection determined (5) violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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, Irvin D. Goode, Licensing Inspector at 804-543-5188 or by email at Irvin.Goode@dss.virginia.gov

Violations:

Standard #:	22VAC40-131-250-O
Description:	Based on the review of the records presented for Foster Child (FC)-1 and based on an interview with Agency Representatives (AR), the licensee failed to document a written assessment for the child. Findings: 1. Based on the review of the Foster Child (FC)-1?s child record, there was no documentation that a written assessment was completed within 30 days of placement and documented in the child?s file. 2. During the exit interview AR-1 confirmed and acknowledged the absence of documentation and arrangement of a written assessment.
Plan of Correction:	TFC agency shall ensure a written assessment will be completed on each child placed. PFS will create a written assessment fonn that a case worker will be required to complete within 30 days. Program Director will be required to sign off on the assessment form and ensure completion within 30 days. Once completed the written assessment will be placed in the child's file.
Standard #:	22VAC40-131-290-C-5
Description:	Based on the review of the records presented for Foster Child (FC)-1 and based on an interview with Agency Representatives (AR), the licensee failed to document an eye exam for the child. Findings: 1. Based on the review of the Foster Child (FC)-1?s child record, there was no documentation that an eye exam was arranged and documented in the child?s file. 2. There was no follow-up appointment arranged and documented in the child?s file 3. During the exit interview AR-1 confirmed and acknowledged the absence of documentation and arrangement of an eye examination.
Plan of Correction:	All foster children shall receive an eye exam within 30 days of placement. 1. TFC agency will create a form to document the eye exam was performed 2. TFC agency staff will document in case notes when a follow up appointment has been arranged. If there is no appointment available case manager will document when the next appointment available 3. TFC agency will document and arrange follow up in case management chart ..
Standard #:	22VAC40-131-290-C-8
Description:	Based on the review of the records presented for Foster Child (FC)-1 and based on an interview with Agency Representatives (AR), the medical examination failed to document that the child was free from communicable disease. Findings: 1. Based on the review of the Foster Child (FC)-1?s child record, the medication examination form dated 6/7/2022 failed to document evidence that the child was free of communicable disease. 2. There was no follow-up appointment arranged and documented in the child?s file 3. During the exit interview AR-1 confirmed and acknowledged the absence of documentation.
Plan of Correction:	1 PFS will create a child's medical form that will include a line for the treating physician to test to see if the child has been exposed to any communicable diseases and document on the form whether the child is free of communicable diseases. 2 If case worker is unable to acquire an appointment in a timely manner, the case worker will document this on a case note with the date of the next available appointment. Program Director shall review charts weekly to ensure completion of all required forms, appointments and documents.
Standard #:	22VAC40-131-340-E-3
Description:	Based on the review of the records presented for Foster Child (FC)-1 and based on an interview with Agency Representatives (AR), the licensee failed to develop an individualized service plan with goals and objectives to meet the child?s needs that include specific independent living services to be provided to assist the child in meeting his goals for a youth 14 years of age or older. Findings: 1.Based on the review of the individualized service plan for FC1, there were no independent living goals or objectives listed on the plan. 2. Based on the review of the individualized service plan for FC1, the plan did not list goals and objectives to meet the child?s needs that include specific independent living services. 3. During the exit interview AR-1 confirmed the youth?s age of 17 and acknowledged the absence of an individualized service plan that documented goals and objectives to meet the child?s needs that include specific independent living services.
Plan of Correction:	TFC case managers will complete and Individualized service plan within 30 days as required by licensing standards. Program Director will meet with case manager to discuss service plan goals. and objectives. Children 14 years and older will receive the 1. Ansell Casey life skills assessment and independent living goals will be established in the individualized treatment plan. Program director will sign off on all completed individualized treatment plans once they are completed to ensure timely completion of ISPs. 2. all treatment plans will be completed withing 30 days and list goal and objectives to include specific independent living goals for each child. Program director and case workers will be required to sign off on all individualized service plans.3 Program director will be required to ensure timely completion of all Individualized service plans by his signature
Standard #:	22VAC40-131-370-M-3
Description:	Based on the review of the records presented for Foster Home (FH)-1 and based on an interview with Agency Representatives (AR), the licensee failed to document a completed home study and supporting documentation. Findings: 1. Based on the review of the Foster Child (FH)-1?s record, there was no documentation that a completed home study was completed with supporting documentation. 2. During the exit interview AR-1 confirmed and acknowledged the absence of the documentation
Plan of Correction:	All TFC foster parent will be required to complete a home study. PFS staff will use the SAFE homestudy model to complete and document the homestudies. All supporting documents will be gathered and placed in the chart. 1. The Homestudy checklist will be used to ensure all documentation is in the charts. TFC Program Director will ensure all information is collected and place in the charts for homestudies and sign off on all completed homestudies.