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: Feb. 7, 2023

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

Technical Assistance:

22VAC40-131-160 Personnel Records. A table of contents for the personnel records should be created and utilized, and the content should be uniformed, organized and filed accordingly.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/7/2023 from 10:00a.m. to 1:00 p.m. The Licensing Inspector met with the Case Manager at the site to initiate the inspection. The Licensing contacted the Program Director via phone to advised that the inspection will be initiated. Number of approved provider homes: (1) Number of children in care: (1) Number of children?s records reviewed: (1). Number of provider home records reviewed: (1). Number of staff records reviewed: (3). Observations by licensing inspector: posting of the license and inspection documents was observed. A pre-liminary meeting was conducted on the date of inspection with the Case Worker and the acknowledgement form was left to schedule a meeting with the Executive Director and the Program Director regarding findings and case issues. There were no major changes made to the policies or procedures since the last inspection. An exit interview and meeting was scheduled and completed on 2/8/2023 at 12:00 p.m. Technical assistance was provided to the licensee regarding a table of contents for the personnel records and the content being uniformed, organized and filed accordingly. The evidence gathered during the inspection determined (7) 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:	Violation: Based on the record review, the agency failed to document a written assessment for (FC-1) 1) (FC-1) was admitted on 8/4/2022 2) The record did not contain a written assessment 3) The Licensing Inspector requested the written assessment for (FC-1) 4) The Licensing Specialist asked (AR-1) if the information could be located 5) The findings were discussed during the preliminary findings review and the staff acknowledged the findings. 6) The findings were reviewed during the exit interview.
Plan of Correction:	A Clinical Diagnostic Assessment and Mental Status Exam" form (See Attachment 2) has been developed. This form has been completed for FC-1 and placed in the record. A "Client Record tracking chart has been created and will be reviewed and updated during supervision.
Standard #:	22VAC40-131-290-C-12
Description:	Violation: Based on the record review, the agency failed to document immunizations for (FC-1). 1) (FC-1) was admitted on 8/4/2022 2) The record did not contain an immunization record for the child 3) The Licensing Inspector requested the immunization record for (FC-1) 4) The Licensing Specialist asked (AR-1) if the information could be located 5) The findings were discussed during the preliminary findings review and the staff acknowledged the findings. 6) The findings were reviewed during the exit interview
Plan of Correction:	FC-1 Immunization record was requested initially during placement. A second request has been sent to obtain this information. In addition, an "information Request" Tracking Form (See Attachment 1) has been developed, completed, and place in FC-1 chart to document the request. A "Client Record tracking chart has been created and will be reviewed and updated during supervision. FC-1 immunization record will be updated and place in the chart once it is received.
Standard #:	22VAC40-131-310-B
Description:	Violation: Based on the record review, the agency failed to document an allowance for (FC-1) 1) (FC-1) was admitted on 8/4/2022 2) The record did not contain a document a spending money allowance 3) The Licensing Inspector requested the spending money allowance documentation for (FC-1) 4) The Licensing Specialist asked (AR-1) if the information could be located 5) The findings were discussed during the preliminary findings review and the staff acknowledged the findings. 6) The findings were reviewed during the exit interview.
Plan of Correction:	An Allowance Documentation form (See Attachment 3) has been developed. This form has been completed for FC-1 and placed in the record . A "Client Record tracking chart has been created and will be reviewed and updated during supervision.
Standard #:	22VAC40-131-340-B-1
Description:	Violation: Based on record review, the agency failed to document an initial plan of care service plan for FC (1) admitted on 8/4/2022. Findings: 1) (FC-1) was admitted on 8/4/2022. 2) The record did not contain the initial plan of care. 3) The Licensing Inspector requested the plan of care. 4) The Licensing Specialist asked (AR-1) if the information could be located. 5) The findings were discussed during the preliminary findings review and staff acknowledged the findings. 6) The findings were reviewed during the exit interview
Plan of Correction:	FC-1 Initial Plan has been printed and placed in the record A "Client Record tracking chart has been created and will be reviewed and updated during supervision
Standard #:	22VAC40-131-340-B-2
Description:	Violation: Based on the record review, the agency failed to document an implement an individualized service plan and treatment plan for FC(1). 1) (FC-1) was admitted on 8/4/2022 2) The record did not contain the comprehensive individualized service and treatment plan 3) The Licensing Inspector requested the plan of care 4) The Licensing Specialist asked (AR-1) if the information could be located 5) The findings were discussed during the preliminary findings review and the staff acknowledged the findings. 6) The findings were reviewed during the exit interview.
Plan of Correction:	FC-1 ISP and Treatment Plan has been printed and placed in the record A "Client Record tracking chart has been created and will be reviewed and updated during supervision
Standard #:	22VAC40-131-350-A
Description:	Violation: Based on the record review, the agency failed to document a quarterly progress review for (FC-1) 1) (FC-1) was admitted on 8/4/2022 2) The record did not contain the quarterly progress review 3) The Licensing Inspector requested the progress review 4) The Licensing Specialist asked (AR-1) if the information could be located 5) The findings were discussed during the preliminary findings review and the staff acknowledged the findings. 6) The findings were reviewed during the exit interview.
Plan of Correction:	FC-1 Quarterly progress notes have been printed and placed in the record. A "Client Record tracking chart has been created and will be reviewed and updated during supervision.
Standard #:	22VAC40-131-370-Q
Description:	Violation: Based on the record review, the agency failed to document case notes for (FC-1) 1) (FC-1) was admitted on 8/4/2022 2) The record did not contain case notes from 09/2022 to the current inspection 3) The Licensing Inspector requested the case notes for (FC-1) 4) The Licensing Specialist asked (AR-1) if the information could be located 5) The findings were discussed during the preliminary findings review and the staff acknowledged the findings. 6) The findings were reviewed during the exit interview.
Plan of Correction:	FC-1 Case Notes have been printed and placed in the record. A "Client Record tracking chart has been created and will be reviewed and updated during supervision.