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: Nov. 6, 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

Comments:

Date of inspection 11/6/23 from 10:30-4:30 p.m. Licensing inspectors present: Irvin Goode and Sherry Woodard. Licensing inspectors met with Program Director Dr. Vickie McDonald and contacted Program Director Mr. Rudi Jackson via phone to advise that the inspection will be initiated. Number of approved provider homes: (1) Number of children in care: (2) Number of children records reviewed (2). Number of provider home records reviewed (1) which included documentation for both foster parents. No staff records were reviewed during this inspection and will be reviewed in a follow-up inspection. Observations by licensing inspector: Posting of license was observed. A pre-liminary meeting was conducted on date of inspection with the Program Director and Case Manager, an acknowledgement form was provided. An exit interview meeting was scheduled and concluded on 11/16/2023. 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 email at Irvin.Goode@dss.virginia.gov

Violations:

Standard #:	22VAC40-131-200-E
Description:	Violation: Based on the record review, the agency failed to notify and complete the approval letter within seven business days. Findings: 1. Certification of approval in record for PH-1 was dated 10/15/22 and the approval letter of completion was dated 2/8/23. 2. The findings were discussed during the preliminary and exit findings review.
Plan of Correction:	Approval letter will be completed and mailed to the foster parent within 7 days of approval. The letters will be signed by the program director.
Standard #:	22VAC40-131-250-O
Description:	Violation: Based on the record review, the agency failed to document and file a completed written assessment in the record containing required elements within 30 days of placement for (FC-2). Findings: 1. The admission date for FC-2 was 2/10/2023. The licensee failed to document a completed written assessment in the record within 30 days of placement. 2. The findings were discussed during the preliminary and exit findings review.
Plan of Correction:	Written assessment for all clients will be completed within 30 days of placement. Written assessment form will be created to facilitate the assessment. Program Director will ensure staff or case manager completes the assessment within 30 days.
Standard #:	22VAC40-131-340-I
Description:	Violation: Based on the record review, the agency failed to document all treatment team members who participated in the development of the comprehensive foster care service plan for (FC-2) who was admitted on 2/10/23. Findings: 1. Comprehensive service plan reviewed for FC-2 did not include the signatures and date of the foster care parents. 2. The findings were discussed during the preliminary findings review.
Plan of Correction:	All members of the treatment team will sign off on the treatment plan. The plan will include signature line to ensure it is signed by all parties. Program Director will be responsible for ensuring the document is signed by all parties present.
Standard #:	22VAC40-131-350-A
Description:	Violation: Based on the record review, the agency failed to document quarterly reviews in record for FC-1 and FC-2 admitted on 2/10/23. Findings: 1. A record review for FC-1 and FC-2 did not reveal quarterly review documentation for May 2023 and August 2023. 2. The findings were discussed during the preliminary findings review and staff acknowledged the findings.
Plan of Correction:	Quarterly reports will be completed along with the quarterly foster care review. Quarterly reports meeting will be held and all parties will be invited. The reports will be completed by the case manager and reviewed by the program director
Standard #:	22VAC40-131-370-D
Description:	Violation: Based on the record review, the agency failed to document the signature of the individual completing social history document in the record for FC-2. Findings: 1. The social history document dated 2/13/2023 did not include the signature of the individual performing the service. 2. The findings were discussed during the preliminary findings review.
Plan of Correction:	Case files will be reviewed weekly to ensure all notes and reports are included. A chart will be created to ensure quality assurance of the charts. Program Director will be responsible for quality assurance. The program director will be responsible for ensuring it is completed
Standard #:	22VAC40-131-370-F
Description:	Violation: Based on the record review, the agency failed to keep the case file documentation for FC-2 up to date. Findings: 1. The record review for FC-2 did not contain monthly reports for August, 2023, September, 2023, October 2023. 2. The findings were discussed during the preliminary and exit interviews
Plan of Correction:	Case files will be reviewed weekly to ensure all notes and reports are included. A chart will be created to ensure quality assurance of the charts. Program Director will be responsible for quality assurance.
Standard #:	22VAC40-80-120-E-2
Description:	Violation: Based on the review of the license posted on the premises of the facility, the agency did not post the findings of the most recent inspection. Findings: 1. The licensee violation notice from the inspection summary dated 2/8/2023 was not posted at the public entrance of the facility. 2. The findings were discussed during the exit interviews
Plan of Correction:	A copy of the license and violation notice will be posted in the public entrance of the office. Program director will be responsible for ensuring it os completed.