VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Highlands Community Services
383 Baugh Lane
Abingdon, VA 24210
(276) 525-1550 (4361)

Current Inspector: Jamie Morgan (276) 525-5656

Inspection Date: Aug. 30, 2021 , Aug. 31, 2021 , Sept. 1, 2021 , Sept. 2, 2021 , Sept. 10, 2021 and Sept. 13, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-131 PERSONNEL 22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN'S SERVICES 22VAC40-80 THE LICENSING PROCESS. 22VAC40-191 Background Checks for Child Welfare Agencies

Comments:

A monitoring inspection was initiated on 8/30/2021 and concluded on 9/13/2021. The Director of Quality and Compliance was contacted by telephone to initiate the inspection. The inspector emailed the Director of Quality and Compliance a list of items required to complete the remote documentation review portion of the inspection. The Director of Quality and Compliance reported four (4) approved provider homes and seven (7) children receiving services. Documents from five (5) personnel, two (2) provider homes, and one (1) child records were reviewed. An exit interview was conducted with the Director of Quality and Compliance and the Program Director on the date of inspection, 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. The information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-131-180-J-1
Description:	Based on review of documents provided for Foster Home 1 and Foster Home 2 (FH1 and FH2), the agency failed to obtain, as required by 22VAC40-131-180.J.1.b, tuberculosis screenings in compliance with requirements of the Virginia Department of Health for the applicant and all other household members who come into contact with the children as described in 22VAC40-131-290 K.1 1. The records for FH1 and FH2 contained documents titled TB Screening Questionnaire and Testing Form for all applicants and an adult household member in FH2. 2. The TB Screening Questionnaire and Testing Form: a. did not include a statement that the individual is free from communicable tuberculosis b. did not include the type of screening administered, date of screening, and results of the screening. c. The forms were not signed by a medical professional with prescriptive authority 3. The findings were discussed during the exit interview and staff acknowledged the findings.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-180-J-2
Description:	Based on a review of documents provided for Foster Home 1 and 2 (FH1 and FH2), the agency failed to include summary content from references, as required by 180.J.2.e, in the Home Studies. 1. The Home Studies for FH1 and FH2 listed the names of references. 2. Comments below the names of references did not include summary of content information from the references. 3. The findings were discussed during the exit interview. Staff indicated the providers have worked with the agency for many years in a capacity other than the child-placing agency. Staff state that they (staff) has first-hand knowledge of the character and ability of FH1 and FH2 to care for children. Staff acknowledged the findings.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-190-O
Description:	Based on review of documents provided for Foster Home 1 and Foster Home 2 (FH1 and FH2), the agency failed to ensure the provider?s emergency plan addressed all required elements. Findings: 1. Emergency plans for FH1 and FH2 were reviewed. 2. The emergency plans did not include procedures to ensure that the plan is reviewed with each placed child 3. The findings were discussed during the exit interview and staff acknowledged the findings.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-200-C
Description:	Based on review of documents from the records and interview, the licensee failed to recommend approval or disapproval of Foster Home 1 and 2 (FH1 and FH2) based on careful assessment of the requirements for providers. Findings: 1. An unsigned Certificate of Approval (COA) for Foster Home 1 (FH1) was reviewed. The COA included a date of 8/23/2021 beside the signature field. a. Child Protective Services search results for the applicants were dated 30 months prior to the date documented on the COA. b. Documentation of Tuberculosis screening or test results in compliance with regulation 22VAC40-131-290.K were not obtained. c. Health Statements as required by 22VAC40-131-290.L were not obtained. d. Content information from references was not documented in the Home Study or record. 2. A certificate of approval for Foster Home 2 (FH2) was signed and included a signature date of 8/23/2021. a. Child Protective Services search results for Applicant 1 (A1) were dated more than 30 months prior to the date the certificate of approval was issued. b. Child Protective Services search results for Applicant 2 (A2) were not provided. c. Child Protective Services search results for an adult household member (HH1) were dated more than 13 months prior to the date the certificate of approval was issued. d. A Sworn Affirmation statement was not provided for HH1. e. Documentation of Tuberculosis screening or test results for A1, A2, and HH1 in compliance with regulation 22VAC40-131-290.K were not obtained. f. Health Statements for A1 and A2 as required by 22VAC40-131-290.L were not obtained. g. Content information from references was not documented in the Home Study. 3. The findings were discussed during the exit interview. Staff 1 and 2 (S1 and S2) were interviewed for additional information. Staff explained FH1and FH2 were approved under standards for Sponsored Residential Homes and have served in this capacity for many years. 4. Discussion occurred regarding information required prior to assessing the homes for full approval under the Standards for Licensed Child Placing Agencies. Staff acknowledged the findings.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-200-G
Description:	Based on review of documents for Foster Home 1 and 2 (FH1 and FH2), the agency failed to issue Certificates of Approval (COA) addressing required elements in 22VAC40-131-200.G. 1. The COAs for FH1 and FH2 did not include the combination of types of approval for the homes. 2. The COAs for FH1 and FH2 did not include signatures and titles by individuals approving the home. 3. The COA for FH2 did not include both applicant?s names as approved providers. The applicants are married and reside in the home. 4. The findings were discussed during the exit interview. Staff explained their home study process is designed to allow multiple individuals to complete various portions of the study in a progressive manner. Each individual who completes a portion of the required work documents their work and indicates by signature whether they recommend approval at that point in time. Upon completion of gathering all required documents, interviews, observations, and assessment, the Foster Care Supervisor reviews all work and makes a recommendation regarding approving or denying a home to the Program Director. The Program Director then issues the final approval decision. 5. Home Study documentation for FH1 and FH2 indicated an approval recommendation by P3, Foster Care Supervisor. The Program Director did not sign the COA for FH1. The COAs for FH1 and FH2 did not provide a place for P3 to sign. 6. Staff acknowledged the findings.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-290-L
Description:	Based on review of documents provided for Foster Home 1 and 2 (FH1 and FH2), the agency failed to obtain required health statements for applicants. Findings: 1. Health statements were not provided for applicants in FH1 or FH2. 2. The findings were discussed during the exit interview and staff acknowledged the findings.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-370-M
Description:	Based on interviews and review of documents, the agency failed to maintain all required documents in the records of Foster Home 1 (FH1). Findings 1. Documentation of references on each applicant from individuals listed in the home study as references was not provided to the Licensing Inspector. 2. The findings were discussed during the exit interview and staff were interviewed. Staff stated under their license to provide Sponsored Residential Services, references are obtained and maintained by their Human Resources Department. Staff reached out to Human Resources in an attempt to locate existing references. 3. The Licensing Inspector did not receive the references. 4. The Licensing Inspector communicated that references are required to be maintained in the approved provider file per regulation 22VAC40-131-370.M.4.
Plan of Correction:	Not available online. Contact Inspector for more information.