VIRGINIA DEPARTMENT OF SOCIAL SERVICES

FAMILIES FIRST OF VIRGINIA, INC.
4701 Columbus Street
Ste. 305
Virginia beach, VA 23462
(757) 689-3818

Current Inspector: Irvin Goode (804) 543-5188

Inspection Date: Nov. 18, 2019 and Nov. 19, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-131 ORGANIZATION AND ADMINISTRATION 22VAC40-131 PERSONNEL 22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN'S SERVICES 63.2 General Provisions. 22VAC40-191 Background Checks for Child Welfare Agencies

Technical Assistance:

Technical Assistance: Regarding standard #22VAC40-131-210, to ensure consistent compliance in this area, the licensee agreed to review this section of the standards, review how they are documenting provider training and determine one consistent method for documenting completion of provider training. Regarding standard #22VAC40-131-90, the licensee agreed to add a section to their policy and procedures regarding the assessment level of services that they are currently utilizing. Regarding standard #22VAC40-131-180 two different social history formats were observed, the licensee is encouraged to utilize one consistent format which captures all required elements. Guidance provided regarding the documentation of compliance for Standard 22VAC40-131-(6)-330.G.

Comments:

An unannounced monitoring inspection was completed on November 18, 2019 from 10:05 am to 5:00 pm and November 19, 2019 from 9:30 am to 2:00 pm at Families First of Virginia located at 4701 Columbus Street, Virginia Beach, VA 23462. The licensee reports a total of thirty-two (32) children receiving foster care services and thirty-three (33) approved foster care provider homes. During this inspection, the following actions were taken: 1.Reviewed four (4) children records. 2.Reviewed five (5) provider home records. 3.Reviewed three (3) employee records (two were newly hired employees) 4.Background checks and references for all board officers were reviewed at the last inspection. 5.Policy and Procedures were reviewed. 6.Interviews were conducted. The Quality Assurance Manager and Executive Director were present for the exit interview at 1:00 pm on November 19, 2019. An Acknowledgement of Inspection form was signed by the Executive Director on November 19, 2019; the Quality Assurance Manager and Executive Director were available during the inspection. There were seven (7) citations for violations of the Standards for Licensed Child-Placing Agencies. Five (5) violations were of designated health and safety standards. Upon receipt of the Violation Notice, the licensee should develop a plan of correction to include the steps to correct non-compliance with the standard(s); measures to prevent re-occurrence of non-compliance; person(s) responsible for implementation and monitoring of preventative measure(s); and date by which noncompliance will be corrected. The licensee has five business days from receipt of the inspection documents to complete the section entitled "Plan of Correction", sign each page of the inspection documents and return to the Licensing Office. The licensee should retain a copy to be posted at the facility. Results of the inspection are subject to public disclosure and will be posted on the Virginia Department of Social Services public web site within five business days, regardless of whether or not the Plan of Correction is completed.

Violations:

Standard #:	22VAC40-131-40-A
Description:	Violation: Based on the review of the foster home records for Foster Homes 2, 3 and 4 as well as based on an interview with agency representatives, the licensee failed to ensure documentation of compliance with other relevant state laws, specifically with ? 63.2-1231-maintaining documentation ensuring that foster home providers are informed that information about shaken baby syndrome, its effects, and resources for help and support for caretakers is available on a website maintained by the Department in accordance with regulations adopted by the Board. Evidence: (1)Based on the file review for FH 2, FH3, and FH4 did not contain documentation that the foster parents were provided information about shaken baby syndrome, its effects, and resources for help and support for caretakers is available on a website maintained by the Department in accordance with regulations adopted by the Board. (2)During an interview with AR2, it was acknowledged that the documentation was not in the records and that they do not provide information related to the availability of information/resources on the website. During the interview, AR1 stated a plan to develop a document to address this area.
Plan of Correction:	The description of this training in the home study in question was not detailed enough. Going forward this will be more conclusively detailed in home studies. Quality Assurance Manager
Standard #:	22VAC40-131-160-B-9
Description:	Violation: Based on the review of the personnel file for Staff 1 (S1) and based on an interview with agency representatives, the licensee failed to document all training as required by these standards. The licensee failed to document annually that S1 completed training applicable to his competencies to perform his job. Evidence: (1)The last documented training for S1 was dated September 20, 2017 with no additional training documented in the record. (2)During the exit interview, AR1 and AR2 acknowledged that the last documented training for S1 was dated September 20, 2017 with no additional training documented in the record. AR1 reported that S1 completed training in 2019; however, she reports that the 2019 training was internal training which was not documented.
Plan of Correction:	S1 received 3 separate trainings in 2019. These will be added to the personnel record. Executive Director
Standard #:	22VAC40-131-180-J-2
Description:	22VAC40-131-180.J.2.E.9 Violation: Based on the review of the record for Foster Home 3 (FH3) and based on an interview with agency representatives, the licensee failed to document that the applicant had the financial resources to provide for current and on-going household needs and maintenance of the family. There was no evidence that the licensee verified the income of FH3. Evidence: (1)There was no evidence that the income of FH3 was verified; there was no evidence that the applicant had the financial resources to provide for current and on-going household needs and maintenance of the family. (2)During the exit interview, AR1 and AR2 acknowledged that due to the formatting concerns with the home history that the required information was not present in the home study and was not present in the file.
Plan of Correction:	An addendum will be placed in the file describing the above in detail and reiterating this information was verified during the home study process. Quality Assurance Manager
Standard #:	22VAC40-131-190-T
Description:	Violation: Based on the review of the provider home record for Foster Home 2 (FH2) and based on an interview with AR1 and AR3, there was no documentation ensuring that the applicant ensured that the household pets are safe to be around children and that the pets present no health hazard to children in the home. Evidence: (1)The record for FH2 did not contain any evidence or documentation that the applicant ensured that the household pet (dog) is safe to be around children and that the pets present no health hazard to children in the home. (2)During the exit interview, AR1 and AR2 acknowledged that due to the formatting concerns with the social history that information was left blank on this section of the social history and they do not capture this information in any other section of the record. AR2 reviewed the record and determined that ?there is an incomplete sentence? for this section of the home study and that there was no additional evidence in the record to ensure that the applicant ensured that the pet was safe to be around children and that the pet presented no health hazard to children in the home.
Plan of Correction:	An addendum will be placed in the file describing above and also reiterating that the immunization report for the pet was viewed. Quality Assurance Manager
Standard #:	22VAC40-131-250-M
Description:	Violation: Based on the review of the record for FC3 and based on an interview with agency representatives, the licensee failed to prepare the child for placement and arrange a preplacement visit for the child in the prospective home. Evidence: (1)According to the review of the record for FC3, based on the date of the referral, the placement was not considered an emergency placement. Based on the record review, the licensee conducted a pre-placement visit; however, there was no documentation of a pre-placement visit. (2)During the exit interview, AR1 and AR2 reported that following the pre-placement interview, the foster parents did not think that a pre-placement visit was necessary therefore they did not conduct a pre-placement visit.
Plan of Correction:	The provider?s response for the Description of Action to be Taken was not received within 5 days of receiving the violation notice and will not appear on the violation notice.
Standard #:	22VAC40-131-290-C
Description:	Violation: Based on the review of the record for FC3 and FC4 and based on an interview with agency representatives, the licensee failed to document a medical examination that contained all of the required elements. Evidence: (1)The medical exam located in the record for FC3 did not contain the following required areas: growth and development, auditory acuity, nutritional status, and allergies, including food and medication allergies. The medical exam located in the record for FC4 did not contain the following required areas: FC4 did not contain the following required areas: auditory acuity, nutritional status and allergies, including food and medication allergies. (2)During the exit interview, AR1 and AR2 acknowledged that the medical exams located in the records did not contain all the required elements.
Plan of Correction:	The agency will attempt to obtain in house documentation of previous physical from physician. Family Counselor
Standard #:	22VAC40-131-340-B-1
Description:	Violation: Based on an interview with an agency representative and based on the review of the Foster Children records for Foster Children 1 thru 5, (FC1, FC2, FC3, FC4, and FC5), the licensee failed to complete an individualized service plan that included specific measurable objectives and strategies describing services to be provided to the child. Evidence: (1)The foster child records for FC1, FC2, FC3, FC4, and FC5 did not contain an individualized service plan that included specific measurable objectives and clearly identified strategies describing services to be provided to the child. The objectives were not measurable and while there were services listed, the strategies were not indicated on the plan. (2)During the exit interview, AR1 and AR2 reviewed foster records and determined that there were no measurable objectives and no clearly identified strategies on the individualized service plans.
Plan of Correction:	In consideration of this new interpretation, the Executive Director will revise the document to ensure clarity of content and compliance with the detail of this standard going forward. Executive Director