VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Joy Ranch, Inc.
813 Joy Ranch Road
Woodlawn, VA 24381
(276) 236-5578

Current Inspector: Jamie Morgan (276) 525-5656

Inspection Date: May 29, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-151 III. RESIDENTIAL ENVIRONMENT 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 DISASTER OR EMERGENCEY PLANNING 22VAC40-80 THE LICENSE. 63.2 Facilities and Programs..

Comments:

An unannounced renewal inspection was conducted on May 29, 2019 from 10:15 AM ? 4:45 PM and on May 30, 2019 from 9:18 AM - 1:30 PM. The facility reports a total of fourteen (14) children in placement; six (6) boys and eight (8) girls. During this inspection, records were reviewed for two current residents, two discharged residents, and four personnel. There are no new staff hires. Staff were reviewed against the CRF Employee Matrix. Interviews were conducted with two residents and nine staff. A tour of the facility?s exterior and all living areas within the facility was conducted to include the gymnasium, administration building, Leebrick Cottage and Exodus Cottage. Residential environment requirements were assessed. The following was reviewed for the past six months: daily communication logs, grievances, menus, staff work schedules, pet records, incident reports, emergency evacuation drill documentation, medication administration records, readily accessible medical information, fire and sanitation inspection documentation, insurance to include indemnity, professional liability, and commercial vehicle coverage for facility vehicles and vehicle insurance on staff cars used to transport residents, overnight recreational trip documentation, and the facility?s annual review and program evaluation documentation. An exit interview was conducted at the conclusion of the inspection to review preliminary inspection findings. An acknowledgement form was signed. There was one violation. Upon the receipt of the violation notice, the licensee should identify the necessary corrective action and develop a plan of correction for each violation. The plan of correction should include the following: The steps to correct noncompliance with the standard(s); measures to prevent re-occurrence of noncompliance; person(s) responsible for implementation and monitoring of preventative measure(s); and date by which noncompliance will be corrected. The licensee has five (5) calendar days from receipt of the inspection documentation to complete the section titled Plan of Correction, sign each page of the documentation and return it to the Licensing Office. The licensee should retain a copy to be posted at the facility. Results of the inspection documentation will be posted on the VDSS web page and available for review by the general public. Do not write any names or other confidential information into your plan of correction.

Violations:

Standard #:	22VAC40-151-660-H-2
Description:	Violation: Based on review of the resident record (CR1) and interview with personnel (P9), the facility failed to involve the resident's family in the development of the quarterly progress report. Evidence: The quarterly progress report form documents the involved parties at the end of the document. The element does not indicate the involvement of the birth family in development of the quarterly progress report dated 03/01/2019 for CR1. The DSS service plan documents a goal of Return Home and the family visits the resident weekly. P9 stated that she was unaware that, in addition to the DSS holding legal guardianship, the birth family must also be involved in the plan's development.
Plan of Correction:	*Upon intake, guardians will be notified family will also be contacted to get input in developing the ISP. *Upon intake, DSS agencies will receive a form with the licensing standard showing family involvement is required unless clearly inappropriate. DSS will sign this form stating they are aware of this requirement. *The participant page of the ISP has been changed to reflect parties who gave input and also to whom the plan was distributed.