VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Youth for Tomorrow-New Life Center
11835 Hazel Circle Drive
Bristow, VA 20136
(703) 368-7995

Current Inspector: Michele Freeman (804) 662-7062

Inspection Date: Dec. 10, 2019 , Dec. 11, 2019 and Dec. 12, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-151 22VAC40-151 III. RESIDENTIAL ENVIRONMENT 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 DISASTER OR EMERGENCEY PLANNING

Comments:

An unannounced monitoring inspection was conducted on December 10, 2019 from 9:38 a.m. to 4:02 p.m., on December 12, 2019 from 9:22 p.m. to 5:16 p.m., and December 12, 2019 from 9:25 a.m. to 5:57 p.m. Sixteen personnel records were reviewed: four reviewed entirely and twelve reviewed for background investigation information only. Sixteen personnel records were reviewed against the matrix. Six contract providers records were reviewed. One hundred and thirty two (132) residents were in care during this inspection. Six resident's records were reviewed: four current residents and two discharged Other documentation reviewed at this inspection included but was not limited to resident grievances, movement logs, daily logs, policies and procedures, case management notes, staff work schedules, menus, emergency drill documentation and medication administration records. Interior physical plant inspections of two houses were conducted. Staff S17, S18, S19, S20, S21, and S22 were available to respond to questions during the inspection. One resident was interviewed. An exit meeting to discuss preliminary findings was held prior to leaving the facility on December 12, 2019 with the Vice President of Programs, Associate Vice President of Program Services, Senior Quality Assurance Coordinator UIM, Quality Assurance Coordinator, Interim Director of Residential Services, Assistant Director of UIM Counseling Services and Case Management, the Director of Human Resources, and a Human Resources Generalist. An acknowledgement form was signed at the exit meeting. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return to the Licensing Office within 5 business days from receipt of the inspection documentation. You will need to specify how the deficient practice will be or has been corrected (merely writing the word corrected is not acceptable). Your plan of correction must contain the steps to correct the noncompliance with the standard(s), the measures to prevent the noncompliance from occurring again; and the position responsible for implementing each step and/or monitoring any preventive measure(s). The licensee should retain a copy to be posted at the facility. Results of the inspection documentation are subject to public disclosure and will be posted on the VDSS web site within 5 days, regardless of whether the Plan of Correction is completed.

Violations:

Standard #:	22VAC40-151-210-B-1
Description:	Based on review of the personnel record for Staff S2 and interview with Staff S21, S2 did not meet the minimum qualification requirements required by the job description. Findings: 1. Review of the resume for S2 revealed that S2's qualifications did not meet the minimum qualifications required by the job description. 2. The job description requires licensure (LMHP) or LMHP-e (eligibility for licensure) to provide counseling services. 3. S2 does not have a license. 2. Staff S21 acknowledged that S2's qualifications did not meet the minimum qualifications required by the job description.
Plan of Correction:	Although ORR approved YFT to hire the employee, the employee's qualifications did not match the job description. HR Director established new protocol for ORR exceptions regarding qualifications with the department hiring manager. Hiring manager will forward all exception approvals to HR for inclusion in the employee records.
Standard #:	22VAC40-151-240-B-3
Description:	Violation: Based on review of the personnel record for Staff S2, written references or notations of references were not documented. Findings: 1. Written references or notations of oral references were not documented in S2's personnel record. 2. During an interview with the Licensing Specialist, Staff S21 confirmed that references were not documented in the personnel record for S2.
Plan of Correction:	Documented written or verbal references is an item on all new hire checklists. A spot check of HR Generalist responsibility for new hires will be reviewed periodically for compliance with internal HR policy to avoid these misses.
Standard #:	22VAC40-151-850
Description:	Based on review of the report regarding an incident involving staff, S23, and resident, CR4, on 11/6/2019, S23 used seclusion. Seclusion is a prohibited action. Findings: 1. The report states, ?Counselor [S23] stayed at the door to make sure that resident [CR4] was not going to harm others or himself due to resident?s [CR4] aggressive behavior in the particular moment. Resident [CR4] proceeded to walk out of the room and saying he wanted to talk to his social worker. While the Counselor [S23]?s arm was on the door frame, resident [CR4] pushed upwards counselor [S23]?s arm aggressively.? 2. Seclusion, as defined in 22 VAC 40-151-10, includes physically blocking the door. 3. The counselor, S23, used physical restraint as a result of the resident taking aggressive action to leave the room. 4. The resident called the police following the restraint. 5. The resident was seen by the director and the nurse following the use of restraint for shin pain.
Plan of Correction:	Residential administration reviewed the incident with the employee and a note to file was placed in the employee's personnel record. Residential conducted a training on search procedures, DSS, and DBHDS regulations regarding the residential milieu.