VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Virginia Home for Boys and Girls
8716 West Broad Street
Henrico, VA 23294
(804) 270-6566

Current Inspector: Dawn Espelage (540) 759-8852

Inspection Date: April 14, 2020 and May 12, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-151 INTRODUCTION. 22VAC40-151 PROGRAMS AND SERVICES

Comments:

An unannounced monitoring inspection was conducted in response to a self-reported incident received on April 13, 2020 involving interaction between staff and resident. Due to the outbreak of COVID-19, the inspection was conducted in the form of a desk review on various dates between 04/14/2020 and 05/12/2020. Inspection activities included an interview with Agency representative AR1, review of documentation including the serious incident report, internal report of the incident, staff emails, policies and procedures, and portions of a personnel record. Exit meeting held with AR1 via telephone on May 12, 2020. 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 #:	22VAC40-151-50-F
Description:	Violation: Based on interview with agency representative AR1 and review of the serious incident report (SIR), dated 04/13/2020, staff emails dated 04/11/2020, and the 04/15/2020 Internal Review of Incident Report, for resident, R1, the provider failed to comply with its own policies and procedures. Findings: A. Review of the facility?s policy and procedure, titled ?1000.407 Therapeutic Holds? with an effective date of 2/28/2020 revealed the following: - ?3. If the therapeutic hold is unsuccessful, contact the Group Home Manager who will determine if contact with police, mental health personnel, or other resource is required.? - ?4. The Group Home Manager is responsible for documenting a therapeutic hold in a serious incident report. See policy #1000.409.? B. The 04/13/2020 SIR and 04/11/2020 emails written by Staff S1 and Staff S2 were reviewed by the Licensing Specialist. C. The email from Staff S2 revealed that a restraint was attempted. "When (S1) restrained (R1) to keep him from stabbing (S1), (R1) said, ?I will kill ya'll especially you?. "(S1) tried to take the spoon they fell into the fish tank breaking it". D. The SIR completed on 4/13/2020 does not document the attempted restraint. E. No documentation was provided by the facility to indicate that the Group Home Manager was contacted following the unsuccessful physical restraint of R1 by S1. Review of the 04/13/2020 SIR revealed that the 04/10/2020 incident was discovered by the Group Home Manager when the Group Home Manager called the home to check in on 04/11/2020. F. During an interview with the Licensing Specialist, AR1 confirmed that the physical restraint was not documented on the SIR.
Plan of Correction:	Quality Assurance Manager to ensure client?s record is modified to include required information about restraint that occurred on 4/10/2020. Vice President of Programs met with Director of Staff Development and Quality Assurance Manager to review violation notice, VHBG P&P 1000.407, retrain on DSS Licensing Standards regarding physical restraint, and determine next steps of corrective action. Vice President of Programs and Director of Staff Development reviewed definition of physical restraint with Group Home Managers, Supervisors, and Quality Assurance Manager and provided training regarding immediate notification of Group Home Manager in the event of a physical restraint as defined by DSS licensing. Vice President of Programs, Director of Staff Development, and Quality Assurance Manager revised VHBG P&P 1000.407 for internal clarity and submitted to DSS Licensing Specialist for review. Director of Staff Development to ensure that All Group Care Services employees are educated regarding the updated VHBG P&P regarding restraints.