VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Seton House Youth Shelter
465 Kings Grant Road
Virginia beach, VA 23452
(267) 973-1144

Current Inspector: Sherry Woodard (757) 987-0839

Inspection Date: April 30, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-151 INTRODUCTION. 22VAC40-151 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 DISASTER OR EMERGENCEY PLANNING

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on April 30, 2020 and concluded on May 14, 2020. The Program Director was contacted by telephone to initiate the inspection. The Program Director reported that the current census was 3. The inspector emailed the Program Director a list of items required to complete the inspection. The inspector reviewed one resident record and five personnel records to include background investigation information, the daily log, case management notes, emergency drill documentation, staff work schedules, menus, and medication administration records submitted by the facility to ensure documentation was complete. Exit meeting was held with AR1 via telephone on May 14, 2020. Information gathered during the inspection determined non-compliance with applicable standards or law, and a violation was documented on the violation notice issued to the facility. 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 #:	22VAC40-151-960-B
Description:	Violation: Based on review of the Serious Incident Report (SIR), dated 03/24/2020, and interview with agency representative AR1, the provider failed to notify the parent/legal guardian of the serious incident. Findings: 1. The serious incident report did not document notification to the parent or legal guardian (element on the form was left blank). 2. During an interview with the Licensing Specialist, AR1 acknowledged that the notification had not occurred.
Plan of Correction:	All staff will be retrained in SIR?s specifically as to who should be notified in the case of a Serious Incident Report. In this specific case the Legal Guardian should have been notified. The Director Shelter Programs will be responsible for implementation of the training and/or monitoring any preventative measures.