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: May 4, 2022 and June 30, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-151 ADMINISTRATION 22VAC40-151 RESIDENTIAL ENVIRONMENT 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 DISASTER OR EMERGENCY PLANNING 22VAC40-80 THE LICENSE

Technical Assistance:

Discussed complying with own policies and procedures as noted in the ?Standards for Licensed Children?s Residential Facilities? - 22 VAC 40-151-50.F. Discussed staff successfully completing a medication training program approved by the Board of Nursing before administering medication or be licensed by the Commonwealth of Virginia to administer medications as noted in the ?Standards for Licensed Children?s Residential Facilities? - 22 VAC 40-151-250.A.8. Discussed personal necessities for the residents for the purposes of personal hygiene and grooming as noted in the ?Standards for Licensed Children?s Residential Facilities? - 22 VAC 40-151-410.A. Discussed the application for admission as it pertains to immunization needs as noted in the ?Standards for Licensed Children?s Residential Facilities? - 22 VAC 40-151-620.B.3. Discussed the written placement agreement as noted in the ?Standards for Licensed Children?s Residential Facilities? - 22 VAC 40-151-630.B. Discussed the face sheet at the time discharge as noted in the ?Standards for Licensed Children?s Residential Facilities? - 22 VAC 40-151-50.F.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/4/22 from 9:50 a.m. to 6:19 p.m., 5/5/22 from 9:35 a.m. to 6:32 p.m., and 5/6/22 from 9:30 a.m. to 4:50 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents in care at the beginning of the inspection: 12 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident?s records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Additional Comments/Discussion: An entrance conference was held on 5/4/22. Reviewed two current resident records and two discharged resident records. Reviewed medication administration records for the residents. One discrepancy was found with the CRF matrix, which was shared with the IV-E unit for follow-up. Other documentation reviewed during this inspection included, but was not limited to the following: emergency drill documentation, menus, staff work schedules, and daily log entries. The Director of Group Homes was available and accessible during the inspection on each date. The Director of Group Homes, two Group Home Managers, the Group Care Compliance Specialist, and the Quality Assurance Manager were interviewed on 5/6/22 in order to seek clarification about several documents. Additional interviews with the Director of Group Homes occurred on 6/3/22 and 6/7/22. Also, additional documentation was requested and provided on 6/7/22. An exit meeting was conducted on 6/30/22 to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Michele Freeman, Licensing Inspector, at (804) 662-7062 or by email at michele.freeman@dss.virginia.gov

Violations:

Standard #:	22VAC40-151-660-E-2
Description:	Violation: Based upon the review of the current resident?s, CR1?s, record and interview with staff, the facility failed to report family involvement in the documented quarterly review. Findings: 1) The current resident?s, CR1?s, record contains a quarterly report dated for 3/28/22. 2) This quarterly report does not report about the family?s involvement. 3) Upon review of this report there is no reason as to why family participation would not be appropriate. 4) Staff, S6, who wrote this report, confirmed it did not include family involvement.
Plan of Correction:	Quality Assurance Manager added Section titled ?Family Involvement in Care/Treatment Plan? to the Individualized Service Plan (Quarterly Review) to ensure that current family involvement is being captured.
Standard #:	22VAC40-151-680-G-1
Description:	Violation: Based upon the review of the discharge resident?s, DR1?s, record and interview with staff, the facility failed to ensure the discharge summary was placed in the resident?s record and sent to the persons or agency that made the placement no later than 30 days. Findings: 1) DR1 discharged from this facility on 4/5/22. 2) DR1?s record did not contain a discharge summary. 3) Staff, S5, admitted that DR1?s discharge summary had not been placed in the resident?s record and sent to the persons or agency that made the placement no later than 30 days because she needed to write it.
Plan of Correction:	Group Home Manager reviewed the Standards (22 VAC 40-151-680.G) and ensure the Discharge Summary is completed within 30 days of discharge. Quality Assurance Manager will complete a weekly compliance check to ensure the Discharge Summary is completed within 30 days of discharge. Compliance Specialist will continue to track the electronic health record system (HER) to distribute the Discharge Summary when approved.
Standard #:	22VAC40-151-740-A
Description:	Violation: Based upon the review of the current resident?s, CR1?s, record and interview with staff, the facility failed to ensure the child accepted for care had a physical examination by or under the direction of a licensed physician no earlier than 90 days prior to admission to the facility or no later than 7 days following admission. Findings: 1) Current resident, CR1, was admitted to this facility on 12/28/21. 2) A ?Doctor Visit? form is in CR1?s record, which notes a well check appointment occurred on 1/11/22 3) Staff, S6, acknowledged that CR1?s physical examination was not completed within 7 days following admission
Plan of Correction:	Group Home Manager is responsible for ensuring the physical exam is completed within 7 days of admission. Quality Assurance Manager will complete a 3 day audit to monitor compliance. Compliance Specialist will conduct a 6 day audit to ensure compliance. If an appointment cannot be secured within the 7 day from admission timeframe, the Group Home Manager will notify the Director of Group Care Services to explore options.
Standard #:	22VAC40-151-740-E-1
Description:	Violation: Based upon the review of the current resident?s, CR1?s, record and interview with staff, the facility failed to ensure each physical examination report included the information necessary to determine the health and immunization needs of the resident. Findings: 1) CR1?s record contained a physical examination form from a doctor?s office, which does not address the information necessary to determine the health and immunization needs of the resident. 2) The physical examination report did not include the following elements: a. Immunizations administered at the time of the exam ? 740.E.1. a b. Hearing exam - 740.E.1. c c. General physical condition, including documentation of apparent freedom of communicable disease including tuberculosis - 740.E.1. d d. Allergies, chronic conditions, and handicaps, if any - 740.E.1. e e. Nutritional requirements, including special diets, if any - 740.E.1. f f. Restriction on physical activities, if any - 740.E.1.g g. Recommendations for further treatment, immunizations, and other examinations indicated - 740.E.1. h h. Signature of a licensed physician, the physician?s designee, or an official of a local health department - 740.E.3 3) Staff, S4, and staff, S6, acknowledged the findings. 4) Staff, S4, mentioned the facility?s physical examination form should have been used.
Plan of Correction:	Compliance Specialist will check for correct and complete health physical form during the 6 day post-admission audit. Quality Assurance Manager will ensure that correct medical forms are being utilized during her quarterly compliance audit. Program Nurse sent an email distributing the correct physical form to ensure compliance.