VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Saving Families Group Home - Najai's House
8903 Sonnet Hill Court
Richmond, VA 23236
(804) 276-1454

Current Inspector: Irvin Goode (804) 543-5188

Inspection Date: April 14, 2023 and July 7, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-151 Administration 22VAC40-151 Residential Environment 22VAC40-151 Programs and Services 22VAC40-151 Programs and Services 22VAC40-151 Disaster or Emergency Planning 22VAC40-80 The License

Technical Assistance:

Discussed monitoring and evaluating service quality and effectiveness on a systematic and on-going basis as noted in the Standards for Licensed Children?s Residential Facilities - 22 VAC 40-151-120.D. Discussed the department being notified within five working days of any change in administrative structure or newly hired chief administrative officer or program director as noted in the Standards for Licensed Children?s Residential Facilities - 22 VAC 40-151-170.A. Discussed the supervision of staff as noted in the Standards for Licensed Children?s Residential Facilities - 22 VAC 40-151-260. Discussed the sanitizing agent used in the laundering of bed, bath, table, and kitchen linens as noted in the Standards for Licensed Children?s Residential Facilities - 22 VAC 40-151-540.D. Discussed accepting and serving those children whose needs are compatible with the services provided through the facility as noted in the Standards for Licensed Children?s Residential Facilities - 22 VAC 40-151-570.B. Discussed the maintenance of residents? records as it pertains to security measures to protect records from loss as noted in the Standards for Licensed Children?s Residential Facilities - 22 VAC 40-151-580.C.3. Discussed the discharge summary in the resident?s record as noted in the Standards for Licensed Children?s Residential Facilities - 22 VAC 40-151-680.G.1. Discussed the policies and procedures governing use of physical restraint and the related elements as noted in the Standards for Licensed Children?s Residential Facilities - 22 VAC 40-151-840.D.1-3.

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: 4/14/23 from 9:50 AM ? 6:22 PM 4/18/23 from 10:30 AM ? 7:07 PM 4/19/23 from 11:17 AM ? 3:23 PM 4/20/23 from 9:57 AM ? 1:33 PM - Preliminary Findings Meeting 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: 4 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: 3 Number of staff records reviewed: 5 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Additional Comments/Discussion: An unannounced renewal inspection was completed by the Licensing Specialist on the previously mentioned dates and times. The following is a listing of the activities for this inspection: Reviewed three current resident records and one discharged resident record. Reviewed medication administration records. Personnel records were reviewed. Four staff members and one resident were interviewed. An inspection of the interior and exterior of the facility was completed. Other documentation reviewed during this inspection included but was not limited to the following: emergency drill documentation, menus, and staff work schedules. The staff member appointed as the Program Director was available and accessible during the inspection. The appointed Program Director participated in the preliminary findings meeting held at the facility on 4/20/23. The Chief Executive Officer also participated in this meeting by phone. An exit meeting was conducted on 7/7/23 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 #:	22VAC40-151-240-B-7
Description:	Violation: Based on review of personnel records and an interview with staff, S7, the facility failed to maintain an up-to-date personnel records including documentation of compliance with background check requirements. Findings: 1) The personnel record for staff, S1, shows the results of the Child Protective Services (CPS) central registry search is dated for 4 days after his date of hire. The Code of Virginia, ? 63.2-1726, requires the facility to receive the results prior to permitting the individual to begin work. 2) The personnel record for S2 shows the results of the criminal history background check were received 4 days after the hire date. The results of the Child Protective Services (CPS) central registry search is dated for 22 days after the date of hire. The Code of Virginia, ? 63.2-1726, requires the facility to receive the results prior to permitting the individual to begin work. 3) The personnel record for S3 shows the results of the Child Protective Services (CPS) central registry search is dated for 4 days after the date of hire. The Code of Virginia, ? 63.2-1726, requires the facility to receive the results prior to permitting the individual to begin work. 4) The personnel record for S4 shows the results of the Child Protective Services (CPS) central registry search is dated for 7 days after the date of hire. The Code of Virginia, ? 63.2-1726, requires the facility to receive the results prior to permitting the individual to begin work. 5) The personnel record for S5 shows the results of the criminal history background check were received 6 days after the hire date. The results of the Child Protective Services (CPS) central registry search is dated for 4 days after the date of hire. The Code of Virginia, ? 63.2-1726, requires the facility to receive the results prior to permitting the individual to begin work.
Plan of Correction:	No potential employee will be permitted to be hired prior to ALL background checks being received and must have a status of eligible and no match. If a background check come back stating ?undetermined? Saving Families will request a written letter of the events of the background, this will be discussed with the Office of Background Investigation and a justification letter will be completed shall Saving Families move forward with the hire.
Standard #:	22VAC40-151-290-D-3
Description:	Violation: Based on review of staff?s, S1?s, personnel record, and interview with staff, S7, the facility failed to appoint a person to direct programs who has a baccalaureate degree and a combination of four years of professional experience with children, in a children's residential facility and in administration or supervision. Findings: 1) Staff?s, S1?s, job application documents a baccalaureate degree in sociology. 2) S1?s resume documents approximately 7 years and 7 months of experience in administration or supervision. 3) S1?s resume and job application does not document any professional experience with children in a children?s residential facility. 4) During the interview, S7 acknowledged that S1?s resume and job application does not document any professional experience with children in a children?s residential facility.
Plan of Correction:	All applicants will be thoroughly screened to ensure they have all requirements for the position in which they?re hired. If transcripts are required, the applicant will not be hired prior to obtaining the official transcripts. The Chief Administrative Officer will be responsible for obtaining all required documents, the Chief Executive Officer will review all documents after received and provide the Chief Administrative Officer with an approval to move forward.
Standard #:	22VAC40-151-290-E-1
Description:	Violation: Based upon review of staff?s, S1?s, personnel record and interview with staff, the facility failed to obtain the official transcripts from the accredited college or university of attendance within 30 days of hire from the applicant for the program director position. Findings: 1) The personnel record for staff, S1, does not include transcripts for the baccalaureate degree in sociology. 2) During the interview, S7 acknowledged the transcripts were not obtained from S1.
Plan of Correction:	All applicants will be thoroughly screened to ensure they have all requirements for the position in which they?re hired. If transcripts are required, the applicant will not be hired prior to obtaining the official transcripts. The Chief Administrative Officer will be responsible for obtaining all required documents, the Chief Executive Officer will review all documents after received and provide the Chief Administrative Officer with an approval to move forward.
Standard #:	22VAC40-151-610-2
Description:	Violation: Based upon review of the current resident records for CR1 and CR3 and interview with staff, the facility failed to document justification in the resident records as to why the residents were admitted on an emergency basis. Findings: 1) Current residents, CR1 and CR3, were admitted into the facility as emergency admissions. 2) Staff, S7, was interviewed about the justification in the resident records as to why the residents were admitted on an emergency basis because the Licensing Specialist was unable to find it. 3) S7 acknowledged the justification is not in CR1?s and CR3?s resident records.
Plan of Correction:	Saving Families Group Home emergency application has been purged to use the regular application form. This form has a section where justification for accepting a youth on an emergency basis is listed. This will ensure that the application is compliance with 22 VAC 40-151-610.2 Once applications has been placed in the resident?s file, the Chief Administrative Officer will sign off on the accuracy of the document.
Standard #:	22VAC40-151-610-3
Description:	Violation: Based upon review of the current resident records for CR1 and CR3 and interview with staff, the facility failed to clearly document in written assessment information gathered for the emergency admission that the individual meets the facility's criteria for admission Findings: 1) Current residents, CR1 and CR3, were admitted into the facility as emergency admissions. 2) Staff, S7, was interviewed about the written assessment information gathered for the emergency admissions that the individuals meet the facility?s criteria for admission because the Licensing Specialist was unable to find it. 3) S7 acknowledged the written assessment is not in CR1?s and CR3?s resident records
Plan of Correction:	Saving Families Group Home has developed a written assessment form for all new residents being placed into the program. This form has been placed within the new resident packet. The Program Director will be responsible for completing this form within 7 days of a youth being places. The Chief Administrative Officer will review this form, along with the new resident packet and sign off on its approval.
Standard #:	22VAC40-151-660-A
Description:	Violation: Based upon review of the current resident?s, CR1?s record, and interview with staff, the facility failed to ensure the individualized service plan was developed and placed in the resident's record within 30 days following admission and implemented immediately thereafter. Findings: 1) Current resident, CR1, was placed at this facility on 3/14/23. 2) Therefore, 30 days following admission falls on 4/13/23. The breakdown of 30 days following is as follows ? a. 3/15/23-3/31/23 is equivalent to 17 days and 4/1/23-4/13/23 is equivalent to 13 days. 3) Upon review of CR1?s electronic record on 4/18/23, the resident?s individualized service plan (ISP) could not be found. 4) Staff, S1, was interviewed about the ISP on 4/20/23. S1 stated the following while looking for the ISP in CR1?s electronic record ? ?It?s not in here.? 5) S1 emailed the Licensing Specialist during the Preliminary Findings Meeting an ISP for CR1, which was missing signatures, for CR1 that stated the following ? ?Date ISP developed 4/14/23.?
Plan of Correction:	Calendar calculator will be placed in the task list file. This will ensure that dates are being calculated correctly. All resident reports with a specified due date must be provided to the Chief Administrative Officer 7 days prior to the due date, so that it can be reviewed for accuracy and to ensure the documents are sent out to all interested parties prior to the required regulation due dates. The Chief Administrative Officer will approve, sign off and date each document.
Standard #:	22VAC40-151-720-C
Description:	Violation: Based on review of the facility?s daily communication log and interview with staff, the facility failed to maintain a daily communication log to inform staff of significant happenings or problems experienced by residents. Findings: 1) According to staff, S6, the facility uses two methods for the daily communication log. One method is in writing in a binder. The other method is electronic via CareSoft, the facility?s electronic record system, which is titled, ?Shift Summary.? 2) Upon review of both methods, neither consistently documents significant happenings or problems experienced by residents on a daily basis. a. For example, the binder contains the following entries for April 2023 ? 4/4, 4/5, 4/6, 4/7, 4/11, 4/13, 4/14, 4/15, 4/16, and 4/17. The Shift Summary contains the following entries for April 2023 ? 4/6, 4/7, 4/8, 4/11, 4/12, 4/13, 4/14, 4/15, 4/17, 4/18, and 4/19. Daily log entries are missing for the following days ? 4/1, 4/2, 4/3, 4/9, 4/10. b. Similar inconsistencies exists as it pertains to the following months ? January 2023, February 2023, and March 2023. 3) Staff, S1 and S7, both acknowledged the daily communication log is not being maintained.
Plan of Correction:	Saving Families Group Home will be utilizing CareSoft (electronic file) to document daily communication. The daily communication log will be entered under ?shift summary?. This is completed on each shift and is required to be read at the beginning of each shift prior to the start of the shift. When this entry is made, an email is sent to all supervisors/managers to reflect that it has been completed. The house manager, will be responsible for contacting any workers that failed to complete the documentation within 24 hours.
Standard #:	22VAC40-151-720-E
Description:	Violation: Based on review of the facility?s daily log and interview with staff, the facility failed to ensure the identity of the individual making each entry in the daily communication log shall be recorded. Findings: 1) Upon review of the binder used for the daily communication log, the identity of the individual making each entry in the daily communication log were not recorded for the following entries ? 4/7/23 and 1/1/23. 2) Staff, S1, acknowledged the identity of the individual making the above-mentioned entries was not recorded.
Plan of Correction:	Saving Families Group Home will be utilizing CareSoft (electronic file) to document daily communication. The daily communication log will be entered under ?shift summary?. This electronic record automatically captures the signature of the person making the entry, which will the record to stay in compliance with 22 VAC 40-151-720.E. This is completed on each shift and is required to be read at the beginning of each shift prior to the start of the shift. When this entry is made, an email is sent to all supervisors/managers to reflect that it has been completed. The house manager, will be responsible for contacting any workers that failed to complete the documentation within 24 hours.
Standard #:	22VAC40-151-750-E
Description:	Violation: Based on review of the current resident?s, CR2?s, medication administration records and interview with staff, the facility failed to demonstrate medication prescribed by a person authorized by law was administered as prescribed. Findings: 1) Medication administration records were reviewed on 4/19/23. 2) The medication administration record has a box for staff to complete electronically for each day of the month for each prescribed medication. 3) Upon review of CR2?s MARs, the April 2023 MAR shows empty boxes for the following medications and dates ? a. M1 ? 4/14/23, 4/15/23, 4/16/23, 4/17/23 and 4/18/23 b. M2, 2:00 PM dose ? 4/14/23, 4/17/23 and 4/18/23 c. M2, 8:00 PM dose ? 4/14/23, 4/15/23, 4/16/23, 4/17/23 and 4/18/23 d. M3 ? 4/14/23, 4/15/23, 4/16/23, 4/17/23 and 4/18/23 4) No explanation was documented on the MAR as to why these medications were not given. 5) Staff, S7, acknowledged the boxes were empty.
Plan of Correction:	A new computer has been placed in the staff?s office within Saving Families Group Home. It was identified that the prior computer failed to stay connected to the internet, which led to QuickMar not accepting medication documentation. A medication shift change has now been implemented using QuickMar and must be completed at each shift change to ensure medication was properly documented for the prior shift. The house manager is required to review the electronic MAR on a daily basis and must submit a report to the Program Director at the end of each of week stating that ALL medication has been entered and given as directed.
Standard #:	22VAC40-151-840-L
Description:	Violation: Based upon the review of the staff schedule and interview with staff, the facility failed to ensure any time children are present that staff must be present who completed all trainings in behavior intervention. Findings: 1) Staff, S7, admitted to not being trained in Crisis Wave as documented in an email dated for 4/24/23. 2) The staff schedule for January 2023 documents S7 worked several shifts without a staff member who completed all trainings in Crisis Wave, the behavior intervention used by this facility, on the following dates and hours ? a. January 1st ? 7:00 AM ? 6:59 PM b. January 10th - 7:00 AM ? 9:59 AM c. January 11th - 7:00 AM ? 11:59 AM d. January 15th - 7:00 AM ? 6:59 PM e. January 16th - 7:00 AM ? 10:00 AM
Plan of Correction:	Saving Families Group Home uses Crisis Wave for behavior intervention (restraining techniques). All staff working with the residents placed at Saving Families Group Home is required to be certified in Crisis Wave within 30 days after beginning employment and may not work alone until properly trained. All employees that are not certified in Crisis Wave and is waiting on enrollment into class, will sign a letter stating they will not restrain a resident.