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: Oct. 25, 2023 and Nov. 13, 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

Technical Assistance:

Discussed staff supervision as noted in Standards for Licensed Children?s Residential Facilities - 22 VAC 40-151-260. Discussed discharge information as noted in Standards for Licensed Children?s Residential Facilities - 22 VAC 40-151-680.E. Discussed discharge summaries as noted in Standards for Licensed Children?s Residential Facilities - 22 VAC 40-151-680.G.1.c. Discussed the medication administration record as noted in Standards for Licensed Children?s Residential Facilities - 22 VAC 40-151-750.F.1.

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/25/23 ? 2:50 PM ? 7:00 PM - Inspection conducted simultaneously with Seton Youth Shelter 10/26/23 ? 10:03 PM ? 7:41 PM - Inspection conducted simultaneously with Seton Youth Shelter 10/27/23 ? 11:00 AM ? 6:30 PM - Inspection conducted simultaneously with Seton Youth Shelter 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: None 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: 6 Number of interviews conducted with residents: None Number of interviews conducted with staff: 2 Additional Comments/Discussion: An entrance conference was held on 10/25/23 with the Interim Shelter Director and the Director of Shelter Programs. This facility was not serving any residents at the time of this inspection; therefore, no current resident records were reviewed. Three discharged resident records were reviewed. Medication administration records were reviewed for two discharged residents. One discrepancy was found with the CRF matrix, which will be 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 Interim Shelter Director and the Director of Shelter Programs were available and accessible during the inspection. Both staff members were interviewed during the preliminary findings meeting on 10/27/23 in order to seek clarification about multiple documents that were reviewed. An exit meeting was conducted on 11/13/23 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, S4, shows the results of the Child Protective Services (CPS) central registry search is dated for 2 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. 2) The personnel record for S5 shows the results of the criminal history background check is dated for 14 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. A Sworn Statement or Affirmation for Children?s Residential Facilities for this staff member is not in the record. 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 S6 shows the results of the criminal history background check is dated for 3 days after the hire date. The results of the Child Protective Services (CPS) central registry search is dated for 12 days after the date of hire. A Sworn Statement or Affirmation for Children?s Residential Facilities for this staff member is not in the record. The Code of Virginia, ? 63.2-1726, requires the facility to receive the results prior to permitting the individual to begin work. 4) During the interview, S7 acknowledged the Licensing Specialist?s findings.
Plan of Correction:	1. [Hire Dates for Staff Records S4, S5 and S6] During the preliminary findings meeting on 10/27/2023, a full discussion of the 2019 changes to this standard was reviewed with the inspectors. A copy of the March 11, 2019 DSS memorandum outlining the hiring changes was obtained and reviewed by 10/31/2023. A conference with CEO, Interim Shelter Director/Administrative Support and Shelter Director was scheduled for 11/6/2023. This meeting resulted in distributing a memorandum to all hiring Directors clarifying the required conditions outlined in standard number 22VAC40-151-240.B.7 as it relates specifically to dates of hire, background checks and Sworn Statement or Affirmation as outlined in the Code of Virginia 63.2-1726. 2. [Sworn Statement or Affirmation for Staff Record S5] The Sworn Statement or Affirmation Form for employee S5 was misfiled in a payroll folder. It has been retrieved and appropriately filed in the employee?s personnel folder on 11/10/2023.