VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Youth for Tomorrow-New Life Center
11835 Hazel Circle Drive
Bristow, VA 20136
(703) 368-7995

Current Inspector: Michele Freeman (804) 662-7062

Inspection Date: Dec. 20, 2023 and Jan. 23, 2024

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 the individualized behavior support plan as noted in the Standards for Licensed Children?s Residential Facilities - 22 VAC 40-151-120.A through 22 VAC 40-151-120.C. Discussed water temperatures as noted in the Standards for Licensed Children?s Residential Facilities - 22 VAC 40-151-390.C. Discussed evacuation drills as noted in the Standards for Licensed Children?s Residential Facilities - 22 VAC 40-151-990.K. Discussed medication administration as noted in the Standards for Licensed Children?s Residential Facilities - 22 VAC 40-151-750.E.

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: 12/20/23 from 1:28 PM ? 7:18 PM 12/21/23 from 9:46 AM ? 8:20 PM 12/22/23 from 9:30 AM ? 4:56 PM 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: 109 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: 5 Number of staff records reviewed: 50 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 12 Additional Comments/Discussion: An entrance conference was held on 12/20/23 with the Director of Quality of Assurance. In addition to what is noted above, the other documentation reviewed during this inspection included but was not limited to the following: emergency drill documentation, menus, staff work schedules, medication administration records, and daily log entries. The Director of Quality Assurance was available and accessible during the inspection. The Director of Quality Assurance, Director of Quality Assurance-UIM, Assistant Vice President-ORR Services, and members of the executive team were present and interviewed during the preliminary findings meeting on 12/22/23 in order to seek clarification about certain documents that were reviewed. An exit meeting was conducted on 1/23/24 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 #:	22VAC40-151-50-F
Description:	Violation: Based on the review of the personnel record for staff, S1, interview with staff, and review of policies and procedures, the facility failed to comply with its own Recruitment, Selection and Retention Policy & Procedures (Date of Adoption: May 1, 2014, Date(s) of Revision: June 17, 2020; February 20, 2021; August 19, 2021) as it pertains to selecting (hiring) new staff members. Findings: 1. A copy of the above-mentioned policy was provided to the Licensing Specialist while on-site for this inspection. 2. Below are excerpts from the above-mentioned policy ? a. Beneath ?Policy? it states the following in the second paragraph ? ?Selection criteria for all new staff members shall meet the minimum qualifications of the position or positions, fully comply with all applicable standards of each function and demonstrate a working knowledge of core competencies, policies, and procedures that are applicable to his/her specific position or positions.? b. Beneath ?Selection,? sentence #2 states the following ? ?Only qualified candidates will be considered for the positions.? 3. The Licensing Specialist reviewed the job description titled, ?Case Aid-UIM.? One of the bullet points beneath the ?Qualifications and Education Requirements? states the following ? Experience working with at-risk and minor refugee youth. 4. Upon review of the application, resume, and interview notes in S1?s personnel record, S1 does not have experience working with at-risk and minor refugee youth. 5. S56 and S57 acknowledged the Licensing Specialist?s findings.
Plan of Correction:	Provider has corrected the Case-Aide job description to accurately reflect the required qualifications for the job. Talent Acquisition Manager is required to review all job candidates and ensure they meet job requirements prior to hire and transfers. This mitigates the risk of hires/transfers not meeting the qualifications of the job description. This process also ensures that job descriptions are being monitored on a routine basis for accuracy.
Standard #:	22VAC40-151-990-I
Description:	Violation: Based on the review of the evacuation drills for the Brenda House and interview with staff, the facility failed to conduct at least one evacuation drill, the simulation of the facility's emergency procedures, during the month the building was occupied by residents. Findings: 1. Upon review of the November 2023 evacuation drills for Brenda House, no drills occurred while it was open and occupied with residents from 11/15/23 ? 11/20/23. 2. Staff, S56 and S58, acknowledged the Licensing Specialist?s findings.
Plan of Correction:	Provider has reinforced current policy that all houses must participate in monthly drills regardless of occupancy status (i.e. closed due to low census). Residential Administration and Quality Assurance will review all fire drills monthly to ensure compliance with facility policy.