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 16, 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 22VAC40-80 The License

Technical Assistance:

Discussion of ensuring that verification that ISP's, Quarterlies, Comprehensive ISP's are shared with the appropriate parties. Discussion of ensuring healthy fruit is available for consumption. Discussion of ensuring that fire drill forms contain the names of all youth participating in the fire drills. Discussion regarding checking driving records for staff transporting youth.

Comments:

Number of residents in care at the beginning of the inspection: 3 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: 1. Number of staff records reviewed: 6. Number of interviews conducted with residents: 1. Number of interviews conducted with staff: 1 An unannounced renewal inspection was completed by the Licensing Specialist on the 4/16/2024 from 10:00 a.m. to 4:00 p.m. at the site location. The Licensing Specialist review the posted license and most recent inspection documentation. The following is a listing of the activities for this inspection: Reviewed (1) current resident record reviewed. Reviewed medication administration records. Personnel records were reviewed. (1) staff member and (1) resident was interviewed. An inspection of the residential facility was conducted of the interior and exterior of the facility. Fire and environmental inspection documentation was reviewed and there were no current violations noted in these inspection reports. Other documentation reviewed during this inspection included but was not limited to the following: emergency drill documentation, menus, and staff work schedules, policy and procedures regarding admissions criteria and acceptance of youth into the facility. The office manager, house manager, and Program Director all participated in the entrance conference. The appointed Program Director participated in the preliminary findings meeting held at the facility on 4/16/24. The Chief Executive Officer and the Program Director participated in the exit meeting on 4/17/24. Also in the exit meeting there was technical assistance provided regarding program and operations. 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 Irvin D. Goode, Licensing Inspector at 804-543-5188 or by email at Irvin.Goode@dss.virginia.gov

Violations:

Standard #:	22VAC40-151-620-B
Description:	Violation: Based on the record review for C1, the agency failed to demonstrate that the intake admission application compiled the necessary information to determine the appropriate admission. Findings: The admission application dated 8/8/2023 in the record for C1 was an emergency placement and the following information was excluded from the document. 1. Information that provides a brief description of the current situation and the reason why the placement was needed was not completed. 2. Section of the document did not describe previous placement history as it was left blank. 3. Audio/videotaping authorization not completed with what is authorized and not signed by the client. 4. Approved visitors/phone calls left blank. 5. C1?s prior physician not listed on the form. 6. Form noted prior psychic evaluation completed for C1, but no name of the previous evaluator. 7. Intake consent to continue medication treatment not completed or signed by the group home representative. The findings were discussed with the CEO and the Program Director during the preliminary findings and exit review
Plan of Correction:	Saving Families Office Manager has been designated as the intake officer. The office manager shall receive all required intake information, review it for accuracy, and then submit to Program Director. If there is still missing information on the intake packet, which includes the application for admission, the Program Director must send it back to the placing agency or guardian to have it completed prior to the resident arriving to the facility. Once all information has been received and recorded as complete, the intake packet will then be uploaded to CarSoft and the CAO will approve the packet, acknowledging that it is in fact complete. C1?s missing information from the intake packet will be sent back to the placing agency for completion and will undergo the verification process.
Standard #:	22VAC40-151-660-B
Description:	Violation: Based on the record review for C1, the agency failed to demonstrate that individualized measurable objectives and strategies that were described in the treatment plan dated 7/16/2023. Findings: 1. Individual treatment plan documentation dated 7/16/2023 in the record for C1 did not contain measurable goals and objectives. Excerpt: C1: ?will be compliant with any prescribed medication? and medication will be dispersed in his weekly medication box on a weekly basis ?This documentation did not list measurable outcomes and strategies. 2. The findings were discussed with the CEO and Program Director during the preliminary findings and exit review.
Plan of Correction:	Documentation training is required during the first 14 days of hire. Examples on how to accurately write an Individual Service Plan, Behavior Support Plan, and Initial Objectives and Strategies has been placed in a training binder within the facility and office. Program Director is responsible for accurately completing documentation and prior to the deadline. CAO is responsible for reviewing the documentation for accuracy. If the documentation is not completed accurately with measurable goals, the report will be sent back to the Program Director to re-complete and an additional training will be held. C1 has been supplied with an updated individual service plan, to reflect his current level of goals and to indicate measurable goals
Standard #:	22VAC40-151-700-B
Description:	Violation: Based on the record review for C1, the agency failed to demonstrate that case management services were documented. Findings: 1. C1 was admitted on 8/8/2023. The case management services were documented for 3/1/2024 and 4/1/2024, and therefore case management services were not documented consistently. 2. The findings were discussed during the preliminary findings and exit review.
Plan of Correction:	It is the responsibility of the Program Director to ensure case management notes are being documented within 7 days of arrival of new residents and then on a monthly basis thereafter. Case Management notes should accurately reflect the services being provided to the resident to aid in helping them obtain their goals and helping them to reach a level of independence. Case Management notes must be filed in each resident?s file upon completion. The CAO must review case management notes at the end of every month to ensure notes have been completed.
Standard #:	22VAC40-151-740-D
Description:	Violation: Based on the record review for C1, the agency failed to complete a follow-up vision exam with a ophthalmologist as recommended by the physician. . Findings: 1. C1 completed a vision screening according to the documentation dated 8/11/2023. C1 did not completed a complete vision examination. 2. The licensing specialist requested the follow-up information and documentation. The findings were discussed during the preliminary findings and exit interview.
Plan of Correction:	Documentation of healthcare appointments must be completed after every healthcare appointment. All healthcare appointment forms must be uploaded to the resident?s files and reviewed by the Program Director on a weekly basis. All additional medical requests made from Physician?s should be documented in the communication log and reviewed by the Program Director. All requested appointments shall be handled within 7 days from the request. The office manager will be responsible for setting the healthcare appointment and the house manager and program director will be responsible for transporting the resident to the appointment to ensure all pertinent information is being recorded. C1 ? Vision exam has been set for May 23, 2024
Standard #:	22VAC40-151-740-G
Description:	Violation: Based on the record review for C1, the agency failed to demonstrate that C1 completed an annual dental examination and follow-up. Findings: 1. Dental examination documentation dated 8/11/2023 in the record for C1 was an emergency appointment to address orthodontics but was not a dental examination. 2. The licensing specialist requested the dental examination follow-up information and documentation. The findings were discussed during the preliminary findings and exit review.
Plan of Correction:	SFGH has a 30 day new resident checklist that must be completed and placed in every resident?s file. The office manager will be responsible for setting medical/dental appointments for residents. All appointments must be set within 7 days from the day of admission. If the resident is transferring from another facility, it?ll be the responsibility of the Program Director to obtain the dental records for the resident. Once the appointment has been made, the house manager or program director will be responsible for transporting the resident to the appointment. Once the appointment is completed, the house manager or program director must request a copy of the dental records for the resident?s file. C1 ? Dental examination has been set for 4/30/2024