VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The James Barry Robinson Institute
6353 Center Drive
Building 8, Suite 106
Norfolk, VA 23502
(757) 455-6233

Current Inspector: Sherry Woodard (757) 987-0839

Inspection Date: Oct. 1, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-131 PERSONNEL 22VAC40-131 PROGRAM STATEMENT 22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN'S SERVICES 63.2 General Provisions. 22VAC40-191 Background Checks for Child Welfare Agencies

Technical Assistance:

Technical assistance provided regarding standard 22VAC40-131-290.J; documenting evidence of compliance in the child or youth?s record.

Comments:

An unannounced renewal inspection was conducted on October 1, 2019 from 9:15 a.m. to 5:20 pm. at Barry Robinson Center, located at 433 Kempsville Road, Norfolk, Virginia 23502. Barry Robinson Center reports that they continue to provide foster care (FC) and treatment foster care (TFC). They report that they have not provided independent living services in their independent living program (ILA) in the last 4 years. The agency reports a total of thirty-one (31) children/youth in placement; zero (0) youth in the ILA program, twenty-two (22) foster children/youth and nine (9) TFC children/youth. They report a total of fifteen (15) certified foster home providers. There were no newly licensed foster homes since the last inspection. There were no changes in board officers since the last inspection. There were a total of nine (9) staff reported with three (3) new hires since the last inspection. The Executive Director/Chief Compliance Officer and Program Director were available for the inspection and present for the exit interview, which commenced on 10/01/19 at 4:15 pm. During the inspection, the following activities were completed: 1. Three (3) foster home provider records were reviewed 2. Three (3) active foster child record were reviewed 3. Three (3) personnel records were reviewed 4. Background checks for all (5) Board Members were reviewed 5. Physical Plant Inspection was completed 6. Policy and Procedures were reviewed 7. Interviews were conducted with agency representatives There were six (6) citations for violation of the Standards for Child Placing Agencies. An exit meeting was conducted with eight (8) ARs (Agency Representatives-Chief Compliance Officer, Program Director, Case Workers, and Foster Parent Recruiter/Trainer) on October 1, 2019 at 4:20 p.m. to discuss the inspection findings. Upon receipt of the violation notice, the licensee should develop a plan of correction for each violation. The plan of correction should include the following: the steps to correct non-compliance with the standard(s); measures to prevent re-occurrence of noncompliance; person(s) responsible for implementation and monitoring of preventative measure(s); and date by which noncompliance will be corrected. The licensee has five (5) calendar days from receipt of the inspection documentation to complete the section entitled "Plan of Correction", sign each page of the Plan of Correction and return it to the Licensing Office. The licensee retains a copy to be posted at the facility. Results of the inspection are subject to public disclosure and will be posted on the VDSS web site within five (5) days, regardless of whether or not the Plan of Correction has been completed.

Violations:

Standard #:	22VAC40-131-250-L
Description:	Violation: Based on a review of the child file (FC2) and an interview with agency representatives, the agency failed to interview the child prior to the child?s placement. Evidence: (1)The child file (FC2) contained a pre-placement summary which stated the reason for not conducting a pre-placement interview was because the child previously resided in a jurisdiction outside of the placing agency. (2)Based on the documentation in the record, the placement did not meet the definition of an emergency placement. (3)During the exit interview, AR2 reported that a pre-placement interview was not conducted due to the location of the child. (4)During the exit interview, AR1 acknowledged that a pre-placement interview could have taken place prior to placement while they were at court or elsewhere.
Plan of Correction:	Prevention: Child Placing supervisor and CW staff will be mindful of the 72 hour regulation regarding emergency placements. Placement documentation will be reviewed for accuracy. Responsible Parties: Child Placing Supervisor and CW Staff.
Standard #:	22VAC40-131-250-M
Description:	Violation: Based on a review of the child file (FC2) and an interview with agency representatives, the agency failed to arrange a pre-placement visit for the child in the prospective home. Evidence: (1)The child file (FC2) contained a pre-placement summary which stated the reason for not conducting a pre-placement visit was because the child previously resided in a jurisdiction outside of the placing agency. (2)Based on the documentation in the record, the placement did not meet the definition of an emergency placement. (3)During the exit interview, AR2 reported that a pre-placement visit was not conducted due to the location of the child.
Plan of Correction:	Prevention: Child Placing supervisor and CW staff will be mindful of the 72 hour regulation regarding emergency placements. Placement documentation will be reviewed for accuracy. Responsible Parties: Child Placing Supervisor and CW Staff.
Standard #:	22VAC40-131-290-C-11
Description:	Violation: Based on a review of the youth file (FC-3), the agency failed to file a copy of a medical examination report that included assessed disabilities. Evidence: The youth file (FC-3) contained a ?Health and Physical? form which did not provide documentation of disabilities.
Plan of Correction:	A new medical examination was completed with proper evidence of assessed disabilities. Responsible Parties: CW Staff and Program Director. Prevention: CW staff will ensure that the physical assesses disabilities upon receipt. If not an appointment will be scheduled as soon as possible to rectify. Program Director will conduct periodic audits to ensure standard is being met.
Standard #:	22VAC40-131-290-C-8
Description:	Violation: Based on a review of the youth file (FC-3), the agency failed to file a copy of a medical examination report that included evidence of freedom from communicable diseases. Evidence: (1)The youth file (FC-3) contained a ?Health and Physical? form which did not provide documentation of evidence of freedom from communicable diseases, including tuberculosis. (2)The youth file (FC-3) contained a ?Health and Physical? form which stated that the youth was not born in an area at high risk for TB without any evidence that the youth was free from communicable diseases, including tuberculosis.
Plan of Correction:	A new medical examination was completed with proper evidence of freedom from communicable diseases. Responsible Parties: CW Staff and Program Director. Prevention: CW staff will ensure that all physicals provide evidence of freedom from communicable diseases upon receipt. If not an appointment will be scheduled as soon as possible to rectify. Program Director will conduct periodic audits to ensure standard is being met.
Standard #:	22VAC40-131-340-E-3
Description:	Violation: Based on the review of the foster youth record (FC3), a youth over the age of 14, the provider failed to complete an individualized service plan that included specific independent living services to be provided to assist the youth in meeting his goals. Evidence: (1)The foster youth?s record contained individualized service plans and service plan updates that did not include specific independent living services to be provided to assist the youth in meeting his goals. (2)The foster youth?s individualized service plan contained a goal that the youth would engage in the local department?s independent living program however, this does not demonstrate how the youth will meet his goals. This did not document the specific independent living services that would be provided to assist the youth in meeting his goals.
Plan of Correction:	Child?s record amended 10/8/19 to reflect specific independent living services to be provided to assist the child in meeting his goals. All other active records to be reviewed by CW staff to assure no other records contain similar concern. Responsible Parties: CW Staff and Program Director. Prevention: CW staff to have documented retraining regarding appropriate objectives and follow through. Program Director to develop audit tool to review all CTSP/QPS and conduct preventative audit until process stabilizes.
Standard #:	22VAC40-191-40-D-3-d
Description:	Violation: Based on the review of the foster home provider record (FH2), the provider failed to ensure that this foster parent complete an updated sworn statement or affirmation before three years of the date of the last sworn statement or affirmation. Evidence: (1)Based on the review of the foster home provider record (FH2), the date of the last sworn statement was 02/04/2016 and there were no additional sworn statements or affirmations beyond this date. (2)During the exit interview, AR2 reviewed the foster home provider record (FH2) and acknowledged that there were no additional sworn statements or affirmations after the 02/04/2016 sworn statement.
Plan of Correction:	Sworn Disclosure was located in the chart after the licensing representative had left the agency. All other recertified homes have been checked to ensure sworn disclosures are present. Responsible Parties: Program Director and Foster Parent Recruiter/ Trainer Prevention: Foster Parent Recruiter and Program Director will develop an audit tool for review of all re-evaluations and conduct preventative audit until process stabilizes.