VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Seton Youth Shelters
3396 Stone Shore Road
Virginia beach, VA 23452
(757) 340-5768

Current Inspector: Sherry Woodard (757) 987-0839

Inspection Date: Nov. 6, 2019 and Nov. 7, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-151 22VAC40-151 III. RESIDENTIAL ENVIRONMENT 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 DISASTER OR EMERGENCEY PLANNING 22VAC40-151 SPECIAL PROGAMS

Comments:

An unannounced monitoring inspection was conducted on November 6, 2019 from 11:07 a.m. to 4:45 p.m. and on November 7, 2019 from 9:00 a.m. to 4:01 p.m. Six personnel records, to include background investigation information, were reviewed. Six personnel records were reviewed against the matrix with no discrepancies. Six residents were in care at the time of the inspection. Two residents records were reviewed: one current and one discharged resident record. Other documentation reviewed at this inspection included but was not limited to the daily log, case management notes, emergency drill documentation, and menus. Interior and exterior physical plant inspections were conducted. Staff 4 assisted with the physical plant inspection. Staff S1 was available to respond to questions during the inspection. Two residents present during the inspection declined to be interviewed. Exit meeting was held with Staff S1 to discuss preliminary inspection findings before leaving the inspection on November 7, 2019. An acknowledgement form was signed at the exit meeting. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return to the Licensing Office within 5 business days from receipt of the inspection documentation. You will need to specify how the deficient practice will be or has been corrected (merely writing the word corrected is not acceptable). Your plan of correction must contain the steps to correct the noncompliance with the standard(s), the measures to prevent the noncompliance from occurring again; and the position responsible for implementing each step and/or monitoring any preventive measure(s). The licensee should retain a copy to be posted at the facility. Results of the inspection documentation are subject to public disclosure and will be posted on the VDSS web site within 5 days, regardless of whether the Plan of Correction is completed.

Violations:

Standard #:	22VAC40-151-800-A
Description:	Violation: Based on review of the resident's record for current resident CR1 and interview with Staff S1, the behavior support plan had not been developed. Findings: 1. The behavior support plan for CR1 was due by 09/23/19 but had not been developed at the time of the inspection. 2. During an interview with the Licensing Specialist, Staff S1 confirmed that the plan had not been developed.
Plan of Correction:	Reworked the current Behavior Support Plan form and have attached it for your review. Behavior Support Plan for CR1 has been completed utilizing the new format and has been incorporated into residents chart. The Director and Assistant Director will be responsible for chart reviews to ensure BSP?s are completed in a timely manner. The Case Manager will be responsible for writing of all BSPs for residents. New form has been created which includes all elements identified in the Standards for Licensed Children?s Residential Facilities