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: Dec. 7, 2020 and Dec. 14, 2020

Complaint Related: No

Areas Reviewed:

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

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on December 7, 2020 and concluded on December 14, 2020. The Program Director was contacted to initiate the inspection. The Program Director reported that the current census were 2 residents. The inspector emailed the Program Director a list of items required to complete the inspection. The inspector reviewed three personnel records to include background investigation information, the CRF employee matrix, the daily log, case management notes, medication administration records, emergency drill documentation, staff work schedules, and menus submitted by the facility to ensure documentation was complete. Exit meeting was held with the Program Director via telephone on December 14, 2020. Information gathered during the inspection determined non-compliance with applicable standards or law, and a violation was documented on the violation notice issued to the facility. The Licensing Inspector has reviewed with the provider COVID-19 Essential Guidance for Children?s Residential Facilities. 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 #:	22VAC40-151-660-B
Description:	Based on review of the service plan for resident R1 and interview with agency representative AR1, the 11/25/2020 service plan did not describe several of the required elements of the service plan. Findings: 1. The plan did not describe or include the following required elements of the service plan: - resident's current level of functioning; - the goals, objectives and strategies; - projected dates for accomplishing each objective; - projected discharge plan; - estimated length of stay 2. During the interview with the Licensing Specialist, AR1 confirmed that the service plan did not describe or include the required elements of the plan.
Plan of Correction:	Program Director provided training on ISP to Case Manager. Form revised.
Standard #:	22VAC40-151-800-A
Description:	Based on review of the behavior support plan for resident, R1, and interview with agency representative AR1, the behavior support plan did not include the required elements. Findings: 1. The behavior support plan did not include the following elements: - identification of successful intervention strategies for problem behavior; - techniques for managing anger and anxiety; - identification of interventions that may escalate inappropriate behaviors; - evidence of consultation with the resident, legal guardian/placing agency, resident's parents, if appropriate, and the Program Director. 2. During an interview with the Licensing Specialist and AR1, AR1 acknowledged that the behavior support plan did not include the required elements of the plan.
Plan of Correction:	Program Director provided training in Behavior Support Plan to Case Manager, Behavior Support Plan was revised