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: April 25, 2022 and April 26, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-151 INTRODUCTION. 22VAC40-151 ADMINISTRATION 22VAC40-151 RESIDENTIAL ENVIRONMENT 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 DISASTER OR EMERGENCY PLANNING

Comments:

An unannounced renewal inspection commenced on April 25, 2022 from 11:30 a.m. to 2:55 p.m. and concluded on April 26, 2022 at 3:05 p.m. Two (2) personnel records, to include background investigation information, were reviewed. The CRF Employee Matrix was reviewed with no discrepancies. Three (3) residents were in care. Two (2) residents? records were reviewed: one current resident and one discharged resident. Other documentation reviewed at this inspection included but was not limited to the daily log, shift notes, serious incident reports, case management notes, and a medication administration record. Interior and exterior physical plant inspections were conducted. Administrator A1 responded to questions during the inspection. One resident was interviewed. A preliminary findings review meeting was conducted with A1 on April 25, 2022 where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Acknowledgement forms were signed. An exit meeting was conducted with A1 on April 26, 2022. Upon the receipt of the violation notice, a plan of correction is requested for the violations. The plan of correction or Description of Action to be Taken should include, as appropriate, the following: the steps to correct noncompliance with the standard(s); measures to prevent re-occurrence of noncompliance; position(s) responsible for implementation and monitoring of preventative measure(s); and date by which noncompliance will be corrected. The licensee has five (5) business days from receipt of the inspection documentation to complete the section titled Plan of Correction, sign each page of the documentation and return it to the Licensing Office. The licensee should retain a copy to be posted at the facility. The results of the inspection are subject to public disclosure and will be posted on the VDSS website within five (5) business days.

Violations:

Standard #:	22VAC40-151-190-B-1
Description:	Violation: Based on review of the personnel record for Staff S2 and interview with administrator A1, the TB (Tuberculosis) screening assessment was not completed within the required timeframe. Findings: 1. The TB screening assessment for Staff S2 was completed on 01/28/2022. The screening assessment was due by 01/20/2022. 2. LI interviewed A1 who confirmed that the TB screening assessment was late.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-151-240-B-3
Description:	Violation: Based on review of the personnel record for Staff S2 and interview with administrator A1, written references or notations of oral references were not documented. Findings: 1. References were not documented. 2. LI interviewed A1 who reported that references were checked but the form used to document the reference checks was not located during the inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-151-240-B-9
Description:	Violation: Based on review of the personnel record for Staff S2 and interview with administrator A1, training required by these standards was not documented. Findings: 1. Training required by the following standards was not documented: - 250.A.3.a. Objectives of the facility; - 250.A.3.c. The decision making plan; - 250.A.3.d. The Standards for Licensed Children's Residential Facilities (CRF); - 250.A.7. appropriate siting of CRF's, good neighbor policies, community relations, and shaken baby syndrome and its effects; 2. LI interviewed A1 who reported that the training was completed but the form used to document the training was not located during the inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-151-390-C
Description:	Violation: Based on measuring the temperature of the water with a temperature gauge and interview with administrator A1, the water temperature exceeded the maximum temperature permitted by the standard. Findings: 1. The water temperature measured 131 degrees Fahrenheit. The maximum temperature permitted by this regulation is 120 degrees Fahrenheit. 2. LI interviewed A1 who confirmed that the water temperature gauge reading exceeded the temperature permitted by the standard.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-151-730-B-1
Description:	Violation: Based on review of the readily accessible medical emergency information for resident R1 and interview with administrator A1, the required information was not documented. Findings: 1. The address and telephone number of the dentist to be notified was not documented in the readily accessible medical emergency information for R1. 2. LI interviewed A1 who confirmed that this information was not documented (missing) for R1.
Plan of Correction:	Not available online. Contact Inspector for more information.