VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Alpha House II
3903 West Autumn Drive
Petersburg, VA 23803
(804) 861-0533

Current Inspector: Irvin Goode (804) 543-5188

Inspection Date: Jan. 11, 2024 and Feb. 9, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-151 Administration 22VAC40-151 Programs and Services 22VAC40-151 Programs and Services

Technical Assistance:

None

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/11/24 ? 3:00 PM ? 8:43 PM 1/17/24 ? 1:43 PM ? 7:01 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/8/23 regarding allegations in the area(s) of: Locked Medication Storage, Staff Supervision of Residents, and Suspected Child Abuse and Neglect. Number of residents in care at the beginning of the inspection: 2 Number of resident?s records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Additional Comments/Discussion: An entrance meeting was held on 1/11/24. The Program Director was available by phone during the inspection. The following is a listing of the activities for this inspection: The record for two discharged residents were reviewed. The personnel record for the staff member named in the complaint was reviewed. Relevant policies and procedures as well as applicable sections from the daily log were reviewed. One current resident was interviewed on 1/11/24. The Program Director was interviewed by phone on 2/1/24. The preliminary findings meeting was also held with the Program Director on the aforementioned date. An exit meeting was conducted on 2/9/24 to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Locked Medication Storage A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. 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 Michele Freeman, Licensing Inspector at (804) 662-7062 or by email at michele.freeman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-151-750-A
Complaint related:	No
Description:	Violation: Based upon an interview with the local agency representative and review of the document titled, ?Virginia Department of Social Services ? Referral/Investigation Interviews and Interactions,? staff, S1, failed to ensure the medication cabinet containing all medication and knives was securely locked and properly labeled. Findings: 1) A local agency representative interviewed S1 about a Child Protective Services allegation. Failing to secure the cabinet, which contained the medication and kitchen knives, which provided the opportunity for discharge resident, DR1, to obtain a knife and threaten DR2 and S1. 2) The ?Virginia Department of Social Services ? Referral/Investigation Interviews and Interactions,? states the following as it pertains this incident ? a. ?CM inquired about S1?s take on the medication closet and DR1 gaining access to the knives. S1 stated, ?now for that, I can accept accountability for. He stated, `I was given the directive by S4 to give her the medication and I can see how I could have done things differently.? b. ?S1 admitted that the knives being in the medication closet was a hindsight because he very seldomly uses those stored away knives. CM explained to S1 camera footage shows him with his back to the open closet and DR1 to help him gain insight on lack of supervision.
Plan of Correction:	The Director shall review with all staff the importance of securing the medication cabinet and its content, as well as the importance of maintain sight supervision of contents of the cabinet while the cabinet is open.
Standard #:	22VAC40-151-960-C
Complaint related:	No
Description:	Violation: Based on review of the serious incident reports for the discharged residents, DR1 and DR2, and interview with staff, the provider failed to notify the department within 24 hours of any serious illness or injury, any death of a resident, and all other situations as required by the department. Findings: 1) DR1 and DR2 were involved in a physical altercation on 11/2/23. A serious incident report (SIR) was completed on the same day. This document describes how these residents quickly escalated from arguing, to spitting at each other, to ultimately fighting each other. According to the SIR for each resident, three ?X?s? were typed by ?YES? as it pertains to ?Are there injuries?? 2) DR1 and DR2 were involved in another physical altercation on 11/3/23. A serious incident report (SIR) was completed on the same day. This document describes how DR2 went to DR1?s bedroom to fight. DR1?s SIR states that ?DR1 grabbed the bucket from the medicine cabinet that contained butcher knives and picked up a butcher knife and began to threaten to kill DR2 and even threaten to stab S1 to be able to get access to DR2.? According to the SIR, for each resident, three ?X?s? were typed by ?YES? as it pertains to ?Are there injuries?? In addition, it states the following on DR1?s SIR ? ?Officers arrived and took DR1 for a psychiatric evaluation as a result of this incident.? 3) The Licensing Specialist did not receive the above-mentioned serious incident reports. 4) The Licensing Specialist interviewed staff, S3, and discussed reporting the serious incident reports to the department as required by the ?Standards for Licensed Children?s Residential Facilities. 5) S3, acknowledged the Licensing Specialist?s findings as it pertains to not notifying the department within 24 hours of any serious illness or injury, any death of a resident, and all other situations as required by the department.
Plan of Correction:	Incident report was sent immediately to the placing agency/ legal guardian. Incident report template will be modified to include a line to document notification of the VA DSS licensing authority as well. All staff shall be instructed by the Director on this modification to the Incident report documentation and policy requiring notification of licensing authority by 2/16/24.