Virginia Home for Boys and Girls

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(4a)-960-A

Based on record review and interview, the agency failed to notify the department of any serious incident, accident or injury to the resident; any overnight absence from the facility without permission; any runaway; and any other unexplained absence. 1. Licensing Inspector (LI) observed 4 serious incident reports (SIRs) in each resident’s record (R1 and R2) indicating runaway, police involvement and serious accidental injury. 2. The department was not included in the external notification section of SIR documentation. 3. The LI had not received SIRs via email. 4. Staff 4 (S4) was interviewed and acknowledged SIRs should be sent to the department.

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(2)-190-B-2

Based on record review and interview, the agency failed to ensure each individual annually submits the results of a screening assessment, documenting that the individual is free of tuberculosis (TB). 1. Licensing Inspector (LI) observed Staff (S1 and S2) records. 2. S1’s record documented a TB screening on 2/27/2025. Upon review for a 2026 updated TB screening, the record did not contain documentation for 2021, 2024 or 2026. 3. S2’s record indicated a TB screening on 2/27/2025. Upon review for a 2026 updated screening, the record did not contain for 2021, 2024 or 2026. 4. S6 was interviewed and acknowledged TB screening assessments for 2021, 2024 and 2026 were not in the record for S1 and S2.

Violation cited by VDSS, monitoring inspection : 22VAC40-80-(G3)-120-E-1

Based on observations, the facility failed to post documents as required. 1. The Licensing Inspector (LI) observed the posted license expired 5/31/2026. 2. The facility was sent the renewed license on 5/27/2026. 3. Staff (S4) acknowledged the renewed license had been received and will need to be posted.

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(4)-640-A

Based upon review of the resident’s record, the facility failed to include in the resident’s record a completed face sheet. 1) Current resident, CR1, was admitted to the licensee’s facility on 7/13/23; the face sheet in the resident’s record was missing the following elements: the last known residence and the religious preference. 2) Staff, S10, acknowledged the findings.

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(4)-730-B

Based on review of the information readily accessible to staff for current residents, CR1 and CR2, and interview with staff, the facility failed to include the following elements in the event of an emergency. 1) 730.B.4.c – Substance abuse and use was blank. 2) During the interview, staff, S10, confirmed the above-mentioned element is missing from CR1’s and CR2’s readily accessible information.

Violation cited by VDSS, renewal inspection : 22VAC40-151-(4)-680-G-1

Based upon the review of the discharge resident’s, DR1’s, record and interview with staff, the facility failed to ensure the discharge summary was placed in the resident’s record and sent to the persons or agency that made the placement no later than 30 days. 1) DR1 discharged from this facility on 4/5/22. 2) DR1’s record did not contain a discharge summary. 3) Staff, S5, admitted that DR1’s discharge summary had not been placed in the resident’s record and sent to the persons or agency that made the placement no later than 30 days because she needed to write it.

Violation cited by VDSS, renewal inspection : 22VAC40-151-(4)-740-E-1

Based upon the review of the current resident’s, CR1’s, record and interview with staff, the facility failed to ensure each physical examination report included the information necessary to determine the health and immunization needs of the resident. 1) CR1’s record contained a physical examination form from a doctor’s office, which does not address the information necessary to determine the health and immunization needs of the resident. 2) The physical examination report did not include the following elements: a. Immunizations administered at the time of the exam – 740.E.1. a b. Hearing exam - 740.E.1. c c. General physical condition, including documentation of apparent freedom of communicable disease including tuberculosis - 740.E.1. d d. Allergies, chronic conditions, and handicaps, if any - 740.E.1. e e. Nutritional requirements, including special diets, if any - 740.E.1. f f. Restriction on physical activities, if any - 740.E.1.g g. Recommendations for further treatment, immunizations, and other examinations indicated - 740.E.1. h h. Signature of a licensed physician, the physician’s designee, or an official of a local health department - 740.E.3 3) Staff, S4, and staff, S6, acknowledged the findings. 4) Staff, S4, mentioned the facility’s physical examination form should have been used.

Violation cited by VDSS, renewal inspection : 22VAC40-151-(4)-740-A

Based upon the review of the current resident’s, CR1’s, record and interview with staff, the facility failed to ensure the child accepted for care had a physical examination by or under the direction of a licensed physician no earlier than 90 days prior to admission to the facility or no later than 7 days following admission. 1) Current resident, CR1, was admitted to this facility on 12/28/21. 2) A “Doctor Visit” form is in CR1’s record, which notes a well check appointment occurred on 1/11/22 3) Staff, S6, acknowledged that CR1’s physical examination was not completed within 7 days following admission

Violation cited by VDSS, renewal inspection : 22VAC40-151-(4)-660-E-2

Based upon the review of the current resident’s, CR1’s, record and interview with staff, the facility failed to report family involvement in the documented quarterly review. 1) The current resident’s, CR1’s, record contains a quarterly report dated for 3/28/22. 2) This quarterly report does not report about the family’s involvement. 3) Upon review of this report there is no reason as to why family participation would not be appropriate. 4) Staff, S6, who wrote this report, confirmed it did not include family involvement.

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(5)-990-K

Based on review of the emergency evacuation drills for two cottages and interview with Administrator A1, during the three consecutive calendar months from June 2021 to August 2021 and from September 2021 to November 2021 at least one evacuation drill was not conducted during each shift. House 10: 1. An emergency evacuation drill was not conducted during the 4:00 p.m. to 12:00 a.m. shift during the three consecutive months from June 2021 to August 2021 or from September 2021 to November 2021. 2. A1 acknowledged that no drills were conducted during the identified shifts during this timeframe. House 13 1. An emergency evacuation drill was not conducted during the 12:00 a.m. to 8:00 a.m. shift or the 8:00 a.m. to 4:00 p.m. shift during the three consecutive months from June 2021 to August 2021. 2. A1 acknowledged that no drills had been conducted during the identified shifts during this timeframe.

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(4)-680-G-1

Based on review of the record for resident, R3, and interview with administrator A1, the discharge summary was not sent to the the persons or agency that made the placement no later than 30 days after discharge. 1. The discharge date for R3 was documented as 10/26/2021. R3's record did not contain documentation the discharge summary was sent to the persons or agency that made the placement no later than 30 days after discharge. 2. A1 confirmed that there was no documentation the discharge summary was sent to the persons or agency that made the placement no later than 30 days after discharge.

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(4)-660-I

Based on review of records for residents R1 and R2, and interview with administrator A1, there is no documentation of distribution to the legal guardian or legally authorized representative and placing agency for R1's quarterly progress report or the service plan and quarterly progress report for R2. 1. Distribution to the legal guardian or legally authorized representative and placing agency was not documented for R1's 07/21/2021 quarterly progress report, at the time the report was completed. 2. Distribution to the legal guardian or legally authorized representative and placing agency was not documented for R2's 08/06/2021 service plan or the 10/06/2021 quarterly progress report., at the time the reports were completed.