VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Child & Family Services of Eastern Virginia, Inc., The Up Center
580 E Main Street
Ste 400
Norfolk, VA 23510
(757) 375-9174

Current Inspector: Sherry Woodard (757) 987-0839

Inspection Date: Aug. 19, 2019 and Aug. 20, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-131 PERSONNEL 22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN'S SERVICES 63.2 General Provisions. 63.2 Adoption 22VAC40-191 Background Checks for Child Welfare Agencies

Comments:

An unannounced monitoring inspection was conducted on August 19, 2019 from 8:40 am to 4:00 pm and August 20, 2019 from 8:30 am to 3:00pm. The Up Center continues to provide foster care, short-term foster care, and treatment foster care and adoption services. The agency reports forty-three children in care, which includes seven children in adoptive home placements, waiting for adoption. The agency reports forty-four approved foster homes which includes twenty six homes that are also approved as adoptive homes. During the inspection, the following activities transpired: 1. Five foster home records were reviewed (4 adoptive home records). 2. Six additional newly approved foster home records were reviewed (TB Screenings, Other household member info, Background Checks, Central Registry and disclosures). 3. Five active foster child record was reviewed (including one adoptive child record). 4. Two staff/personnel records were reviewed. 5. Six additional staff/personnel records of Board Members were reviewed. (Background only) 6. Policy and Procedures were reviewed. 7. Interviews were conducted with agency representatives. There were five citations for violation of the Standards for Child Placing Agencies. An exit meeting was conducted with four ARs (Agency Representatives) on August 20, 2019 at 2:00 p. m. to discuss the inspection findings. Upon receipt of the violation notice, the licensee should develop a plan of correction for each violation. The plan of correction should include the following: the steps to correct non-compliance with the standard(s); measures to prevent re-occurrence of noncompliance; person(s) responsible for implementation and monitoring of preventative measure(s); and date by which noncompliance will be corrected. The licensee has five (5) calendar days from receipt of the inspection documentation to complete the section entitled "Plan of Correction", sign each page of the Plan of Correction and return it to the Licensing Office. The licensee retains a copy to be posted at the facility. Results of the inspection are subject to public disclosure and will be posted on the VDSS web site within five (5) days, regardless of whether or not the Plan of Correction has been completed.

Violations:

Standard #:	22VAC40-131-200-E
Description:	Violation: Based on the review of the file for FH2, there was no documented evidence that the licensee notified the applicant in writing of the decision of approval. Findings: 1. Based on the review of the file, there was no written documentation of a written notice to FH2 regarding the approval decision. 2. During the exit interview, AR2 and AR4 reviewed the record for FH2 and could not locate a letter or any form of written notice to FH2 regarding the decision of approval.
Plan of Correction:	The Up Center will ensure that all approved families receive an approval letter upon opening their home and re-certification. The letter will be completed in ExtendedReach as well. A new tab for approval/recertification letters will be added to the compliance section of ExtendedReach. Responsible: Director of Foster Care & Adoptions, Family Development Clinicians, Resource Family Supervisor, Resource Home Coordinator
Standard #:	22VAC40-131-330-G-1
Description:	Violation: Based on the review of the record for child, FC1, and interviews with AR2 and AR3, the licensee failed to document a face-to-face contact with the child no less than twice in the month of June 2019. Findings: 1.There was one face-to-face contact for the month of June 2019 documented in the record for FC1. 2. AR2 and AR3 reviewed the electronic record during the inspection, and they were unable to locate documentation of any additional face-to-face contact with the child for the month of June 2019. During the interview, AR2 and AR3 reported that they see where an ?activity? noted in the file for June which may have been the second face-to-face contact; however, there was no documentation in the record of the second face-to-face contact for the month of June 2019. Violation: Based on the review of the record for child, FC4, the licensee failed to document two face-to-face contacts with the child no less than twice in the month of June 2019. Findings: 1. There was one face-to-face contact for the month of June 2019 documented in the record for FC4. 2. AR2 and AR3 reviewed the electronic record during the inspection, at the time of the exit interview, no documentation was provided of a second June 2019 face-to-face visit.
Plan of Correction:	The Up Center will ensure to document a face-to-face contact with the child no less than twice in the month. Responsible: Director of Foster Care & Adoptions, Supervisor of Foster Care & Adoptions, Therapeutic Family Clinicians
Standard #:	22VAC40-131-340-E-3
Description:	Violation: Based on the review of the file for FC3, the licensee failed to develop goals and objectives related to specific independent living services to be provided. Findings: 1. Based on the review of the file, the most recent ?Individual Comprehensive Treatment and Service Plan? did not indicate goals and objective related to independent living services to be provided to the youth who was at least 14 years old. 2. On Page 7 of this form, there is a statement that targeted areas of weakness based on the life skills assessment will be incorporated into the treatment plan and progress documented on a quarterly basis. 3. There was a recent life skills assessment located in the record however, the licensee failed to incorporate goals and objectives identifying independent living services to be provided into the individualized service plan.
Plan of Correction:	The Up Center will ensure to develop goals and objectives related to specific independent living services to be provided to youth on the youth?s 14th birthday. This will be documented as an addendum to the youths Individual Comprehensive Treatment and Service Plan progress and progress documented on a quarterly basis. Responsible: Director of Foster Care & Adoptions, Supervisor of Foster Care & Adoptions, Therapeutic Family Clinicians
Standard #:	22VAC40-131-340-F-1
Description:	Violation: Based on the review of the file for Foster Child (FC) 1 and FC5, the licensee failed to document in the child?s record, the birth parents involvement in developing the child?s individualized service plan, child?s treatment plan as appropriate and quarterly progress reports and in updating the service plan and treatment plans as necessary. Findings: 1.There was no documentation in FC1 and FC5?s record of birth parent involvement in the development of the individualized service plans, treatment plans and quarterly progress reports and updates of the service plans. 2. The parental rights of the birth parents have not been terminated. 3. The birth parents are involved and actively working toward the identified goal of return home and secondary goal of relative placement. 3. The birth parents attended a monthly visit. 4. During the exit interview, based on interviews with AR2, AR3 and AR5, the ?Comprehensive Treatment and Service Plan? has a generic statement as follows: the legal guardian will ensure that the biological parent(s) are informed of all treatment plans and needs, where appropriate however, there is no documentation of the birth parent(s) involvement in the development of the child?s plan.
Plan of Correction:	The Up Center will ensure to document in the child?s record, the birth parents involvement in developing the child?s individualized service plan, child?s treatment plan as appropriate and quarterly progress reports and in updating the service plan and treatment plans as necessary. Responsible: Director of Foster Care & Adoptions, Supervisor of Foster Care & Adoptions, Therapeutic Family Clinicians
Standard #:	22VAC40-191-40-C-1-d
Description:	Violation: Based on the review of the file for Foster/Adoptive Home (FH/AH) #2, the licensee failed to ensure that a complete Sworn Statement or Affirmation for Foster and Adoptive Parents was completed for the foster/adoptive father. Based on the review of the Foster/Adoptive Home file, the foster father did not answer questions #5-in what states have you lived within the last five (5) years. This home was approved on 01/28/2019 and there were no additional sworn statements or affirmations for this parent in the file at the time of the inspection. Findings: 1. FH/AH2 file does not have valid documentation of states that the foster father lived within the last 5 years; this section was left blank on the Sworn Statement or Affirmation form dated 12/13/2018. 2. During the exit interview, agency representatives reviewed a copy of this form; acknowledged that this section of the form was blank and did not present any additional acknowledgments that were in place prior to the foster/adoptive home approval date of 01/28/2019.
Plan of Correction:	The Up Center will ensure that the all fields on the ?Sworn Disclosure? form are completed in its entirety at the time of application and at the time a ?Sworn Disclosure? form has been updated to include a check box to indicate if ?no? if a household member has not lived in any other states. Responsible: Director of Foster Care & Adoptions, Resource Family Supervisor, Resource Development Clinicians