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: Jan. 27, 2020 and Jan. 28, 2020

Complaint Related: No

Areas Reviewed:

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

Technical Assistance:

Technical Assistance provided regarding standard # 22VAC40-131-330.G.4-Visitation and Continuing Contact with Children. The Specialist and Licensee discussed in depth the use of the provider?s current forms and ensuring consistent and clear documentation of private face to face interviews with children at least once time each month. Technical Assistance provided regarding standard # 22VAC40-131.340.F.1 maintaining clear and consistent documentation of birth parent involvement in the development of the child?s individualized service plan, quarterly progress reports and updating the service plan as necessary.

Comments:

An unannounced mandated renewal inspection was conducted to Child and Family Services of Eastern VA-The Up Center located at 150 Boush Street, Suite 500 Norfolk, VA on January 27, 2020 from 9:00 am to 4:30pm and January 28, 2020 from 9:00 am to 3:00 pm. Child and Family Services of Eastern VA-The Up Center continues to provide foster care, short-term foster care and treatment foster care services. The agency reports thirty-six (36) children in care and thirty-nine (39) approved foster homes. During the inspection, the following activities transpired: 1. Four (4) complete foster home records were reviewed 2. Four (4) complete foster child records were reviewed 3. Four (4) staff records were reviewed; including One (1) new staff record and One (1) student intern 4. A Physical Plant inspection was completed 5. Serious Incident Reports were reviewed 6. Policy and Procedures were reviewed 7. Interviews with agency representatives were conducted 8. Board Officer Records were reviewed (background only) There were four (4) citations for violation of the Standards for Child Placing Agencies. An exit meeting was conducted with agency representatives on December 6, 2019 at 1:15 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 #:	22VAC40-131-180-J-2
Description:	22VAC40-131-180.J.2.e Based on a review of the Foster Home (FH) record for FH1, FH2, FH3 and FH4, the licensee failed to document a narrative documentation of the summary of content information from interviews conducted with the applicant. Findings: 1.The home study reports for FH1, FH2, FH3 and FH3 contained the dates of the interviews for each interview however, the reports did not contain a narrative summary of the content information from each interview conducted with the applicant. 2.During an interview, AR3 stated that the home study report itself was a summary of the content of the information from each interview. 22VAC40-131.180.J.2.A.2 Based on a review of the record for FH2 and based on an interview with Agency Representatives, the licensee failed to provide a signature of the licensee?s executive director or designee on the home study report for FH2. Findings: 1.Based on the review of the home study report for FH2, AR8?s signature was listed on the home study and the title listed behind this signature was ?Resource Home Supervisor.? The other signature on the home study for FH2 was from a staff identified as ?Family Development Clinician.? There was no signature of any staff identified as ?Executive Director or Designee.? 2.According to the ?Staff List? that was provided during the entrance interview, AR3 is identified as the ?Executive Director Designee.? However, AR3 did not sign the home study for FH2.
Plan of Correction:	The home study report will reflect the date of each interview and contain a narrative summary of the content of information from each interview conducted with the applicant. Responsible: Resource Family Supervisor and Family Development Clinician The home study report signatures will identify staff as ?Executive Director or Designee?. Responsible: Resource Family Supervisor and Executive Director or designee.
Standard #:	22VAC40-131-210-A
Description:	Based on the review of the review of the records for FH2 and FH3 and based on an interview with agency representatives, the licensee failed to document core-competency training for treatment foster home providers-FH2 and FH3. Findings: 1.Based on the review of the records for FH2 and FH3, there were no documentation of the core competencies training for FH2 and FH3. The records for FH2 and FH3 documented other agency required trainings training however, there was no documentation of core competency training. 2.During the exit interview, AR2, AR3, AR6 and AR8 reviewed the records of FH2 and FH3 and were not able to locate documentation of core-competency training. AR2, AR3 and AR8 acknowledged the absence of documentation of core competency training for FH2 and FH3.
Plan of Correction:	Pre-service Training logs will be completed and filed in each FH record. FH signature acknowledgement of pre-service training and core competencies will be collected prior to approval. Responsible: Resource Family Supervisor and Family Development Clinician
Standard #:	22VAC40-131-360-E-3
Description:	Based on the review of the file for Foster Child (FC) 4 and based on an interview with agency representatives, the licensee failed to state the name of the individual with whom the child was placed or to whom the child was discharged. Findings: 1.The discharge summary located in the record for FC4 did not document the name of the individual to whom the child was discharged to or to whom the child was placed. 2.During the exit interview AR3 and AR8, acknowledged that the name of the individual to whom the child was discharged to was not listed on the discharge summary. During the exit interview, AR3 stated that they would need to review additional documentation not located in the record to obtain the name of the individual to whom the child was discharged/placed.
Plan of Correction:	The Up Center will ensure to request and document the name(s) of the individual(s) that a child is discharged to or placed with from the legal guardian at time of discharge. Responsible: Therapeutic Family Clinician and Supervisor of Foster Care and Adoption Supervisor
Standard #:	22VAC40-191-40-D-1-c
Description:	Based on the review of the documentation for Board Officer 4 (BO4) and based on an interview with agency representatives,the licensee failed to obtain a central registry and criminal history record check before three years since the date of the last central registry and criminal history record check. Findings: 1.Based on the review of the documentation, the last central registry check for BO4 is dated 10/27/2016. There was no additional evidence of compliance available at the time of the inspection. 2.Based on the review of the documentation, the last criminal history record check for BO4 is dated 09/15/2016. There was no additional evidence of compliance available at the time of the inspection.
Plan of Correction:	LCPA Background Checks standards for board officers were reviewed with Human Resources. Board members will receive required background checks within required time frames. Human Resources will obtain central registry and criminal history checks before three years since the previous checks. Once central registry findings checks have been submitted to the Office of Background Investigations Human Resources will follow up with OBI if the results have not been returned within 21 days. Responsible: Human Resources Officer and Human Resources Staff