VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Catholic Charities
1601 Rolling Hills Drive
Henrico, VA 23229
(804) 285-5900

Current Inspector: Dawn Espelage (540) 759-8852

Inspection Date: Feb. 11, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-131 PERSONNEL 22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN'S SERVICES 22VAC40-131 ADDITIONAL REQUIREMENTS FOR SPECIFIC PROGRAMS 22VAC40-80 THE LICENSE. 63.2 Adoption 22VAC40-191 Background Checks for Child Welfare Agencies

Comments:

An unannounced mandated monitoring inspection was conducted on February 11, 2020 from 10:00 am to 3:00 pm and on February 12, 2020 from 10:00 to 2:00 at Commonwealth Catholic Charities located at 1601 Rolling Hills Drive. The Program Manager and the Foster Care Director were available for the inspection and for the exit interview at the end of the second day. The agency is currently working with 27 foster children and youth. During this inspection, four adoptive home records, four foster home records, and three foster children's records were reviewed. Four personnel records were also reviewed. There were two citations for violations of the Standards for Child Placing Agencies. One was a key health and safety standard. Upon receipt of the Violation Notice, the licensee should develop a plan of correction to include the steps to correct non-compliance with the standard(s); measures to prevent re-occurrence of non-compliance; person(s) responsible for implementation and monitoring of preventative measure(s); and date by which noncompliance will be corrected. The licensee has five business days from receipt of the inspection documents to complete the section entitled "Plan of Correction", sign each page of the inspection documents and return to the Licensing Office. The licensee should retain a copy to be posted at the facility. Results of the inspection are subject to public disclosure and will be posted on the Virginia Department of Social Services public web site within five business days, regardless of whether or not the Plan of Correction is completed.

Violations:

Standard #:	22VAC40-131-190-O-7
Description:	Violation: Based on a review of the adoptive home records for AH-1 and AH-3 and an interview with an agency representative, the agency failed to address elements in the providers' emergency preparedness and response plans. Evidence: 1) The Emergency Preparedness and Response plans in the files of AH-1 and AH-3 don;t address how the parents plan to rehearse the plan with each child at least one time every 6 months. 2) The agency representative reviewed the files at the time of the inspection and acknowledged that how to rehearse the plan was not addressed.
Plan of Correction:	Staff will update form to ensure that applicants understand that the plan needs to be rehearsed with infants as well as children that are old enough to understand the plan.
Standard #:	22VAC40-191-40-D-1-c
Description:	Violation: Based on a review of the personnel records for P-1 and P-4 and an interview with an agency representative, the agency failed to obtain sworn disclosures statements for two employees within three years of the most recent sworn disclosure statements. Evidence: 1) The sworn statements contained in the personnel records of P-1 and P-4 are more than three years old. 2) The agency representative reviewed the files at the time of the inspection and acknowledged that this was an oversight.
Plan of Correction:	Human Resources staff will develop system to track when staff need to update their sworn disclosure statements.