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: Jan. 12, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-131 ORGANIZATION AND ADMINISTRATION 22VAC40-131 PERSONNEL 22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN'S SERVICES 22VAC40-131 ADDITIONAL REQUIREMENTS FOR SPECIFIC PROGRAMS 63.2 Adoption 22VAC40-191 Background Checks for Child Welfare Agencies

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 1/12/21. The inspection was concluded on 01/21/21. The Program Manager was contacted by email to initiate the inspection. The agency reports 24 children in care, 37 approved foster homes, and 33 approved adoptive homes. The inspector emailed the Program Director a list of items required to complete the inspection. The inspector reviewed documents from 7 provider home records, 3 children's records, and 4 personnel records submitted by the agency. Background checks for 4 corporate officers and 2 agents were reviewed in compliance with regulations regarding license renewals. An exit interview was conducted on 1/21/21 with the Program Director. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the agency. Upon receipt of the violation notice, the licensee must develop a plan of correction for each violation. The plan of correction must include the following: 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 non-compliance will be corrected. The licensee has ten (10) 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 #:	22VAC40-131-250-G
Description:	Violation: Based on a review of the "Intake Form" report submitted for a child (FC-1) and an interview with an agency representative (AR-1), the agency failed to document required information in the child's file. Evidence: 1) The "Intake Form" for FC-1 does not include dosages and instructions for medication being taken by the child. 2) The agency representative (AR-1) reviewed the "Intake Form" with this Licensing Specialist during the exit interview on 1/21/21 and acknowledged that the information listed above was not included as required.
Plan of Correction:	Foster Care casework staff and supervisors will be retrained in all requirements of the standard as evidenced by a training log.
Standard #:	22VAC40-131-260-B
Description:	Violation: Based on a review of the social history reports submitted for three children (FC-1, FC-2, and FC-3) and an interview with an agency representative (AR-1), the agency failed to include required information in the children's social history reports as required. Evidence: 1) The Social History report for FC-1 does not include previous placement dates. 2) The Social History reports for FC-1, FC-2, and FC-3 do not include addresses of providers of medical treatment. 3) The agency representative (AR-1) reviewed the Social History reports with this Licensing Specialist during the exit interview on 1/21/21 and acknowledged that the information listed above was not included as required.
Plan of Correction:	Foster Care casework staff and supervisors will be retrained in all requirements of the standard as evidenced by a training log. The program will update the Social History form to ensure all required information is included.
Standard #:	22VAC40-131-340-F
Description:	Violation: Based on a review of the quarterly report submitted for a child (FC-1) and an interview with an agency representative (AR-1), the agency failed to document the involvement of the child's birth parents in the development of the plan. Evidence: 1) The quarterly report for FC-1 does not document the involvement of the child's birth parents in the development of the plan. 2) The agency representative (AR-1) reviewed the quarterly report with this Licensing Specialist during the exit interview on 1/21/21 and acknowledged that the information listed above was not included as required.
Plan of Correction:	Foster Care casework staff and supervisors will be retrained in all requirements of the standard as evidenced by a training log.