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: May 23, 2024 and May 24, 2024

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

Technical Assistance:

22VAC40-131-200.D Discussion regarding documentation of supervisor consultation when approving home studies. 22VAC40-131-180.D Discussion regarding acceptable "face to face" meetings. 22VAC40-131-330.G.4 Discussion regarding detailed notes for private child interviews.

Comments:

Type of inspection: Monitoring A monitoring inspection was initiated on 5/23/24 and concluded on 5/24/24. The Program Manager was contacted by telephone to initiate the inspection. The Program Manager reported that the current census was 54 children/youth. The inspector emailed the Program Manager a list of items required to complete the inspection. The inspector reviewed three children records, three foster home records, one adoptive home record, one post placement adoption record, and four staff records submitted by the facility to ensure documentation was complete. An exit interview was conducted with the Foster Care and the Adoptions Program Managers on 5/28/24, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Dawn Espelage, Licensing Inspector at 540-759-8852 or by email at dawn.espelage@dss.virginia.gov

Violations:

Standard #:	22VAC40-131-290-C
Description:	22VAC40-131-290.C.4, 5, 6, and 8 Violation: Based on review of documents received, the agency failed to obtain a complete medical examination report for Foster Child (FC) 1. Findings: 1) A medical exam was completed on 1/12/24. 2) The question of growth and development within normal limits was left blank. 3) Visual acuity was not addressed. 4) Hearing acuity was not addressed. 5) The case record did not have documentation of efforts made to address the missing elements of the physical. 6) The findings were discussed at the exit.
Plan of Correction:	Citation: The agency failed to obtain a complete examination report as required by 22VAC40-131-290 C 4, 5, 6, and 8. The Richmond Foster Care program will implement a new procedure effective 5/28/24 until 12/31/24 requiring all physicals (initial and annual exam) to be reviewed by the Program Manager or designee prior to filing or uploading the document in the child?s record to ensure they are completed as required by 22VAC40-131-290.C.4, 5, 6, and 8. Any blanks or discrepancies will require staff to follow up with the medical provider to either get the form completed or corrected or provide evidence of at least three attempts to have the form completed or corrected. Date of Correction implemented, 5/28/24.