VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lutheran Family Services of Virginia operating as EnCircle
2965 Colonnade Dr. SW
Ste. 310
Roanoke, VA 24018
(804) 288-0122

Current Inspector: Sherry Woodard (757) 987-0839

Inspection Date: Oct. 17, 2019

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

Comments:

An unannounced monitoring inspection was completed on October 17, 2019 from 8:45 am to 4:40 pm at Lutheran Family Services of Virginia located at 4901 Dickens Road, Suite 115, Richmond, Virginia, 23230. The agency reports seven (7) children in foster care placement and twelve (12) approved provider homes. Agency representatives were available for the inspection and present for the exit interview at the end of the day. During this inspection, the following actions were taken: 1.Reviewed two (2) complete children records. 2.Reviewed one (1) complete provider home record. 3.Reviewed two (2) additional newly approved provider home records (background and reference check only). 4.Reviewed three (3) new employee records. 5.Background checks and references for all board officers were reviewed on 10/16/2019. 6.Policy and Procedures were reviewed. 7.Interviews were conducted. There were (5) citations for violations of the Standards for Child Placing Agencies. An Acknowledgement Form was signed by the Regional Manager for Foster Care on October 17, 2019 during the exit interview which was held at 3:13 pm on October 17, 2019. The exit interview was held with the Regional Manager, Program Director and Program Supervisor. 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 #:	22VAC40-131-260-B-3
Description:	Violation: Based on the review of the foster child record (FC1) and based on an interview with agency representatives, there was no documentation of the child?s services needed to reach the child?s permanency goal located in the child?s social history. Evidence: (1)Based on the review of the social history located in FC1?s record, the services section of social history was left blank. (2)During an interview with AR1 and AR3, they carefully reviewed the social history and acknowledged that the services section was left blank in one area (permanency services section) and not addressed in a second section of the social history (under the educational section).
Plan of Correction:	Staff will be trained on the importance of including this information in the social history and review form for completeness before submission to supervisor. Supervisors will conduct a thorough review of report before approving. Additionally, the social history form will be reviewed to determine if any changes need to be made regarding the format to ensure all questions are answered fully.
Standard #:	22VAC40-131-260-B-6
Description:	Violation: Based on the review of the foster child record (FC1) and based on an interview with agency representatives, there was no documentation of the child?s developmental history located in the child?s social history. Evidence: (1)Based on the review of the social history located in FC1?s record, the developmental section of the record contained one incomplete sentence which stated the following: ?According to discharge paperwork, FC1? with no additional documentation regarding the child?s developmental history. (2)During an interview with AR1 and AR3, they carefully reviewed the social history and acknowledged that the developmental was ?cut off? and acknowledged that the social history did not contain documentation regarding the child?s developmental history.
Plan of Correction:	Staff will be trained on the importance of including this information in the social history and review form for completeness before submission to supervisor. Supervisors will conduct a thorough review of report before approving. Additionally, the social history form will be reviewed to determine if any changes need to be made regarding the format to ensure all questions are answered fully.
Standard #:	22VAC40-131-290-C-6
Description:	Violation: Based on the review of the foster child record (FC2) and based on an interview with agency representatives, the licensee failed to obtain a medical examination that included an assessment of auditory acuity. Evidence: (1)The foster child record for FC2 contained a medical examination dated 08/28/2018 which documented that auditory acuity was ?not assessed.? The foster child record for FC2 contained a medical examination dated 08/29/2019 which documented that auditory acuity was ?not assessed.? All medical documentation located in the file and there was no other documentation which documented that FC2?s auditory acuity was assessed. (2)Based on an interview with AR2 and AR3 (agency representatives), who reviewed the electronic records, the 08/28/2018 and 08/29/2019 medical examinations did not assess auditory acuity. During the interview AR2 and AR3 confirmed that on the 08/28/2019 medical examination, the examiner checked ?not assessed for auditory acuity. During the interview AR2 and AR3 confirmed that auditory acuity was left blank by the examiner on the 08/29/2019 medical examination. AR2 and AR3 thoroughly reviewed all medical documentation located in the file and were not able to locate any other documentation which documented that FC2?s auditory acuity was assessed.
Plan of Correction:	Staff will be trained on the importance of reviewing all submitted forms for completion prior to submitting to Supervisors and administrative staff for filing. Supervisors will review forms to ensure all sections are completed fully before filing in the foster child record. Additionally, the medical examination form will be reviewed to determine if any changes need to be made regarding the format to ensure medical professionals answer all questions.
Standard #:	22VAC40-131-330-G-1
Description:	Violation: Based on the review of the foster child record (FC1) and based on an interview with agency representatives, there was no documentation of a face-to-face contact at least twice for the month of July 2019. Evidence: (1)The review of the record for FC1 documented one face-to-face contact with the child on 07/31/2019 with no additional face-to-face contacts for the month of July 2019. (2)During an interview with AR1 and AR3, they carefully reviewed several sections of the record and were not able to locate a second face-to-face contact with FC1 during the month of July 2019.
Plan of Correction:	Staff will be trained using organizational tools to ensure that required face-to-face contacts are met each month. Supervisors will ensure that all contacts are completed as required prior to approving documentation in the record.
Standard #:	22VAC40-131-340-B-1
Description:	Violation: Based on the review of the foster child records (FC1 and FC2) and based on an interview with the agency representative, the licensee failed to complete individualized service plans that included specific measurable objectives and strategies describing services to be provided to the children. Evidence: (1)The foster child records for FC1 and FC2 did not contain individualized service plans that included specific measurable objectives and strategies describing services to be provided to the children. (2)During the exit interview, AR1 and AR3 reviewed the foster parent records and determined that the objectives for FC1 and FC2 were not measurable.
Plan of Correction:	Intake staff/all staff will be trained on developing measurable goals for the initial service plan that takes place within 14 days of admission. Supervisors will review initial service plan thoroughly to ensure there are measurable objectives present in the initial service plan.
Standard #:	22VAC40-191-40-D-1-b
Description:	Violation: Based on the review of the staff record (S-2), the licensee failed to obtain a search of central registry and criminal history record check before the 30 days of employment at the facility ends. Evidence: (1)Based on the review of the staff record (S?2), there was no documentation in the record of a central registry check before the 30 days of employment at the facility ends. (2)Based on an interview with AR2 and AR3, they acknowledged that the central registry check have not been returned. They reported that on the day of the inspection, they followed up to determine the status of this document. (3)Based on an interview with AR2 and AR3, they presented an email from a person in their corporate office that contained an attachment of the central registry check request however, this document was not dated. Therefore the inspector was not able to confirm if the document was submitted or when it was submitted. Violation: Based on the review of the record for S1 and based on an interview with agency representatives, the licensee failed to document a sworn statement or affirmation prior to the first day of employment at the facility. Evidence: (1)Based on the review of the record for S1, there was an instruction page uploaded into the staff record with no documentation of a sworn statement or affirmation in the personnel record. (2)During the exit interview, AR2 and AR3 reviewed the record and acknowledged that the sworn statement instruction page was uploaded with no documentation of the sworn statement or affirmation for S1. During the interview, AR2 and AR3 reached out to the corporate office to locate a copy of the sworn statement or affirmation. As of 4:40 pm on the day of the inspection, the document was not provided.
Plan of Correction:	Staff responsible for submitting background checks for new employees will be reminded of the required time frame for submission, as well as, documentation needed. This includes administrative assistants, staff members in the finance department, and staff members in human resources.