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: May 26, 2020 and June 8, 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

Violations:

Standard #:	22VAC40-131-160-B-3
Description:	Based on the review of the personnel file for Staff 1 (S#1) and based on an interview representatives (AR), the licensee failed to document at least two written references, notification of oral references or record of interviews with references. Evidence: (1) According to the review of the personnel record for Staff 1 (S#1), there were no references, no documented notification of oral references or record of interviews with references located in the personnel record for this employee at the time of inspection. (2)During the exit interview, AR#1, AR#2 and AR#3 reviewed the personnel record for S#1 and acknowledged the absence of references, the absence of documented notification of oral references and the absence of record of interviews with references in the personnel record of S#1.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-200-G
Description:	Based on the review of the record for foster home 2 (FH#2) and based on an interview with agency representatives, the licensee failed to document the issuance of a certificate of approval to the provider and failed to maintain a copy of the certificate in the provider?s file. Findings: (1)Based on the review of the record for FH#2, there was no copy of a certificate located in the file at the time of the inspection. (2)During the exit interview, AR#1 and AR#2 reviewed the record and were not able to locate a certificate of approval; both acknowledged the absence of the certificate at the time of the inspection. During this exit interview, AR#1 stated that she recalls that the certificate had been completed however, the certificate was not in the record at the time of the inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-230-E-1
Description:	Based on the review of the record for foster home 3 (FH#3) and based on an interview with agency representatives (AR), the licensee failed to conduct the re-evaluation in the home of the approved provider with all providers present for the re-evaluation, interviewing the provider in his home at least once. Findings (1) Based on the review of the record for FH#3, there was no documented of an interview conducted at re-evaluation in the home of the approved provider with foster home provider A (FH#3.a). (2) Based on the re-evaluation home-study addendum located in the record at the time of the review, dated, 09/18/2018, page one of this addendum states that FH#3.a was not present in the home and was not interviewed as a part of the re-evaluation. (3)During the exit interview, AR#1 reviewed the record and was not able to locate documentation of an interview conducted with FH#3.a, in the home at the time of re-evaluation. During the exit interview AR#1 and AR#2 acknowledged that there was no documentation of compliance in this area located in the provider home record at the time of inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-290-E
Description:	Based on the review of the foster child record for foster child 1 (FC#1) and based on interviews with an agency representative, the licensee failed to file a copy of the dental examination report in the child?s file. (1)Based on the review of the record for foster child 1 (FC#1) there was a dental bill located in the record with the absence of a dental examination report. (2)During the exit interview, AR#1 confirmed the absence of a dental examination report but stated that the ?itemized bill? contained a list of procedures that were completed during a dental examination. AR#1 and AR#2 acknowledged that the ?itemized bill? did not contain recommendations from the dentist and did not contain the dentist signature.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-191-40-D-1-b
Description:	Based on the review of the personnel record for Board Officer 1 (BO#1), based on an email from agency representative 1 (AR#1) and based on an interview with agency representatives, the licensee failed to obtain a central registry search, a sworn statement or affirmation and criminal history record check for BO#1 before 30 days of employment at the facility ends. Evidence: (1)According to the personnel record for BO#1, the sworn disclosure was completed and signed by BO#1 on 01/30/2020 with a documented board officer appointment date of 10/10/2019. (2)According to the personnel record for BO#1, the central registry search was received for BO#1 on 06/02/2020 with a documented board officer appointment date of 10/10/2019. (3)According to the personnel record for BO#1, the criminal history record check for BO#1 was dated 04/06/2020. (4)During the inspection, AR#1 presented an email dated 06/05/2020 at 2:28 pm with an attachment of the ?Lutheran Family Services of Virginia Board of Directors Meeting Minutes,? dated 10/10/2019 which documents the appointment of BO#1 to the board as an officer to serve from 10/10/2019 to 10/10/2020. (5)During the exit interview, AR#2 acknowledged that the required background checks were completed two months behind the regulated time-frame. During this same interview AR#1 acknowledged non-compliance in this area.
Plan of Correction:	Not available online. Contact Inspector for more information.