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: Nov. 19, 2020 and Nov. 25, 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

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 monitoring inspection was initiated on November 18, 2020 and concluded on November 25, 2020. The Program Director was contacted by email to initiate the inspection. The agency reported 5 children in care, 12 approved foster provider homes and no newly hired employee. The inspector emailed the Program Director a list of items required to complete the inspection. The inspector reviewed 2 complete child records, 1 complete foster home provider records and 1 staff record submitted by the agency to ensure documentation was complete. Board Officers records were previously reviewed. Information gathered during the inspection-determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the agency. 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 website within five business days, regardless of whether or not the Plan of Correction is completed.

Violations:

Standard #:	22VAC40-131-200-A-3
Description:	Based on the review of the record for Foster Home (FH) 4 and based on an interview with agency representatives, the licensee failed to consider all information gathered when assessing the applicant?s capabilities to care for children. Findings: 1. Based on the review of the DMV driving record for FH1-Parent A, the licensee did not consider the information gathered regarding convictions and accidents documented on the Foster Parent A?s driving record. The home study and no other documentation located in the record addressed the driving record and any potential risk to the health and safety of foster child/youth. 2. During the exit interview, AR1 and AR 2 reviewed the available data located in the record. At the time of the interview neither AR1 nor AR2 could locate data that documented how safety concerns as it related to Foster Parent A?s DMV driving record were considered.
Plan of Correction:	Regional Manager and Program Supervisor will train home study staff to document any discussions regarding DMV record and document if there are safety concerns or no safety concerns.
Standard #:	22VAC40-191-40-D-1-c
Description:	Based on the review of the file for Staff (S)-1 and based on an interview with an agency representative (AR), the licensee failed to complete a criminal history record check report before three years since the date of the last criminal history record check report. Findings: 1.The records presented contained documentation of criminal history record checks for 10/09/2017 and 11/19/2020 (the day after this inspection was initiated). The 11/19/2020 criminal history record check was not completed before three years since the last criminal history record check report. 2.Upon interview on 11/25/20, AR-1 and AR-2 acknowledged that the criminal history record check report dated 11/19/2020 was not completed before the three years since the last criminal history record check report dated 10/09/2017.
Plan of Correction:	Chief Quality Officer will re-train Human Resources staff regarding the importance of deadlines for reoccurring background checks for personnel. The agency?s new HRIS system will also be utilized to help track and send reminders so that future rechecks will not be missed.