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: April 27, 2022

Complaint Related: No

Areas Reviewed:

Background Checks for Child Welfare Agencies Personnel Provider Records Children's Services

Comments:

An unannounced renewal inspection was conducted on 4/27/2022 from approximately 9:50 am to 4:45 pm. The regional manager/director of TFC and adoption was available throughout the inspection. The agency reported 6 children in care and 7 approved provider homes. The inspector reviewed 1 child record, 1 provider home record and 5 staff records. Background checks for the 4 board officers were reviewed. Three employees were interviewed during this inspection. An exit interview was conducted on 4/27/2022 at approximately 4:20 pm with the regional manager/director of TFC and adoption, foster care program supervisor, chief engagement officer, chief quality officer, and the director of quality to discuss the preliminary inspection findings. An acknowledgement form was left with the regional manager/director of TFC and adoption. An additional interview was conducted with the regional manager/director of TFC and adoption on 5/22/22 at approximately 1:00 pm to discuss inspection findings. There was 1 violation of the Standards for Licensed Child Placing Agencies. 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 #:	22VAC40-191-40-D-1-c
Description:	Based on review of the background checks for Staff (S) S1, and interview with the regional manager/director of TFC and adoption, the licensee failed to ensure a sworn statement or affirmation, central registry finding and criminal history check was completed before three years since the dates of the last sworn statement or affirmation, central registry finding and criminal history check. Findings: S1 was hired on 11/10/12. The most recent sworn statement or affirmation for S1 is dated 11/23/21 and the previous sworn statement or affirmation for S1 is dated, 8/22/18, which is beyond 3 years of 11/23/21. The most recent criminal history check for S1 is dated 12/3/21 and the previous criminal history check for S1 is dated, 9/26/18, which is beyond 3 years of 12/3/21. The most recent central registry finding for S1 is dated 1/7/22 and the previous central registry finding for S1 is dated, 9/28/18, which is beyond 3 years of 1/7/22.
Plan of Correction:	Chief Quality Officer will work closely with Human Resources and Quality staff on the following: The agency?s new HRIS system has automated reminders that can be initiated and sent to managers three months prior to the expiration of the current background checks to correct issues of late renewal of background checks. Additionally, we are creating a position within our Human Resources Department solely for personnel record management with a focus on background checks.
Standard #:	22VAC40-191-40-D-1-c
Description:	Based on review of the background checks for Staff (S) S1, and interview with the regional manager/director of TFC and adoption, the licensee failed to ensure a sworn statement or affirmation, central registry finding and criminal history check was completed before three years since the dates of the last sworn statement or affirmation, central registry finding and criminal history check. Findings: S1 was hired on 11/10/12. The most recent sworn statement or affirmation for S1 is dated 11/23/21 and the previous sworn statement or affirmation for S1 is dated, 8/22/18, which is beyond 3 years of 11/23/21. The most recent criminal history check for S1 is dated 12/3/21 and the previous criminal history check for S1 is dated, 9/26/18, which is beyond 3 years of 12/3/21. The most recent central registry finding for S1 is dated 1/7/22 and the previous central registry finding for S1 is dated, 9/28/18, which is beyond 3 years of 1/7/22.
Plan of Correction:	Chief Quality Officer will work closely with Human Resources and Quality staff on the following: The agency?s new HRIS system has automated reminders that can be initiated and sent to managers three months prior to the expiration of the current background checks to correct issues of late renewal of background checks. Additionally, we are creating a position within our Human Resources Department solely for personnel record management with a focus on background checks.