VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Embrace Foster Care, LLC
5014 Monument Avenue
Richmond, VA 23230
(757) 847-9385

Current Inspector: Jamie Morgan (276) 525-5656

Inspection Date: Oct. 19, 2021 and Oct. 22, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-131 ORGANIZATION AND ADMINISTRATION 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:

A monitoring inspection was initiated on October 19, 2021 and concluded on October 22, 2021. The Executive Director was contacted by telephone to initiate the inspection. The Executive Director reported there were 9 approved foster homes and 3 child in foster care. The inspector emailed the Executive Director a list of items required to complete the inspection. The inspector reviewed three personnel records, one child?s record, and four foster home records submitted by the agency to ensure documentation was complete. Exit meeting was held with the Executive Director on October 22, 2021. 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.

Violations:

Standard #:	22VAC40-131-180-G
Description:	Violation: Based on review of the record for foster home FH2 and interview with agency representative AR1, the licensee failed to document a minimum of three references on each applicant. Findings: 1. References for FH2 were not documented in the record. 2. AR1 confirmed that the references were not in the record.
Plan of Correction:	ED will retrain SD?s and Supervisors on audit requirements prior to certification of new homes. The audit for all foster homes certified since the last inspection has been completed. The new QA Specialist will now audit new foster homes at certification to ensure all required components are present, to include applications
Standard #:	22VAC40-131-180-H
Description:	Violation: Based on review of the record for foster home FH2 and interview with agency representative AR! the licensee failed to determine the results of a previous application with a public child-placing agency. Findings: 1. Beyond the disclosure made by the foster parent on the initial application, there was no documentation in the foster home file regarding the foster parent's previous application with a public child-placing agency or the results of this application. 2. AR1 confirmed that there was no other information documented regarding FH2's disclosure.
Plan of Correction:	ED will retrain SD?s and Supervisors on audit requirements prior to certification of new homes. The audit for all foster homes certified since the last inspection has been completed. The new QA Specialist will now audit new foster homes at certification to ensure all required components are present, to include information from previous CPA?s
Standard #:	22VAC40-131-180-I
Description:	Violation: Based on review of the record for foster home FH2 and interview with agency representative AR1 the licensee failed to obtain from the applicant a signed authorization allowing the previous child-placing agency to release information to the licensee about a previous application. Findings: 1. A signed authorization authorizing the licensee to obtain information regarding the previous application to a public child-placing agency was not documented in the record. 2. AR1 confirmed there was no signed authorization.
Plan of Correction:	ED will retrain SD?s and Supervisors on audit requirements prior to certification of new homes. The audit for all foster homes certified since the last inspection has been completed. The new QA Specialist will now audit new foster homes at certification to ensure all required components are present, to include references from previous CPA?s
Standard #:	22VAC40-131-180-J-1
Description:	Violation: Based on review of the records for foster homes FH1 and FH2 and interview with agency representative AR1, the home study completed for FH1 and FH2 did not include all of the required components. Findings: Foster Home 1: 1. The home study completed for FH1, dated 2/25/2021, and the home study completed for FH2, dated 3/14/2021, did not include the dates of the TB screenings. This element was left blank. .2. The home study completed for FH2, dated 03/14/2021, did not include information about the driving record for Foster Parent B. The home study included the following statement: "VA DMV record will be submitted ASAP". 3. AR1 confirmed that the home study did not include the above information.
Plan of Correction:	SD?s/Supervisors will retrain foster parent coordinators on audit requirements prior to certification of new homes, and use of the new home checklist for auditing The new QA Specialist will now audit new foster homes at certification to ensure all required components are present.
Standard #:	22VAC40-131-180-J-2
Description:	Violation: Based on review of the record for foster home FH1 and interview with agency representative AR1, the home study completed for FH1 did not include all of the required components. Findings: 1. The home study, dated 02/25/2021, for FH1 did not include accurate information as follows: - The employment history for foster parent A was not accurately documented in the home study: the home study documented that foster parent A currently worked as a Teacher for a private school but Foster Parent A had left this employment in 10/15/2020, according to the "Financial Statement & Work History" provided by foster parent A. . - The home study documented incorrect financial information regarding the monthly income for foster parent A, as compared to the information provided by foster parent A in the "Financial Statement & Work History". - According to the "Resource Family Residence Checklist", FH1 includes a household pet, a dog. 22 VAC 40-131-180-J-2-f requires that the home study includes documentation that the home complies with the standards for the home as required by 22 VAC 40-131-190. - The home study does not document compliance with 22 VAC 40-131-190-S and 22 VAC 40-131-190-T. The home study does not documents test, inoculations, and license required by law for the dog. - The home study does not document that the dog is safe to be around children and that the dog presents no health hazard to children in the home. 3. AR1 acknowledged the above information.
Plan of Correction:	An addendum will be completed to add all missing elements to the home study of FH1. All newly certified homes since the last inspection have been audited by the QA Specialist. Any needed addendums will be completed by the date listed
Standard #:	22VAC40-131-180-M
Description:	Violation: Based on review of the record for foster home FH1 and interview with agency representative AR1, the licensee did not consider all information received about an applicant, prior to making a decision on the applicant. Findings: 1. The home study for FH1 documents that FH1 was approved 02/25/2021, however, the foster home application was dated 03/02/2021. 2. AR1 confirmed that the application was dated 03/02/2021 after the date of the home approval.
Plan of Correction:	ED will retrain SD?s and Supervisors on audit requirements prior to certification of new homes, and the use of the new home checklist for auditing. The audit for all foster homes certified since the last inspection has been completed. The new QA Specialist will now audit new foster homes at certification to ensure all required components are present, to include applications
Standard #:	22VAC40-131-200-G-2
Description:	Violation: Based on review of the record for foster home FH1 and interview with agency representative AR1, the certificate of approval did not document the correct issuance and expiration dates for the approval. Findings: 1. The certificate of approval, dated 02/25/2021, included an issuance date of 01/06/2021 and an expiration date of 01/06/2024. 2. The approval letter, dated 02/25/2021, revealed the issuance date as 02/25/2021 and expiration date as 02/25/2024. 2. AR1 confirmed the certificate of approval did not document accurate issuance and expiration dates.
Plan of Correction:	ED will retrain SD?s and Supervisors on audit requirements prior to certification of new homes. The audit for all foster homes certified since the last inspection has been completed. The new QA Specialist will now audit new foster homes at certification to ensure all required components are present, to include the effective dates on the certification
Standard #:	22VAC40-131-320-E
Description:	Violation: Based on review of the record for foster home FH1 and interview with agency representative AR1, the licensee failed to report a serious incident report (SIR) to the department's representative. Findings: 1. The record for FH1 contained a SIR for a child in foster care (FC2) dated 07/12/2021 and 07/13/2021. The SIR for FC2, dated 07/12-13/2021, had not been reported to the department's representative. 2. AR1 acknowledged that the SIR had not been reported, as required by this regulation. .
Plan of Correction:	Executive Director is working with the IT department to create a 3rd approval requirement and place to document when a SIR is sent to licensing.
Standard #:	22VAC40-131-370-F
Description:	Violation: Based on review of the record for foster home FH1 and interview with agency representative, the case file was not up to date. Findings: 1. The record for FH1 did not include the medical examination and Tuberculosis (TB) screening for household member, HM1. 2. AR1 acknowledged that the medical examination and TB screening were not filed in the record.
Plan of Correction:	ED will retrain SD?s and Supervisors on audit requirements prior to certification of new homes. The audit for all foster homes certified since the last inspection has been completed. The new QA Specialist will now audit new foster homes at certification to ensure all required components are present, to include health statements from other household members.
Standard #:	22VAC40-131-370-M-7
Description:	Violation: Based on review of the record for foster home FH1 and interview with agency representative AR1, the record did not document receipt of the most current background checks. Findings: 1. The child protective services checks located in the record for foster parent A, foster parent B, and household member HM1 were dated 09/01/2020. 2. Child protective services checks dated 12/21/2020 were located but had not been filed into the record. 3. AR1 acknowledged that the most recent checks was not in the record.
Plan of Correction:	The new QA Specialist will now audit new foster homes at certification to ensure all required components are present in the record, to include all background checks, sworn statements and CPS checks for all foster homes and other household members
Standard #:	63.2-901.1 B
Description:	Violation: Based on review of the record for foster home FH1 and interview with agency representative AR1, the background check did not meet the requirements of this code section. Findings: 1. The foster home for FH1 was approved on 02/25/2021. The sworn disclosure statement form for household member, HM1, was not found in the record for foster home FH1. 2. AR1 acknowledged that the sworn disclosure statement was not found in the record.
Plan of Correction:	SD?s/Supervisors will retrain foster parent coordinators on audit requirements prior to certification of new homes, and use of the new home checklist for auditing The new QA Specialist will now audit new foster homes at certification to ensure all required components are present including all documents needed for other household members