VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Catholic Charities
2131 Valley View Blvd. NW
Roanoke, VA 24012
(540) 342-0411

Current Inspector: Dawn Espelage (540) 759-8852

Inspection Date: April 24, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-131 ORGANIZATION AND ADMINISTRATION 22VAC40-131 PERSONNEL 22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN?S SERVICES 22VAC40-131 ADDITIONAL REQUIREMENTS FOR SPECIFIC PROGRAMS 63.2 ADOPTION 22VAC40-191 BACKGROUND CHECKS FOR CHILD WELFARE AGENCIES

Technical Assistance:

22VAC40-131-180.I Discussion regarding signed authorizations of involvement with prior child-placing agencies.

Comments:

Type of inspection: Monitoring An unannounced monitoring inspection was conducted on 4/24/2023 from 9:45 a.m. to 3:45 p.m. An entrance conference and preliminary findings review was held with the Foster Care and Adoption Program Managers. The Acknowledgement of Inspection form was signed, and a copy left at the agency. An exit interview was conducted on 4/26/23. Number of children in care: 16 Number of approved provider homes: 13 Number of approved adoptive homes: 13 The licensing inspector completed a tour of the physical plant that included the office setting and conditions. Number of children?s records reviewed: 2 Number of provider home records reviewed: 2 Number of adoptive home records reviewed: 3 Number of staff records reviewed: 1 The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Dawn Espelage, Licensing Inspector at 540-759-8852 or by email at dawn.espelage@dss.virginia.gov

Violations:

Standard #:	22VAC40-131-180-J-2
Description:	Violation: Based on record review, the agency failed to obtain a signed, confidentiality statement from Provider Home (PH) 2. Findings: 1) The confidentiality statement was not in the file of PH 2. 2) The agency was given the opportunity to produce the record. 3) Staff (S) 1 acknowledged that the statement was not in the record or available to be filed. 4) The findings were discussed during the preliminary findings review. 5) S1 acknowledged the finding that the required form had not been completed.
Plan of Correction:	Program Manager obtained required signatures and filed the Confidentiality statement on the date of the preliminary findings review, following the finding of the violation. Program Manager will review the list of required documents for home studies and ensure that the Confidentiality Statement is included. Program Manager will review all forthcoming home studies to ensure that the required documents, including the Confidentiality statement are included.
Standard #:	22VAC40-131-350-B
Description:	Violation: Based on record review, the agency failed to include required information on a quarterly progress summary for Foster Child (FC) 1. Findings: 1) The quarterly progress summary stated ?TBD? regarding participation of birth and foster family for the prior quarter. 2) The quarterly progress summary indicated no changes in progress towards permanency planning, although documented communication stated otherwise. 3) The quarterly progress summary did not provide a summary of contacts between child and birth family. 4) The findings were discussed during the preliminary findings review. 5) S1 acknowledged the finding.
Plan of Correction:	The Program Supervisor and Program Manager will provide updated training on completing quarterly reviews that include the necessity of matching the narrative record, identifying permanency plan changes and summarizing birth family contacts. Going forward, Program Supervisor will review quarterlies and narratives prior to filing to ensure this regulation is met.
Standard #:	22VAC40-131-370-R-2
Description:	Violation: Based on record review, the agency failed to file documentation within 30 days in PH1 and PH2 records. Findings: 1) The completed re-evaluation dated 1/31/23 was not in PH1 file. 2) The agency was given the opportunity to produce the record and did have the evaluation completed. 3) The fingerprint results were not in the file for PH2. 4) S1 produced the documentation dated 3/6/23 and 2/3/23. 5) The findings were discussed during the preliminary findings review. 6) S1 acknowledged the finding.
Plan of Correction:	The required re-evaluation was located and filed in PH1 file on the date of the finding, 4/24/2023. The fingerprint results were located and filed in the PH2 file on the date of the finding, 4/24/2023. Program Manager and Foster Parent Specialist shall conduct quarterly reviews of all foster parent files to ensure that all necessary documentation is filed appropriately.