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: June 18, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN?S SERVICES 22VAC40-131 ADDITIONAL REQUIREMENTS FOR SPECIFIC PROGRAMS 22VAC40-191 BACKGROUND CHECKS FOR CHILD WELFARE AGENCIES

Technical Assistance:

22VAC40-131-230.F.3 Discussion regarding documentation in the provider home re-evaluation specific to a foster child?s relationship with each member in the provider home.

Comments:

Type of inspection: Monitoring A monitoring inspection was initiated on 6/18/2024 and concluded on 6/20/24. The Program Manager was contacted by telephone to initiate the inspection. The Program Manager reported that the current census was 8. The inspector emailed the Program Managers a list of items required to complete the inspection. The inspector reviewed 1 resident record and 3 provider home records submitted by the facility to ensure documentation was complete. An exit interview was conducted with the program manager on 6/21/24, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. 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 #:	22VAC40-131-290-C-8
Description:	Violation: Based on record review, the agency failed to obtain a medical examination that included an assessment that Foster Child 1 (FC1) was free from communicable disease including TB. Findings: 1) FC1 had a physical examination completed on 5/18/23. 2) The question regarding TB was left blank on the medical evaluation form. 3) FC1?s file did not contain documentation of efforts to have the form corrected or TB assessed. 4) The agency was provided time to locate additional information. 5) S1 acknowledged the finding.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-191-40-D-5-a
Description:	Violation: Based on record review, the agency failed to obtain Central Registry background checks for Household Member (HM) 1 and 2 of Provider Home 1 (PH1) within 30 days of their 14th birthday. Findings: 1) PH1?s record did not contain Central Registry background checks for HM1 or HM2. 2) HM1 turned 14 in December of 2021. 3) HM2 turned 14 in September of 2022. 4) PH1 was re-approved on 2/28/24 without this information. 5) The agency was provided with additional time to search for more documentation. 6) Staff 1 (S1) produced a check request dated 12/21/21 for the background check of HM1. 7) No other information was available. 8) S1 acknowledged the finding.
Plan of Correction:	Central Registry background checks for HM1 and HM2 have been submitted on 6/21/2024 .
Standard #:	22VAC40-191-40-D-5-a
Description:	Violation: Based on record review, the agency failed to obtain Central Registry background checks for Household Member (HM) 1 and 2 of Provider Home 1 (PH1) within 30 days of their 14th birthday. Findings: 1) PH1?s record did not contain Central Registry background checks for HM1 or HM2. 2) HM1 turned 14 in December of 2021. 3) HM2 turned 14 in September of 2022. 4) PH1 was re-approved on 2/28/24 without this information. 5) The agency was provided with additional time to search for more documentation. 6) Staff 1 (S1) produced a check request dated 12/21/21 for the background check of HM1. 7) No other information was available. 8) S1 acknowledged the finding.
Plan of Correction:	FC has physical exam scheduled for 7/9/2024 and will have TB risk assessed 7/9/2024 at that exam and it will be documented on the on the medical evaluation formed and placed in the child's file.