VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Catholic Charities
507 Park Avenue SW
Norton, VA 24273
(276) 679-1195

Current Inspector: Jamie Morgan (276) 525-5656

Inspection Date: Dec. 19, 2019

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 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-191 Background Checks for Child Welfare Agencies

Comments:

An unannounced renewal inspection was conducted on 12/19/2019 from 10:30 AM - 5:00 PM. Commonwealth Catholic Charities reports a total of 23 provider homes and 44 foster children in placement. During this inspection, three provider home records, five foster child records, and three personnel records were reviewed. One additional personnel record and four Board Officer records (background checks) were reviewed on 12/17/2019 at the Roanoke location. Two personnel were interviewed during the inspection. An exit interview was conducted at the conclusion of the inspection with the Director of Operations, Clinical Supervisor, and Director of Children's Services (by phone) to review preliminary inspection findings. An acknowledgement form was signed. There were two violations. Upon the receipt of the violation notice, the licensee should identify the necessary corrective action and develop a plan of correction for each violation. The plan of correction should include the following: The steps to correct noncompliance with the standard(s); measures to prevent re-occurrence of noncompliance; person(s) responsible for implementation and monitoring of preventative measure(s); and date by which noncompliance will be corrected. The licensee has five (5) calendar days from receipt of the inspection documentation to complete the section titled Plan of Correction, sign each page of the documentation and return it to the Licensing Office. The licensee should retain a copy to be posted at the facility. Results of the inspection documentation are subject to public disclosure and will be posted on the VDSS web site within 5 days, regardless of whether the Plan of Correction is completed.

Violations:

Standard #:	22VAC40-131-180-J-2
Description:	Violation: Based on a review of the record for provider homes (PH1, PH2, PH3) and interview with personnel (S1 and S2), the agency failed to verify applicant divorces as required by 22VAC40-131-180.J.2.b.2. Evidence: 1. The home study for PH1 did not contain verification of divorce for provider 1 and provider 2 (P1, P2). 2. The home study for PH2 did not contain verfication of divorce for provider 3 and provider 4 (P3, P4). 3. The home study for PH3 did not contain verification of divorce for provider 5 and provider 6 (P5, P6). 4. When asked about verification of divorce for P1 - P6 from PH1, PH2, and PH3, personnel (S1 and S2) acknowledged that the the homestudies for PH1, PH2, and PH3 did not contain verification of the applicants (P1 - P6) divorces.
Plan of Correction:	CCC will obtain copies of any and all divorce decrees from prospective foster parents prior to approval. Copies of these documents will be filed in the foster parent record. All applicable staff will be trained to ensure compliance with this requirement. Program Manager and Clinical Supervisor will review Foster Parent records to ensure applicable copies of divorce decrees are included in the record.
Standard #:	22VAC40-131-340-E-4
Description:	Violation: Based on a review of the record for a foster child (FC1) and interview with personnel (S1, S2), the agency failed to include the target date for the child's discharge from the program on the individualized service plan and treatment plan. Evidence: 1. The individualized service plan and treatment plan for FC1 did not include a target date for FC1's discharge from the program. 2. When asked during the exit interview, S1 and S2 stated that they thought this date was generated by the DSS service plan which had not been completed yet. 3. S1 and S2 acknowledged that the individualized service plan and treatment plan for FC1 did not contain a target date for discharge.
Plan of Correction:	CCC will include discharge target dates on all individualized service plans and treatment plans for all placements. All applicable staff will be trained to ensure compliance with this requirement. Program Manager and Clinical Supervisor will continue to monitor and review files for adherence to this policy.