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: Jan. 3, 2024 and Jan. 4, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-131 GENERAL PROVISIONS 22VAC40-131 ORGANIZATION AND ADMINISTRATION 22VAC40-131 PERSONNEL 22VAC40-131 PROGRAM STATEMENT 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:

22VAC40-131-320.F Discussion regarding completion of serious incident reports.

Comments:

Type of inspection: Renewal An unannounced monitoring inspection was conducted on 1/3/2024 from 12:45 p.m. to 5:30 p.m. A desk review for staff records was completed on 1/4/2024 from 9:00 a.m. ? 9:30 a.m. A preliminary findings review was held on 1/3/2024. An Acknowledgement of Inspection form was e-mailed for signature. An exit interview was completed on 1/11/2024. Number of children in care: 44 Number of approved provider homes: 30 Number of approved adoptive homes: 5 The licensing inspector completed a tour of the physical plant that included the office setting and conditions. Number of children?s records reviewed: 5 Number of provider home records reviewed: 3 Number of adoptive home 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 #:	22VAC40-131-290-C
Description:	22VAC40-131-290.C. 3, 4, 5, 6 & 8 Violation: Based on record review and interview, the agency failed to obtain a physical for Foster Child 2 (FC2) addressing all required elements. Findings: 1) A medical exam report dated 6/22/23 was in the record. 2) The medical report did not address growth and development; visual and auditory acuity; or evidence of freedom of communicable disease. 3) The file did not contain any other medical documentation. 4) The file did contain a request for the medical provider to complete the missing required elements, dated 1/2/24. 5) The findings were discussed during the preliminary findings review. 6) S2 acknowledged the finding.
Plan of Correction:	FPS will be trained once again in expectations of standards. All new physicals will be given to director to review to ensure compliance.
Standard #:	22VAC40-131-290-L-1
Description:	Violation: Based on record review and interview, the agency failed to obtain additional reports from specialists due to a concern noted on PH3?s medical exam. Findings: 1) PH3 had a medical exam completed on 8/29/23. 2) The medical provider indicated that PH3?s physical health ?could affect the care of a child.? 3) The record did not contain any additional medical reports. 4) The record did not contain additional documentation regarding clarification of the medical provider?s concern. 5) The findings were discussed during the preliminary findings review. 6) Staff 7 (S7) acknowledged there were no follow up medical reports.
Plan of Correction:	All standards will be reviewed and all physicals will be looked at by director before filed to ensure compliance.
Standard #:	22VAC40-191-40-D-1-c
Description:	Violation: Based on record review, the agency failed to obtain background checks within three years of the prior background checks for Provider Home 3 (PH3). Findings: 1) The Sworn Statement for PH3?s re-evaluation was dated on 8/14/23. 2) The previous Sworn Statement was completed on 7/10/20. 3) The Criminal History background check for PH3?s re-evaluation was dated 8/18/23. 4) The prior National Criminal background check was completed on 7/27/20. 5) The findings were discussed during the preliminary findings review. 6) Staff acknowledged the finding.
Plan of Correction:	Foster parent specialist will review standard and let director see all background checks when they arrive to office before filed in record. FPS will send tracker to Director monthly.