VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Embrace Foster Care, LLC.
4656 Brambleton Avenue
Roanoke, VA 24018
(540) 376-3968

Current Inspector: Jamie Morgan (276) 525-5656

Inspection Date: March 12, 2020 , March 13, 2020 , March 17, 2020 and March 23, 2020

Complaint Related: No

Areas Reviewed:

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 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 3/12/2020 from 9:25 a.m. to 4:30 p.m. and 3/13/2020 from 9:00 a.m. to 2:25 p.m. The agency reported 48 children in foster care and 36 approved provider homes. During this inspection five (5) child and nine (9) provider home were reviewed. Personnel records were reviewed by another Licensing Specialist at the Henrico Human Resources Office on 03/12/2020 and by desk audits of additional personnel record documentation on 03/17/2020 and 03/23/2020. The Treatment Foster Care Site Director and Treatment Foster Care Foster Parent Coordinator/TFC Supervisor participated in the entrance conference, remained available during the inspection, and participated in the exit interview. The Executive Director participated in the exit interview. The exit interview was conducted on 3/13/2020 from 1:45 p.m. to 2:25 p.m. An acknowledgment of inspection form was signed and a copy left with the agency at the end of the inspection on 3/13/2020. There were five citations for violations of the Standards for Child-Placing Agencies. See the violation notice on the Department?s public web site for violations of the Standards. Upon receipt of the Violation Notice, the licensee should develop a plan of correction to include the steps to correct non-compliance with the standard(s); measures to prevent re-occurrence of non-compliance; person(s) responsible for implementation and monitoring of preventative measure(s); and date by which noncompliance will be corrected. The licensee has five business days from receipt of the inspection documents to complete the section entitled "Plan of Correction", sign each page of the inspection documents and return to the Licensing Office. The licensee should retain a copy to be posted at the facility. Results of the inspection are subject to public disclosure and will be posted on the Virginia Department of Social Services public web site within five business days, regardless of whether or not the Plan of Correction is completed. The provider?s response for the ?plan of correction? was not received as of 4/6/2020 and will not appear on the Violation Notice.

Violations:

Standard #:	22VAC40-131-160-B-5
Description:	Violation: Based on review of the personnel records for Personnel 1 (P1) and Agency Representatives AR1, AR2, AR3, AR4, AR5, AR6, AR7 and interview with AR5, the records of each staff person did not include an annual performance evaluation. Findings: An annual performance evaluation was completed but not included in the personnel records for AR3. Annual performance evaluations were not completed for the following staff: P1, AR1, AR2, AR4, AR5, AR6, and AR7. During an interview with the Licensing Specialist, AR5 confirmed these findings.
Plan of Correction:	The missing performance evals were completed but not in the HR file. HR will ensure all needed evals are in the HR record. Performance Evaluations will be completed with a July 1 deadline beginning this July 2020 to ensure they are all completed and in the HR record within 13 months of the last evaluation.
Standard #:	22VAC40-131-160-B-9
Description:	Violation: Based on review of the personnel records for Personnel 1 (P1) and Agency Representatives AR1, AR2, AR3, AR4, AR5, AR6, AR7 and interview with AR5, the personnel records of each staff person did not include documentation of all training. Findings: Annual training was completed but not included in the personnel records for the following staff: P1, AR1, AR2, AR3, AR5, AR6, and AR7. Annual training was not completed for AR4. During an interview with the Licensing Specialist, AR5 confirmed these findings
Plan of Correction:	Embrace?s Executive Director and HR specialist will review the trainings required by Administrative staff and make corrections to our policy and procedure manual to ensure training is completed and in the Relias system.
Standard #:	22VAC40-131-190-O-4
Description:	Violation: Based on record review and interview, the agency failed to ensure that Foster Home 6 (FH6) maintained an emergency evaluation plan addressing all required elements. Findings: The case record for FH6 contained an emergency evacuation plan that listed two locations the family could re. The locations were within the same zip code as the foster home address. There were no locations provided that the family could evacuate to in a large scale community evacuation. The findings were discussed with agency staff during the exit interview. Staff reviewed the evacuation plan document and acknowledged the findings.
Plan of Correction:	Site Director will train all staff on requirements of evacuation plan to include a location outside of the home?s zip code.
Standard #:	22VAC40-131-240-B
Description:	Violation: Based on record review and interview, the agency failed to complete written justification approved by a child-placing supervisor for the placement of more than two children in treatment Foster Home 6 (FH6). Findings: At the time of inspection, five (5) children were placed in FH6. The foster home record did not contain written documentation of consultation and approval by supervision for more than 2 children to be placed in the home. During the exit interview, the finding was discussed with agency staff. Staff reviewed the record. Staff were unable to locate the required documentation. Staff acknowledged the finding.
Plan of Correction:	Site Director will train the placement staff on the regulation requiring justification for more than 2 children to be placed in the home (even if it is a sibling set). S.D./Supervisor will review charts of homes with more than 2 children and correct any deficits.
Standard #:	22VAC40-191-40-D-1-c
Description:	Violation: Based on a review of the personnel record for Agency Representative AR2 and interview with AR5, the agency failed to obtain a repeat background check within the required time frame. Findings: A current sworn statement or affirmation was not documented in the personnel record for AR2. The sworn statement or affirmation was due before three years since the date of the last sworn statement or affirmation. During an interview with the Licensing Specialist, AR5 acknowledged the background check was not in compliance.
Plan of Correction:	The sworn statement in question was due on 3/9/2020 and was not signed until 3/25/20. It has been completed and is in the file. HR Specialist will be monitoring compliance of all background checks to ensure they are completed and in the file prior to the 3-year mark. HR Specialist and Executive Director will monitor 3-year anniversary dates to ensure the checks are began 6 months prior to the due date.