VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Embrace Foster Care
6345 Center Drive
Norfolk, VA 23502
(757) 847-9385

Current Inspector: Sherry Woodard (757) 987-0839

Inspection Date: Oct. 9, 2019 , Oct. 10, 2019 , Oct. 16, 2019 , Oct. 21, 2019 , Oct. 23, 2019 , Oct. 28, 2019 and Nov. 5, 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 22VAC40-191 Background Checks for Child Welfare Agencies

Comments:

An unannounced monitoring inspection was conducted at the Norfolk location on October 9, 2019 from 10:09 a.m. to 3:45 p.m., on October 10, 2019 from 9:27 a.m. to 5:54 p.m., on October 16, 2019 from 9:33 a.m. to 5:40 p.m. On October 9, 2019, the agency reported thirty children in care and thirty-six approved provider homes. Two provider home records, a portion of a provider home record, and three foster child records were reviewed. Background checks for eleven additional provider homes were reviewed. Two staff were interviewed during this inspection. Preliminary inspection findings were reviewed at the conclusion of the inspection with the Site Director and Executive Director. An acknowledgement form was signed. Five personnel records were reviewed at the Henrico office on October 21, 2019. Desk audits of additional training documentation were conducted on October 23 and 28, 2019. Exit meeting was held via telephone with the Executive Director on November 5, 2019. 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; position(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. Please do not post the Supplemental form. 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 #:	22VAC40-131-110
Description:	Violation: Based on a review of the records for foster home FH1, foster child FC1, foster child FC2, and interview with Staff S1, materials and information received by the licensee did not indicate the dates received. Findings: 1. FH1 record: review of the following documents in the foster home record did not document dates received: driving record, child protective services central registry search result, car insurance, and homeowners insurance. 2. FC1 record: review of the July 26, 2019 dental report for an orthodontic consult did not document date received. 3. FC2 record: review of a physical examination form received from a previous placement did not document date received. 3. During an interview with the Licensing Specialist, Staff S1 acknowledged that the dates received were omitted from the documents.
Plan of Correction:	Site Director/Executive Director will retrain all staff to ensure anything received externally has a date stamp on it
Standard #:	22VAC40-131-40-B
Description:	Based on review of the records for foster homes, review of the agency's policies and procedures manual, and interview with Staff S1, the licensee failed to require each home provider to complete and keep current training required by the agency's policies and procedures. 1. "Becoming a Love and Logic Parent Certification", mandatory training required by the agency's policies and procedures manual, was not completed prior to the approval of each foster home: FH3, FH6, FH7, FH9, FH11, FH12 and FH13. "Becoming a Love and Logic Parent Certification" had expired 12/04/18 for foster home FH14. 2. Review of the agency's policies and procedures revealed that this is mandatory training for foster homes. 3. During an interview with the Licensing Specialist, Staff S1 confirmed that this training had not been completed prior to approving the foster homes noted in this violation and S1 confirmed that the training had expired for foster home FH14.
Plan of Correction:	Upon review of Embrace P&P, Love and Logic was required for families who were taking clients at an Acute level (which was under the old level system indicating the policy was out of date). P&P was updated to the new levels by Executive Director. Executive Director retrained Site Director and Foster Parent Coordinator on our internal policies. All Foster Families will receive Love and Logic training, documented in their file by the FPC or SD
Standard #:	22VAC40-131-160-B
Description:	Violation: Based on review of the personnel record for Staff S8 and interview with Staff S3, the agency failed to document training required by these standards in the personnel record. Findings: 1. The personnel record for Staff S8 did not document pre-service training core competencies, as required by Standard 150.B.8. Required initial orientation. 2. During an interview with the Licensing Specialist, Staff S3 confirmed that although the training had been completed, it was not documented in S8's personnel record at the time of the inspection.
Plan of Correction:	S8's file has been updated to include his pre-service core competency requirements Executive Director will work with HR to ensure all training is logged in Relias prior to new staff receiving credentials to the EHR to ensure training is in the file.
Standard #:	22VAC40-131-180-K
Description:	Violation: Based on review of the foster home record for foster homes FH5 and FH11 and interview with Staff S1, the results of background checks received by the licensee were not maintained in the respective applicant's file. Findings: 1. The results of the fingerprint checks located in the record for FH5 were not current. 2. No fingerprint results were found in the record for FH11. 3. During an interview with the Licensing Specialist, Staff S1 confirmed that current fingerprint results for FH5 and FH11 had been obtained but had not been filed in the record.
Plan of Correction:	Prior to certification, Site Director will audit certification checklist in the EHR to ensure all background checks are filed in the FP chart.
Standard #:	22VAC40-131-200-G
Description:	Violation: Based on review of the record for foster home FH1 and interview with Staff S1, the certificate of approval did not document required information. Findings: 1. The certificate of approval for FH1 did not include the signature and title of the individual who completed the home study. 2. During an interview with the Licensing Specialist, Staff S1 acknowledged that the certificate did not include the signature and title of the individual who completed the home study.
Plan of Correction:	The Certificate of Approval was missing signature in the EHR, which is an electronic signature. Executive Director will work with IT Dept to ensure the Certificate is coded correctly to pick up the signature. Foster Parent Coordinator will audit FP charts to ensure Cert of Approval have signatures, and do addendums to any which are missing
Standard #:	22VAC40-131-210-B
Description:	Violation: Based on review of the training records for foster homes FH11 and FH13 and interview with Staff S1, the licensee failed to require each home provider to complete all required training as a condition of initial approval. Findings: 1. FH11 was approved on 05/30/19 and FH13 was approved on 06/11/19. Training documented for FH11 and FH13 did not indicate the required core competencies were addressed prior to approval. 2. During an interview with the Licensing Specialist, Staff S1 acknowledged this training documentation was missing.
Plan of Correction:	These Foster Homes were transferred to Embrace when a prior agency closed, and pre-service training was transferred to Embrace file. SD and FPC will ensure Foster Parents received a refresher PRIDE pre-service training. If future homes transfer in to Embrace, SD and FPC will ensure the homes receive a pre-service refresher prior to certification.
Standard #:	22VAC40-131-250-O
Description:	Violation: Based on review of the records for foster child FC2, foster child FC3, and interview with Staff S1, the licensee failed to document in the written assessments all required elements specified in 22VAC40-151-250.G. Findings: 1. FC2: a list of the strengths of the child's birth family and preplacement visits were not documented. 2. FC3: instructions for all medication being taken by the child and reasons for taking each medication, the emotional and psychological needs and problems of the child, dates of preplacements visits, and the dates of staffing the child's case were not documented. 3. During an interview with the Licensing Specialist, Staff S1 confirmed that these required elements had been omitted from the written assessments.
Plan of Correction:	Intake/Social Hx has been updated by Executive Director to ensure all required fields are completed. Intake/Soc Hx will be audited by Case Managers and Site Director and add addendums to forms which may have it missing.
Standard #:	22VAC40-131-260-B
Description:	Violation: Based on review of the records for foster child FC2, foster child FC3, and interview with Staff S1, the social history failed to include required information. Findings: 1. FC2: the child's medical history to include the names and addresses of providers of medical treatment was not documented. 2. FC3: names and addresses of providers of medical treatment were not documented. 3. During an interview with the Licensing Specialist, Staff S1 confirmed that the required information was not documented in the social histories.
Plan of Correction:	Executive Director has adjusted the Intake/Social Hx document to ensure the names, addresses of all medical providers are documented. SD will retrain staff on this regulation. Case managers will audit files to determine if addendum is needed to ensure above information is documented
Standard #:	22VAC40-131-280-C-2
Description:	Violation: Based on review of the record for foster child FC1 and interview with Staff S1, the financial responsibilities of each party, including payment for foster care and payment for other expenses, were omitted from the foster home agreement. Findings: 1. The foster care payment was not documented in the foster home agreement. 2. During an interview with the Licensing Specialist, Staff S1 acknowledged that this information had been omitted from the agreement.
Plan of Correction:	Site director will review all current Foster Home agreements and complete new agreements for any one missing financial responsibilities.SD will retain staff to ensure they are completing the Foster Home Agreements in their entirety.
Standard #:	22VAC40-131-290-C-12
Description:	Violation: Based on review of the record for foster child FC2 and interview with Staff S1, the 09/10/19 physical examination did not include all of the requirements of this regulation. Findings: 1. The physical examination did not include a copy of the immunizations the child has received since his last examination. 2. During an interview with the Licensing Specialist, Staff S1 confirmed that this information had been omitted.
Plan of Correction:	Site Director will retrain staff on expectations of the physical exam standard, including immunizations. Site Director and Case managers will review all current client charts to ensure immunizations are documented in the file
Standard #:	22VAC40-131-290-J
Description:	Violation: Based on review of the record for foster child FC3 and interview with Staff S1, the licensee failed to document the medication's intended effects and any adverse reactions the child has experienced. Findings: 1. FC3's medication's intended effects and adverse reactions were not documented. 2. During an interview with the Licensing Specialist, Staff S1 acknowledged that this information was not documented.
Plan of Correction:	Comprehensive, and Quarterly report have been updated to include a section on side effects. Site Director will audit files to ensure side effects are listed. If missing, the CM will complete an addendum to add information
Standard #:	22VAC40-191-40-C-1-d
Description:	Violation: Based on review of the record for foster home FH1 and interview with Staff S1, the sworn statement for FH1 was incomplete. Findings: 1. FH1's 02/19/19 sworn statement did not document responses to two questions (left blank). 2. During an interview with the Licensing Specialist, Staff S1 acknowledged that the sworn statement was incomplete.
Plan of Correction:	Executive Director re-trained Foster Parent Coordinator and Site Director on completion of the Sworn Statement. All Foster Parent Charts will be reviewed by Embrace Staff to ensure Sworn Statement are 100% and will have any charts deficient in this completed again by the foster parents
Standard #:	22VAC40-191-40-D-4-b
Description:	Violation: Based on a review of the record for foster child FC2, and interview with Staff S1, the agency failed to ensure background checks were completed within 30 days of the foster child becoming 18 years old. Findings: 1. A sworn statement or affirmation, central registry search, and national criminal background check were not completed for FC2 within 30 days of becoming 18 years old. 2. During an interview with the Licensing Specialist, Staff 1 reported that two forms of identification were needed in order to process the background investigations and that FC2 did not have the necessary documentation at the time.
Plan of Correction:	Embrace will begin flagging 18 year birthdays of foster clients at 17 years and 8 months in the electronic health record to provide time for proper identification in the event there is difficulty receiving it for completion of the background investigation documents.
Standard #:	22VAC40-191-50-A-1-a
Description:	Violation: Based on review of the records for foster home FH1, foster child FC4, and interview with Staff S1, the sworn statements were not fully completed, as required by this standard. Findings: 1. FH1's 02/19/19 sworn statement did not document responses to questions #1 and #2 (left blank). 2. FC4's 04/11/19 sworn statement did not document a response to question #5 (left blank). 3. During an interview with the Licensing Specialist, Staff S1 acknowledged that the sworn statements were incomplete.
Plan of Correction:	Executive Director re-trained Case Managers, Foster Parent Coordinator and Site Director on completion of the Sworn Statement. All Foster Client files of clients 18 and over will be reviewed by Embrace Staff to ensure Sworn Statement are 100% and will have any charts deficient in this completed again by the foster client