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: Feb. 25, 2020 , Feb. 26, 2020 , March 3, 2020 , March 12, 2020 , March 17, 2020 , March 23, 2020 and March 24, 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. 22VAC40-191 Background Checks for Child Welfare Agencies

Comments:

An unannounced renewal inspection was conducted at the Norfolk agency on February 25, 2020 from 10:11 a.m. to 3:57 p.m., on February 26, 2020 from 9:48 a.m. to 4:22 p.m. and on March 3, 2020 from 9:30 a.m. to approximately 4:00 p.m. Eleven personnel records were reviewed at the Henrico Human Resources office on March 12, 2020 from 11:45 a.m. to 4:43 p.m. Desk audits of additional personnel record documentation were conducted on March 17 and March 23, 2020. On February 25, 2020, the agency reported 50 children in care and thirty-five approved provider homes. Three provider home records and four records of children in foster care were reviewed. Background checks for three additional provider homes were reviewed. Two staff were interviewed during this inspection. Preliminary inspection findings were reviewed at the conclusion of the inspection with Staff S1 and Staff S2. An acknowledgement form was signed. Exit meeting was held via telephone with S2 on March 24, 2020. 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 #:	22VAC40-131-160-B-5
Description:	Violation: Based on review of the personnel records for Staff S1, Staff S2, 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: 1. Annual performance evaluations were completed but not included in the personnel records for the following staff: S1 and AR3. 2 Annual performance evaluations were not completed for the following staff: S2, AR1, AR2, AR4, AR5, AR6, and AR7. 3. 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 Staff S2, S4, 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: 1. Initial orientation in the licensee's emergency preparedness and response plan was not documented for S4. 2. Initial orientation in the grief and loss issues for children in foster care was not documented for S4. 1. Annual training was completed but not included in the personnel records for the following staff: S2, AR1, AR2, AR3, AR5, AR6, and AR7. 2. Annual training was not completed for AR4. 3. 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 system.
Standard #:	22VAC40-131-180-H
Description:	Violation: Based on review of the record for foster home FH2 and interview with Staff S1, the licensee failed to determine the results of a previous application with a public child-placing agency. Findings: 1. Beyond the disclosure made by the foster parent on the initial application, there was no documentation in the foster home file regarding the foster parent's previous application with a public child-placing agency or the results of this application. 2. During an interview with the Licensing Specialist, Staff S1 confirmed that there was no other information documented regarding FH2's disclosure.
Plan of Correction:	Executive Director and Site Director will re train staff on the regulations for foster parents? certification to ensure documentation of prior agencies are completed and in the file. An audit will be done to correct any current deficits.
Standard #:	22VAC40-131-180-I
Description:	Violation: Based on review of the record for foster home FH2 and interview with Staff S1, the licensee failed to obtain from the applicant a signed authorization allowing the previous child-placing agency to release information to the licensee about a previous application. Findings: 1. A signed authorization authorizing the licensee to obtain information regarding the previous application to a public child-placing agency was not documented in the record. 2. During an interview with the Licensing Specialist, Staff S1 confirmed there was no signed authorization.
Plan of Correction:	Executive Director and Site Director will re train staff on the regulations for foster parents? certification to ensure release of information of prior agencies are completed and in the file. An audit will be done to correct any current deficits.
Standard #:	22VAC40-131-180-J-1
Description:	Violation: Based on review of the records for foster homes FH1 and FH3, and interview with Staff S1, a tuberculosis (TB) screening assessment was not documented for household member HM1 in foster home FH1 or one of the foster parents in foster home FH3 Findings: 1. On 01/24/2020, HM1 became a household member of foster home FH1 and as of the 02/25/2020 date of the inspection, a TB screening assessment was not documented in the record. 2. The TB screening assessment result was omitted on the medical form completed for one of the foster parents in FH3. 3. During an interview with the Licensing Specialist, Staff S1 reported that the TB screening assessment was in progress for HM1 and confirmed that the TB result was not documented on the form for the foster parent in FH3.
Plan of Correction:	Executive Director and Site Director will re train staff on the regulations for foster parents and other household members to ensure documentation is completed and in the file of health statements, specifically the TB screening and/or test. An audit will be done to correct any current deficits.
Standard #:	22VAC40-131-180-K
Description:	Violation: Based on review of the foster home record for foster home FH4 and interview with Staff S1, the results of the background checks received by the licensee were not maintained in the applicant's file. Findings: 1. The out-of-state child protective services results for foster home FH4, to include the two foster parents and household member HM3, were not found in the record during the inspection. Staff S1 provided the results during the inspection. 2. The sworn disclosure statement for HM3 was not found in the record for foster home FH4. S1 provided the sworn disclosure statement during the inspection. 3. During an interview with the Licensing Specialist, Staff S1 acknowledged that the required background checks had not been uploaded into the record.
Plan of Correction:	All background checks in question have been completed and are now in the record. Executive Director will work with Site Director on an auditing process to ensure all required documents are in the file as it related to foster home and household members.
Standard #:	22VAC40-131-200-E
Description:	Violation: Based on review of the record for foster home FH1 and interview with Staff S1, the licensee failed to notify the applicant in writing of the approval decision. Findings: 1. There was no written notification in the record for FH1 of the approval decision. 2. During an interview with the Licensing Specialist, Staff S1 acknowledged that the notification had not been documented in writing.
Plan of Correction:	Executive Director and Site Director will re train staff on the regulations for foster parents? certification to ensure notification of approval in writing is completed and in the file. An audit will be done to correct any current deficits.
Standard #:	22VAC40-131-240-B
Description:	Violation: Based on review of the record for foster home FH1, foster child FC1, and interview with Staff S1, the agency failed to complete written justification as required by this regulation. Findings: 1. Four foster children, to include FC1, were placed in foster home FH1 on 10/29/19 without required written approval for exceeding two placements in a treatment foster home. 2. During an interview with the Licensing Specialist, Staff S1 acknowledged that the written approval had not been completed.
Plan of Correction:	Document in question has now been completed and is in the record. ED/ Site Director will train supervisor and foster parent coordinator on this regulation and an audit will be completed to correct any files which are missing the justification form
Standard #:	22VAC40-131-250-J
Description:	Violation: Based on review of the record for foster child FC1 and interview with Staff S1, the agency failed to document assisting the prospective foster family with making an informed decision as to whether the particular child is appropriate for them. Findings: 1. The "Interview Summary and "Preparation for Placement" form, dated 10/29/19, was signed by the agency representative on 11/19/19 but the foster parent did not sign. 2. During an interview with the Licensing Specialist, Staff S1 acknowledged that the "Interview Summary and Preparation for Placement form" was in a draft form with no documentation that the prospective foster parent, FH1, had been given this information.
Plan of Correction:	Executive director will meet with the referral/placement team to retrain them on preplacement regulations and the Interview Summary and Preparation for Placement form.
Standard #:	22VAC40-131-250-M
Description:	Violation: Based on review of the record for foster child FC1 and interview with Staff S1, the licensee failed to arrange a pre-placement visit to prepare the child for placement and failed to document why the pre-placement visit did not occur. Findings: 1. Based on the documentation in the record, the placement did not meet the definition of an emergency placement. The date of placement for FC1 was documented as 10/29/19. FC1's record revealed that FC1 did not meet FH1 in person until placed with FH1. Prior to the placement, FC1 and FH1 had interacted via phone and video conference since FC1's birth (at the time of placement, FC1 was 2 years of age). 2. During an interview with the Licensing Specialist, Staff S1 confirmed that a pre-placement visit in the prospective home did not occur due to travel distance.
Plan of Correction:	Executive director will meet with the referral/placement team to retrain them on preplacement regulations for all non-emergency cases. Staff will be required to staff all placements with ED prior to placement to ensure regulation is met.
Standard #:	22VAC40-131-330-G-5
Description:	Violation: Based on review of the records for foster child FC1 and FC3 and interview with Staff S1, a private interview at least one time each month was not documented. Findings: 1. FC1's record did not document a private interview in December 2019 or January 2020. 2. FC3's record did not document a private interview in November or December 2019. 3. During an interview with the Licensing Specialist, Staff S1 confirmed that the records did not document private interviews during these months.
Plan of Correction:	FC1 is a 2-year-old child. ED and Site Director will retrain staff on the requirement to attempt a private interview and to document when it occurs (or that a private interview was attempted). FC3 record reflects the 2 private visits but were completed late.
Standard #:	22VAC40-131-350-B-16
Description:	Violation: Based on review of the records for foster child FC1, FC2, and FC4 and interview with Staff S1, the progress summary reports did not document the signatures of the individuals who wrote the reports. Findings: 1. The 01/27/2020 progress summary report written for FC1, the 12/23/19 report written for FC2, and the 12/25/19 report written for FC4 did not document the signatures of the individuals who wrote the reports. 2. During an interview with the Licensing Specialist, Staff S1 confirmed that the electronic signatures were not documented on the reports.
Plan of Correction:	ED will discuss issue with IT department. Signatures are e-signatures in the system and should automatically create staff signature.
Standard #:	22VAC40-131-350-E
Description:	Violation: Based on review of the records for foster child FC1, FC2, FC3, and FC4 and interview with Staff S1, the licensee failed to document the participation of the required parties in the review of progress. Findings: 1. The 01/27/2020 progress report written for FC1, the 12/23/19 report written for FC2, the 12/28/19 progress report written for FC3, and the 12/28/19 progress report written for FC4 did not document the participation of the required parties. 2. During an interview with the Licensing Specialist, Staff S1 confirmed that the participation of required parties in the progress reviews were not documented.
Plan of Correction:	ED and Site Director will train staff on ensuring the treatment team signs off on the quarterly reports even when participation is conducted by phone. A review of records will occur to assess correction needs.
Standard #:	22VAC40-131-370-M-12
Description:	Violation: Based on review of the foster home records for FH1 and FH3 and interview with Staff S1, the agency failed to list the names and dates of birth of all members of the household and the relationship of each member to the provider. Findings: 1. Record reviews revealed the biological daughter resided in the home of FH1 and the biological son resided in the home of FH3. The biological daughter residing in the home of FH1 was not documented on the face sheet for FH1 and the biological son residing in the home of FH3 was not documented on the face sheet for FH3, as required by this regulation. 2. Based on an interview with the Licensing Specialist, Staff S1 acknowledged that the face sheets did not document the required information.
Plan of Correction:	Executive Director met with IT department and the coding was incorrect on the face sheet and has been corrected.
Standard #:	22VAC40-131-370-R-2
Description:	Violation: Based on review of the record for foster child FC1, foster home FH4, and interview with Staff S1, the licensee failed to maintain documentation in the provider and child files, as required by this standard. Findings: 1. FC1 was placed on 10/29/19. The 11/08, 11/13, 11/22, 11/27, 12/03, 12/10, 12/26, and 01/17/20 case notes, 10/19/19 foster home agreement, and 11/20/19 foster care service plan were entered into the electronic record on 02/25 and 02/26/2020. 2. FH4 was approved on 12/31/19. A 11/15/19 home study addendum had not been entered into the electronic record until 02/25/2020. 3. During an interview with the Licensing Specialist, Staff S1 confirmed these inspection findings.
Plan of Correction:	ED and supervisor will audit charts weekly to ensure progress notes are completed and in the chart in a timely manner. All staff will be retrained to ensure they understand the expectation.
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: 1. A current sworn statement or affirmation was not documented in the personnel record for AR2. 2. The sworn statement or affirmation was due before three years since the date of the last sworn statement or affirmation. 3. During an interview with the Licensing Specialist, AR5 acknowledged the background check was not in compliance.
Plan of Correction:	The sworn statement in question 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.
Standard #:	22VAC40-191-40-D-4-b
Description:	Violation Based on review of the records for foster homes FH1 and FH6 and interview with Staff S1, the background checks did not meet the requirements of this regulation. Findings: 1.Household member HM1 began residing in the foster home FH1 with four siblings placed in the home. A sworn disclosure statement was not documented in the record for HM1 and the CPS result was not received. 2. No sworn disclosure statement or current national criminal background checks for household member HM4 were found in the record for foster home FH6. 2. During an interview with the Licensing Specialist, Staff S1 confirmed the findings.
Plan of Correction:	Executive Director and Site Director will re train staff on the regulations for other household members to ensure documentation is completed and in the file. HM1?s background check has been sent prior to this inspection. HM4 was not in the home but there was no addendum completed to report she was no longer in the home.