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: April 7, 2021 and April 23, 2021

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:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on April 7, 2021 and concluded on April 23, 2021. The Executive Director was contacted by telephone to initiate the inspection. The Executive Director reported there were 38 children in care and 36 approved foster homes. The inspector emailed the Executive Director a list of items required to complete the inspection. The inspector reviewed four children?s records, four foster home records, and two personnel records submitted by the agency to ensure documentation was complete. Exit meeting was held with the Executive Director on April 23, 2021. The agency previously their COVID-19 policies and procedures. Information gathered during the inspection determined non-compliance with applicable standards or law, and a violation was documented on the violation notice issued to the agency. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return to the Licensing Office within 5 business days from receipt of the inspection documentation. You will need to specify how the deficient practice will be or has been corrected (merely writing the word corrected is not acceptable). Your plan of correction must contain the steps to correct the noncompliance with the standard(s), the measures to prevent the noncompliance from occurring again; and the position responsible for implementing each step and/or monitoring any preventive measure(s). The licensee should retain a copy to be posted at the agency. 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 review of the record for foster home, FH2, and interview with agency representative AR1, the licensee failed to ensure the home study documented required components. Findings: 1. According to the 02/01/2021 ?Resource Family Residence Checklist?, FH2 includes household pets, two dogs and one cat. 22 VAC 40-131-180-J-2-f requires that the home study includes documentation that the home complies with the standards for the home as required by 22 VAC 40-131-190. The home study does not document compliance with 22 VAC 40-131-190-S and 22 VAC 40-131-190-T. The home study does not documents test, inoculations, and license required by law for the cat. The home study does not document that the cat is safe to be around children and that the cat presents no health hazard to children in the home. 2. AR2 confirmed that the home study did not document the required components for the household?s pet cat.
Plan of Correction:	1. Home study will be amended to include the required elements of this standard 2.HS addendums will be completed to ensure we are in compliance with the regulation
Standard #:	22VAC40-131-230-B
Description:	Violation: Based on review of the records for foster homes FH2 and FH3 and interview with agency representative AR2, licensee failed to complete monitoring of the foster homes within the required time frame. Findings: 1. FH3 was approved June 10, 2020. 2. A 90 day monitoring visit was due in September 2020. There is no documentation this visit was conducted. 3. AR2 confirmed there was no documentation that this visit was conducted.
Plan of Correction:	Director will retrain staff on 90-day monitoring visits, specifically that they should be completed whether a placement is in the home or not every 90 days beginning at certification date.
Standard #:	22VAC40-131-260-D
Description:	Violation: Based on review of the records for foster children, FC1, FC2, FC3, and FC4 and interview with agency representative AR2, the agency failed to include all required elements in the children's social histories. Findings: 1. FC1, FC2, FC3, and FC4 are siblings. 2. The social histories completed for FC1, FC2, FC3, and FC4 did not include education, occupation, medical, or psychiatric information for the children's aunts, uncles and grandparents. The reason the information was not included was not documented in the children's social histories. 3. AR2 stated that the child did not have any known aunts, uncles or grandparents.
Plan of Correction:	Director will re-train all staff to include a statement about grandparents, aunts and uncles to indicate if they are unknown.
Standard #:	22VAC40-131-290-C
Description:	Violation: Based on review of the records for foster children FC2 and FC3 and interview with agency representative AR2, the licensee failed to include all elements of a medical examination as required by 22 VAC 40-131-(6)-290-C-5 and 6 of the regulation. Findings: 1. Review of the 02/25/2021 physical exam form for FC2 failed to include visual and auditory acuity. 2. Review of the 02/25/2021 physical exam form for FC3 failed to include visual and auditory acuity and nutritional status. 3. AR2 confirmed that this information was missing from the physical exam forms.
Plan of Correction:	Director will re-train staff and supervisor to look for information on the physical exam for visual, auditor, and nutritional status. A line through the section is not permitted.
Standard #:	22VAC40-131-370-M-11
Description:	Violation: Based on review of the record for foster home, FH2, and interview with agency representative, AR2, the licensee failed to maintain documentation of results of observations and findings from monitoring visits in the home provider file. Findings: 1. The record for FH2 did not include documentation from the June 2020 contact to monitor the performance of the provider. 2. AR2 reported the visit was conducted virtually and that this was documented in a placement note in the record for the child to be placed.
Plan of Correction:	Director will retrain staff on 90-day monitoring visits, specifically that they should be completed whether a placement is in the home or not every 90 days beginning at certification date.