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 11, 2022 , April 13, 2022 and April 15, 2022

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 renewal inspection was conducted on-site at the Norfolk agency on April 11, 2022 from 10:33 a.m. to 2:51 p.m., on April 13, 2022 from 9:38 a.m. to approximately 4:00 p.m., and on-site at the Fredericksburg agency for personnel records review on April 15, 2022 from 11:24 a.m. to 12:09 p.m. The agency reported forty-two (42) children in care. During this inspection, the inspector reviewed two (2) personnel (staff) records, four (4) children?s records, four (4) foster home records, background checks were reviewed for three (3) additional approved foster homes. Preliminary inspection findings were reviewed with agency representatives AR1 on April 13, 2022 and AR3 on April 15, 2022 where an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Acknowledgement forms were signed. An exit meeting was conducted with AR2 on April 15, 2022. Upon the receipt of the violation notice, a plan of correction is requested for the violations. The plan of correction or Description of Action to be Taken should include, as appropriate, 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) business 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. The results of the inspection are subject to public disclosure and will be posted on the VDSS website within 5 business days.

Violations:

Standard #:	22VAC40-131-250-G
Description:	Violation: Based on review of the record for foster child FC4 and interview with agency representative AR1, the licensee failed to gather, review, and document all required information prior to accepting FC4 for placement. Findings: 1. The 02/14/2022 written intake assessment did not include the dates of staffing the child's case. 2. The 02/14/2022 written intake assessment did not accurately document the date the acceptance decision was made. The acceptance date included in the written intake assessment was after the date of placement for FC4. 3. Interview with AR1 confirmed that the dates of staffing the child?s case were not included in the written intake assessment and confirmed the acceptance date was not accurately documented in the written intake assessment.
Plan of Correction:	QA Specialist will continue to audit charts for such errors. Site Director will retrain child placing staff on information intake assessment as it pertains to dates staffing the case, and acceptance date
Standard #:	22VAC40-131-320-E
Description:	Violation: Based on review of the record for foster home FH2 and interview with agency representative AR2, the licensee failed to report a serious incident report (SIR) to the department's representative. Findings: 1. The record for FH2 contained a SIR for a child in foster care (FC2) dated 12/03/2021. The SIR for FC2, dated 12/03/2021, had not been reported to the department's representative. 2. AR2 acknowledged that the SIR had not been reported, as required by this regulation.
Plan of Correction:	Embrace set up a 3rd approval set to notify ED to send out SIR following the November inspection, however it was not implemented in time for this SIR. This issue should no longer be an issue moving forward.
Standard #:	22VAC40-131-340-L
Description:	Violation: Based on a review of the record for foster child FC2 and interview with agency representative AR1, the licensee failed to obtain a copy of the service plan sent to the court. Findings: 1. The record did not document a copy of the court service plan or requests for the plan. 2. AR2 acknowledged that the required information was not documented in the record.
Plan of Correction:	QA Specialist will continue to audit for DSS service plan sent to the court. Site Director will retrain staff on this file requirement.