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: March 13, 2024 , March 20, 2024 and March 25, 2024

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

Technical Assistance:

22VAC40-131-370.F- Discussed organization and maintenance of documents in electronic health record. Documents need to be up to date and in uniform organized manner.

Comments:

An unannounced renewal inspection was initiated in person on 3/13/24 with assistance from program Director via phone consultation and supervisor who assisted licensing inspector with coordinating and gaining access to electronic health record log-in credentials once arriving to licensed location. Several foster home and children records were reviewed via electronic health record on 3/15/24 and 3/20/24 and during the exit meeting on 4/1/24. An entrance conference was conducted on 3/13/24 with a supervisor who arrived following inspector?s arrival. Specialist was given a tour of the office settings and conditions and reviewed current posted license at the entrance of the license location and noted that the violation summary from last inspection was not posted for review. Supervisor ensured violation report was posted near license prior to specialist departure. Specialist discussed serious incident reporting requirements, documentation in EHR record that had dates that were off and forms identified during review that were incomplete or had blanks. A preliminary finding meeting was conducted at license office office on 3/25/24. An exit interview was conducted with Executive Director on 4/1//2024 by Teams Meet. Number of children in care: 43 Number of approved provider homes: 36 The licensing inspector completed a tour of the physical plant that included the office setting and conditions. Number of children?s records reviewed: 5. One record was a discharge record. Number of provider homes reviewed: 3 Number of personnel/staff records reviewed: 5 which included 2 records that were reviewed by another inspector during the agency?s licensing period. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee can submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area.

Violations:

Standard #:	22VAC40-131-230-B
Description:	Violation: Based on record review, the agency failed to conduct monitoring visits at least once every 90 days for Foster Home (FH#2). Findings: 1. The record for Foster Home (FH#2) failed to document and demonstrate that a monitoring visit was conducted April 2023, October 2023, and January 2024. 2. The EHR record for Foster Home (FH#2) had an entry dated 4/30/2023, however, once opened the note was blank. 3. The electronic record showed the last 90-day monitoring was submitted 7/26/23. 4. The findings were discussed during the preliminary findings review meeting on 3/25/24 and staff acknowledged the findings after reviewing the foster home record. 5. The findings were reviewed during the exit interview. Violation: Based on record review, the agency failed to conduct monitoring visits at least once every 90 days for Foster Home (FH#3). Findings: 1. The record for Foster Home (FH#3) failed to document and demonstrate that a monitoring visit was conducted July 2023. The record showed a 90-day monitoring was documented prior to July on April 7th, 2023, and then on 9/16/23 per review of electronic record. 2. The findings were discussed during the preliminary findings review on 3/25/24 and staff acknowledged the findings after reviewing the foster home record. 3. The findings were reviewed during the exit interview.
Plan of Correction:	All FPC will be trained on requirements of 90 day monitoring reports. QA specialist will target 90 day monitoring reports of on going chart audits to ensure these are completed
Standard #:	22VAC40-131-290-C-11
Description:	Based on record review, medical examination report in foster Child record did not address all the required areas. Findings: 1. The physical examination form in record dated 10/31/23 for Foster Child (FC#3), did not address the area on the form labeled: ?Evidence of disabilities? and was left blank. 2. The findings were discussed during the preliminary findings review meeting on 3/25/24 and staff acknowledged the findings after reviewing the foster home record. 3. The findings were reviewed during the exit interview. 4. The findings were reviewed during the exit interview
Plan of Correction:	Medical/Physical/Dental forms will be updated to check boxes to help prevent providers from missing questions. Staff will be retrained on requirement to ensure forms are filled out correctly.
Standard #:	22VAC40-131-290-C-8
Description:	Based on record review, medical examination/physical report in foster Child record did not address all the required areas. Findings: 1. The physical examination/medical exam document dated 6/1/23 in the record for Foster Child (FC#2), did not indicate whether (FC#2) was free from ?tuberculosis in a communicable form?. 2. The physical examination/medical exam document dated 10/31/23 in the record for Foster Child (FC#3), did not aindicate whether (FC#3) was free from ?tuberculosis in a communicable form?. 3. The findings were discussed during the preliminary findings review meeting on 3/25/24 and staff acknowledged the findings after reviewing the foster home record. 4. The findings were reviewed during the exit interview
Plan of Correction:	Medical/Physical/Dental forms will be updated to check boxes to help prevent providers from missing questions. Staff will be retrained on requirement to ensure forms are filled out correctly.
Standard #:	22VAC40-131-320-E
Description:	Violation: Based on record review, two incidents were identified in the foster child record that was not reported to department and/or licensing representative and not reported within 24 hours following the incident. Findings: 1. The record review for Foster Home (FP#1) identified a reportable incident involving foster Child (FC#4) on 2/20/24 that was not reported to a licensing representative with the identified timeframe. 2. The record review for Foster Child (FC#3) documented a reportable incident on 12/16/2023 that was not reported to a licensing representative within the required 24 hr. timeframe. 3. The findings were discussed during the preliminary findings review meeting on 3/25/24 and staff acknowledged the findings after reviewing the foster home record. 4. The findings were reviewed during the exit interview.
Plan of Correction:	All Supervisors and Directors will be retrained on timeframe requirements to submit SIRs to licensing.
Standard #:	22VAC40-191-40-C-1-e
Description:	Violation: Based on record review for Foster Home (FH#2), agency failed to complete and demonstrate sworn statement was completed for household member. Findings: 1. The record for Foster Home (FH#2) was reviewed and household member (HM#1) had Central Registry letter in record dated 7/15/23 but no documentation to show that a sworn statement or affirmation had been completed and maintained in the record for (HM#1). 2. The findings were discussed during the preliminary findings review meeting on 3/25/24 and staff acknowledged the findings after reviewing the foster home record. 3. The findings were reviewed during the exit interview.
Plan of Correction:	All background checks will be completed annually going.