VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Embrace Foster Care
10705 Spotsylvania Avenue
Suite 101
Fredericksburg, VA 22408
(540) 815-6908

Current Inspector: Kevin Lassiter (804) 241-2093

Inspection Date: Sept. 18, 2019 , Sept. 19, 2019 , Sept. 30, 2019 , Oct. 1, 2019 and Oct. 3, 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 63.2 General Provisions. 22VAC40-191 Background Checks for Child Welfare Agencies

Comments:

An unannounced monitoring inspection was conducted at the Fredericksburg agency on September 18, 2019 from 10:31 a.m. to 4:00 p.m. and September 19, 2019 from 9:25 a.m. to 12:00 p.m. Personnel record review was conducted at the Henrico office location on September 30, 2019 from 11:36 a.m. to 12:36 p.m. A desk audit of additional training documentation was conducted on October 1, 2019. The agency reported a total of thirteen children in care and seventeen approved foster homes. The agency reported one staff had been hired since the last inspection. During this inspection, a staff interview was conducted, one personnel record was reviewed, two children's records and three foster homes were reviewed (two of the three foster homes approved since the last inspection were reviewed for background investigation requirements only). Preliminary inspection findings were reviewed at the conclusion of the inspection with agency representative, AR1. Acknowledgement forms were signed. A telephone exit meeting was held on October 3, 2019 with AR1. 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; person(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. 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
Description:	Violation: Based on review of the personnel record for Staff S1 and an interview with an agency representative (AR1), the agency failed to document all training required by these standards in the personnel record. Findings: 1. The training record for Staff S1 did not document pre-service training core competencies, as required by Standard 150.B.8. Required initial orientation. 2. Interview with AR1 confirmed that while this training had been completed by S1 on July 15, 2019, the completed training was not documented in the personnel record.
Plan of Correction:	The Relias software which houses all staff trainings was not showing the per-service trainings for staff members. The pre-service has been added back in and is now corrected by the Director of Training and Professional Development All staff PRIDE certs will be added in to Relias from the HR charts.