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: March 11, 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 Fredericksburg location on March 11, 2020 from 10:00 a.m. to 3:50 p.m. and on March 12, 2020 from 8:49 a.m. to 10:30 a.m. Ten personnel records were reviewed at the Henrico 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, 2020 and March 23, 2020. On March 11, 2020 the agency reported 14 children in care and 16 approved foster homes. Two provider home records and three records of children in foster care placements were reviewed (two current and one discharged record). 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 were 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, 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. 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 Relias system.
Standard #:	22VAC40-191-40-D-1-c
Description:	Violation: Based on 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.