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: Oct. 25, 2021 and Nov. 8, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-131 ORGANIZATION AND ADMINISTRATION 22VAC40-131 PERSONNEL 22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN'S SERVICES 22VAC40-191 Background Checks for Child Welfare Agencies

Comments:

A monitoring inspection was initiated on October 25, 2021 and concluded on November 8, 2021. The Executive Director was contacted by telephone to initiate the inspection. The Executive Director reported there were 14 approved foster homes and 10 children in foster care. The inspector emailed the Executive Director a list of items required to complete the inspection. The inspector reviewed three personnel records, one child?s record, and two foster home records submitted by the agency to ensure documentation was complete. Exit meeting was held with the Program Manager on November 8, 2021. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the agency

Violations:

Standard #:	22VAC40-131-40-B
Description:	Violation: Based on review of the record for foster child FC1, review of the agency's policies and procedures manual, and interview with agency representatives AR1 and AR1, the licensee failed to comply with its own policies and procedures. Findings: 1. During an interview with AR1 and AR2, when asked what level FC1 was on, AR1 and AR2 confirmed FC1 is on Level 2. 2. Section II: Program Structure, Policy Name and Number: Program Levels II.b. of the agency's policies and procedures manual revealed TFC Level 2 requires "the caseworker will provide face-to-face contact with the clients a minimum of three (3) times per month". 3. The case notes reviewed for FC1 for the months of June and July 2021 revealed the following: - June 2021: two face-to-face contacts were documented - July 2021: no face-to-face contacts were documented 4. AR1 and AR2 confirmed that the above information was accurate.
Plan of Correction:	QA Specialist will ensure the number of visits matches the placement level during audits. Prior to staff member leaving, QA specialist will do a full chart audit to ensure all documentation is accounted for in the chart. Directors will re-train all staff on level/visit requirements
Standard #:	22VAC40-131-190-S
Description:	Violation: Based on a review of the record for foster home FH1 and interview with agency representatives AR1 and AR1, the agency did not obtain documentation or verify that the provider had received inoculations and a pet license, as required by law. Findings: 1. The "Resource Family Residence Checklist", dated 11/18/2020 and the Home Study, completed 01/22/2021, documented a pet canine and documented in the checklist and home study that this pet was licensed and inoculated. 2. There was no documentation in the record that this pet had received inoculations or a pet license. 3. AR1 and AR2 confirmed that this documentation was not in the record.
Plan of Correction:	All foster parent charts are now being audited prior to certification QA Specialist will ensure pet inoculations and pet license are in the foster parent file at the time of certification.
Standard #:	22VAC40-131-350-B-15
Description:	Violation: Based on a review of the record for a foster child FC1 and interview with agency representatives AR1 and AR2, the agency failed to document a required element FC1's May and August 2021 quarterly progress summaries. Findings: 1. The quarterly progress summaries completed in May 2021 and August 2021 for FC1 did not include a future or projected discharge date. 2. The projected discharge date or "target date" is documented as 08/30/2020. 3. AR1 and AR2 acknowledged that the projected discharge date was a past date.
Plan of Correction:	Director will re-train staff on target discharge dates and the foster care services plan. IT is making corrections to the form to allow Embrace to put in our projected discharge date if the DSS discharge date is past due
Standard #:	22VAC40-131-370-Q
Description:	Violation: Based on review of the record for foster child FC1 and interview with agency representatives AR1 and AR2, the narrative case notes were not current within 30 days. Findings: 1. The narrative case notes reviewed for FC1 for the months of August 2021 and September 2021 revealed the following: - 08/10/2021 face-to-face contact note was signed on 10/26/2021 - 08/20/2021 face-to-face contact note was signed on 10/26/2021 - 08/24/2021 face-to-face contact note was signed 10/26/2021 - 09/09/2021 face-to-face contact note was signed 10/26/2021 - 09/16/2021 face-to-face contact note was signed 10/26/2021 - 09/24/2021 face-to-face contact note was signed 10/26/2021 2. AR1 and AR2 confirmed that the notes were signed 10/26/2021.
Plan of Correction:	Director will retrain staff on case note requirement to be current and in the file within 2 weeks. Supervisors/Director/QA Specialist will review progress notes regularly to ensure notes are up to date
Standard #:	22VAC40-131-370-R
Description:	Based on review of the record for foster home FH1 and interview with agency representatives AR1 and AR1, the home study addendum, dated 05/22/2021, was not completed until 10/20/2021. Findings: 1. A home study addendum, reviewed in the record, was dated 05/22/2021. 2. The addendum was not signed until 10/20/2021. 3. AR1 and AR2 confirmed that the addendum was not signed until 10/20/2021.
Plan of Correction:	Director will retrain foster parent coordinators to ensure any home study addendum is completed timely.