VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Embrace Foster Care
817 Cedar Creek Grade #202
Winchester, VA 22602
(540) 376-3968

Current Inspector: Kevin Lassiter (804) 241-2093

Inspection Date: Jan. 28, 2020 and Feb. 3, 2020

Complaint Related: No

Areas Reviewed:

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

Technical Assistance:

Technical assistance was provided to the agency on their revised policies and procedures.

Comments:

An unannounced monitoring inspection was completed by two Licensing Specialists on January 28, 2020 from 10:15 a.m. to 4:05 p.m. The agency reported nine (9) children in foster care and eleven (11) approved provider homes. During this inspection one (1) child and three (3) provider home records were reviewed. The Site Director participated in the entrance conference, remained available during the inspection, and participated in the exit interview. The Site Director for the agency?s Fredericksburg office participated in the exit interview by phone. An exit interview was conducted from 3:25 p.m. to 4:10 p.m. An acknowledgment of inspection form was signed and a copy left with the agency at the end of the inspection on 1/28/2020. The agency submitted revised policies and procedures which were reviewed off-site by two Licensing Specialists. An additional exit interview was conducted with the Executive Director on 2/3/2020 to provide technical assistance on the agency?s revised policies and procedures. There were four citations for violations of the Standards for Child-Placing Agencies. See the violation notice on the Department?s public web site for violations of the Standards. Upon receipt of the Violation Notice, the licensee should develop a plan of correction to include the steps to correct non-compliance with the standard(s); measures to prevent re-occurrence of non-compliance; person(s) responsible for implementation and monitoring of preventative measure(s); and date by which noncompliance will be corrected. The licensee has five business days from receipt of the inspection documents to complete the section entitled "Plan of Correction", sign each page of the inspection documents and return to the Licensing Office. The licensee should retain a copy to be posted at the facility. Results of the inspection are subject to public disclosure and will be posted on the Virginia Department of Social Services public web site within five business days, regardless of whether or not the Plan of Correction is completed. The provider?s response(s) for the ?plan of correction? was (were) not received as of (enter date) and will not appear on this Violation Notice.

Violations:

Standard #:	22VAC40-131-110
Description:	Violation: Based on a review of the records for Foster Homes 1 and 3 (FH1 and FH3), the agency failed to indicate the date received on all documents. Findings: The case records for FH1 and FH3 contained Child Protective Services Central Registry search result letters for all applicants. The result letters did not indicate the date the letters were received. Discussion occurred during the exit interview regarding the automated records management document creation date. This date is automatically generated when documents are uploaded to the system. Staff acknowledged the system generated creation date does not always represent the date the material was received.
Plan of Correction:	ED/Site Director will retrain all staff on physical date stamping of all documents coming into the chart.
Standard #:	22VAC40-131-180-G
Description:	Violation: Based on a review of the record for Foster Home 2 (FH2), the agency failed to obtain three references for each applicant. Findings: The record for FH2 contained three references addressing applicant 1 and two references addressing applicant 2. The findings were discussed with agency staff during the exit interview. S1 acknowledged the finding.
Plan of Correction:	Site Director/Case Manager will review all open foster homes to ensure that each foster parent in the home has 3 references (the reference must mention both parents if it is a combined reference). If there are any missing, SD will work with the foster parent coordinator to obtain these references and put an addendum note to the homestudy in the chart. Site Director will review all reference as part of the chart audit prior to certification of a new family.
Standard #:	22VAC40-131-290-C-7
Description:	Violation: Based on a review of the record for Foster Child 1 (FC1), the agency failed to obtain an annual physical examination report that addressed all required elements. Findings: The record for FC1 contained an annual physical examination report that did not address the child?s nutritional status. The finding was discussed with agency staff during the exit interview. S1 reviewed the physical exam report and acknowledged the finding.
Plan of Correction:	ED/Site Director will re-train Case Manager on requirements as it relates to the child?s physical exam, specifically the nutritional status Site Director/Case Manager will review all current client?s physical exams to ensure the nutritional status is completed, and obtain the information for any which may be missing from the doctor?s office.
Standard #:	22VAC40-131-370-M-10
Description:	Violation: Based on a review of the record for Foster Home 1 (FH1), the agency failed to maintain all required documents in the provider case records. Findings: The case record for FH1 did not contain health statements or Tuberculosis screening/test results for either applicant. The agency was able to locate the Health Statements and Tuberculosis screening/test results in hard copy. The documents were in the agency and included date stamps indicating the documents were received prior to the agency approving the home. The documents had not been filed in the case record. The findings were discussed with agency staff during the exit interview. S1 acknowledged the findings.
Plan of Correction:	site Director will review all documents in the EHR system prior to approving the home. A review of all current homes will be completed to ensure health statements and TB screenings/tests are in the EHR for each person in the home