VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lutheran Family Services of Virginia, Inc. operating as enCircle
11818 Rock Landing Drive
Suite 207
Newport news, VA 23606
(757) 722-4707

Current Inspector: Sherry Woodard (757) 987-0839

Inspection Date: Oct. 16, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-131 PERSONNEL 22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN'S SERVICES 63.2 General Provisions.

Comments:

An unannounced monitoring inspection was conducted on October 16, 2019 8:45 am to 3:30 pm at Lutheran Family Services of Virginia located 11832 Rock Landing Drive, Newport News, Virginia, 23606. The agency reports 6 children in foster care placement and 18 approved provider homes. The Regional Manager for Foster Care and Adoption was available for the inspection. The Regional Manager for Foster Care and Adoption, the Program Supervisor, and the Director of Foster Care and Adoption were present for the exit interview at 2:40 pm on October 16, 2019. During this inspection, the following actions were taken: 1.Reviewed two (2) complete children records. 2.Reviewed two (2) complete provider home records. 3.Reviewed two (2) new employee records. 4.Background checks and references for all board officers were reviewed. 5.A physical plant inspection was conducted. 6.Interviews were conducted. 7. Policy and Procedures were reviewed. There were two (2) citations for violations of the Standards for Child Placing Agencies. An Acknowledgement Form was signed by the Regional Manager for Foster Care on October 16, 2019 during the exit interview which was held at 2:40 pm. The exit interview was held with the Regional Manager, Program Director and Quality Officer. 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.

Violations:

Standard #:	22VAC40-131-290-C-6
Description:	Violation: Based on the review of the foster child record (FC2) and based on an interview with agency representatives, the licensee failed to obtain a medical examination that included an assessment of auditory acuity. Evidence: (1)The foster child record for FC2 contained a medical examination dated 07/29/2019 which documented that auditory acuity was ?not assessed.? All medical documentation located in the file and there was no other documentation which documented that FC2?s auditory acuity was assessed. (2)Based on an interview with AR2 and AR3 (agency representatives), who reviewed the electronic records, the 07/29/2019 medical examinations did not assess auditory acuity. During the interview AR2 and AR3 confirmed that on the 07/29/2019 medical examination, the examiner checked ?not assessed? for auditory acuity. AR2 and AR3 thoroughly reviewed all medical documentation located in the file and were not able to locate any other documentation which documented that FC2?s auditory acuity was assessed.
Plan of Correction:	Staff will be trained on the importance of reviewing all submitted forms for completion prior to submitting to Supervisors and administrative staff for filing. Supervisors will review forms to ensure all sections are completed fully before filing in the foster child record. Additionally, the medical examination form will be reviewed to determine if any changes need to be made regarding the format to ensure medical professionals answer all questions.
Standard #:	22VAC40-131-340-B-1
Description:	Violation: Based on the review of the foster child records (FC1 and FC2) and based on an interview with the agency representatives, the licensee failed to complete individualized service plans that included specific measurable objectives and strategies describing services to be provided to the children. Evidence: (1)The foster child records for FC1 and FC2 did not contain individualized service plans that included specific measurable objectives and strategies describing services to be provided to the children. (2)During the exit interview, AR2 and AR3 reviewed the foster parent records and determined that the objectives for FC1 and FC2 were not measurable.
Plan of Correction:	Intake staff/all staff will be trained on developing measurable goals for the initial service plan that takes place within 14 days of admission. Supervisors will review initial service plan thoroughly to ensure there are measurable objectives present in the initial service plan.