VIRGINIA DEPARTMENT OF SOCIAL SERVICES

United Methodist Family Services
6935 Columbia Pike
Annandale, VA 22003
(703) 941-9008

Current Inspector: Kevin Lassiter (804) 241-2093

Inspection Date: Feb. 23, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-131 PERSONNEL 22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN'S SERVICES 22VAC40-131 ADDITIONAL REQUIREMENTS FOR SPECIFIC PROGRAMS 22VAC40-191 Background Checks for Child Welfare Agencies

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. An announced renewal inspection was initiated on 02/23/2021 and concluded on 03/01/2020. The regional director was contacted by telephone to initiate the inspection. The agency reported 15 children are in care, and 22 approved provider homes. The agency reported two new staff since the last inspection. The inspector emailed the regional director a list of items required to complete the inspection. The inspector reviewed 2 children?s records, 3 provider home records, and 2 staff records. One staff was interviewed during the inspection. An exit interview was conducted by telephone on 3/1/2021 at approximately 4:00 pm with the regional director. 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. There were two citations for violations of the Standards for Child-Placing Agencies. 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 #:	22VAC40-131-230-B
Description:	Violation: Based on review of Provider Home (PH) PH2 and interview with Agency Representative (AR) AR1, the licensee failed to monitor the provider home every 90 days. Findings: PH2 was approved by the licensee on 9/22/2020. The first monitoring contact was due by 12/22/2020. At the time of review no monitoring contacts were documented in the record for PH2. During an interview with AR1, when asked where the 90 day contacts were located in PH2's record, AR1 confirmed no monitoring contacts were documented as being completed for PH2.
Plan of Correction:	Following the exit interview the Family Service Coordinator was made aware of the citation and released she had never entered her 90-day monitoring activities for both families into evolve. These visit have subsequently been entered. All current resource family records will be reviewed to ensure all 90-day monitoring events have occurred and are entered into the Evolv EHR system. The Family Systems Coordinator will implement a revised system to ensure all families have documented 90-day monitoring visit with or without a child placed in the home. These activities will be completed by March 15,2021.
Standard #:	22VAC40-131-370-M-11
Description:	Violation: Based on review of the record for Provider Home (PH) PH3 and interview with Agency Representative (AR) AR1, the licensee failed to document the results of observation findings from monitoring visit to PH3. Findings: PH3 was approved by the licensee on 6/29/2020. PH3 had a child placed in the home from 7/27/2020 to 10/31/2020 and again in December 2020. The first monitoring contact was due by 9/29/2020 and the second monitoring contact was due by 12/29/2020. At the time of review the record did not document the required monitoring contacts with PH3. During an interview with AR1, when asked what monitoring contacts were documented in the electronic record for PH3, AR1 confirmed, no contacts were documented in PH3's record.
Plan of Correction:	Following the exit interview the Family Service Coordinator was made aware of the citation and released she had never entered her 90-day monitoring activities for both families into evolve. These visit have subsequently been entered. All current resource family records will be reviewed to ensure all 90-day monitoring events have occurred and are entered into the Evolv EHR system. The Family Systems Coordinator will implement a revised system to ensure all families have documented 90-day monitoring visit with or without a child placed in the home. These activities will be completed by March 15,2021.