VIRGINIA DEPARTMENT OF SOCIAL SERVICES

United Methodist Family Services
1320 Central Park Blvd.
Suite 310
Fredericksburg, VA 22401
(540) 898-1773

Current Inspector: Dawn Espelage (540) 759-8852

Inspection Date: Feb. 6, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-131 ORGANIZATION AND ADMINISTRATION 22VAC40-131 PERSONNEL 22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN'S SERVICES 22VAC40-131 ADDITIONAL REQUIREMENTS FOR SPECIFIC PROGRAMS 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 63.2 Child Abuse and Neglect 22VAC40-191 Background Checks for Child Welfare Agencies

Comments:

An unannounced renewal inspection was conducted on 2/06/2020 from approximately 9:15 am to 5:10 pm at the Fredericksburg location of United Methodist Family Services (UMFS). The agency reports 25 approved provider homes and 21children in care. During this inspection, one personnel record, three provider home records and three foster child records reviewed. Five additional provider home records were reviewed for compliance with background checks. Background checks for the board officers were reviewed on 12/10/2019 at the Richmond office of United Methodist Family Services and are in compliance. The human resources recruitment and talent manager and the human resources coordinator were present for the exit interview to discuss background check findings for the board officers, which took place on 12/10/19 from 2:00 pm to 2:15 pm. The regional director and program manager were available for the inspection and participated in the exit interview to discuss preliminary findings for the provider homes and children records which commenced at approximaely 4:10 pm on 2/06/2020. There were five violations of the Standards for Licensed Child Placing Agencies. See the violation notice on the Department?s public web site for violation of the Standards. An acknowlegment of inspection form was left with the regional director on 2/06/2020. 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 #:	22VAC40-131-180-F
Description:	Violation: Based on a review of the record for Foster Home (FH) FH1 and interview with the program manager, the licensee failed to ensure each household member was interviewed. Findings: FH1 was approved on 10/28/19. The record documents that other household member (OHM) was residing in the home at the time of approval. The home study fails to document that OHM was interviewed. During an interview with the program manager it was acknowledged that the home study did not document that OHM was interviewed. The record did not document an interview with OHM prior to FH1's approval.
Plan of Correction:	UMFS Fredericksburg Office will complete initial case file reviews on all resource parents prior to approval to include a requirement that all household members are interviewed.
Standard #:	22VAC40-131-180-M
Description:	Violation: Based on review of the record for Foster Home (FH) FH2 and interview the program manager and regional director, the licensee failed to consider all information received prior to making an approval decision. Findings: FH2 was approved on 10/31/19. The certificate of approval in the record documents approval for ages 4-21. The homestudy documents that FH2 has two dogs. The veterinarian statement for one of the dogs states, "she is scared and does try to bite when handled." The veterinarian statement also documents "her aggression issues" are of concern regarding the safety or well being of chidlren in the home and that the dog would not be a good match for children under 12 and "maybe" for children over 12. The home study completed by the licensee documents the same dog is "allowed to roam freely on the property". During the exit interview it was acknowledged by the program manager, that the record failed to document that the dog's aggression and veterinarian statement was considered prior to approval.
Plan of Correction:	Reviews of all veterinarian statements will be completed prior to approval to ensure thorough exploration of pet safety. Safety plans for pets rated as dangerous by veterinarians or as reported by resource parents will be created to address concerns.
Standard #:	22VAC40-131-290-C
Description:	Violation: Based on review of FC1's record and interview with the program manager, the licensee failed to ensure the medical examination included all required information. Findings: FC1 was placed with the licensee on 11/21/19. At the time of review the medical examination documented in the record dated 12/2/19 failed to address FC1's growth and development and evidence of freedom from communicable diseases. During an interview with the program manager, it was acknowledged that the medical examination in the record at the time of review did not address all required elements. The program manager acknowledged that she revised the form by documenting the missing information and placing the revised medical examination form in FC1's record.
Plan of Correction:	Resource parents and TFC social workers will be retrained to ensure that medical forms are filled in their entirety at the visit. Should a form come into the office with blanks, UMFS will request the information from the doctor?s office.
Standard #:	22VAC40-131-350-B
Description:	Violation: Based on a review of the record for Foster Child (FC) FC2 and interviews with the regional director and program manager, the licensee failed to document quarterly reviews as required by the standards. Findings: FC2 was placed with the licensee on 4/11/19. The first quarterly progress review was due to be documented in the record by 7/11/19 and subsequent progress reviews every 90 days thereafter. The record for FC2 documents several monthly reports but fails to document quarterly progress reviews every 90 days as required by the standards.
Plan of Correction:	UMFS Fredericksburg Office will perform case file reviews on all TFC client files every three months, as opposed to the previous process of every 6 months, for one year to ensure all reports are completed in a timely fashion.
Standard #:	22VAC40-131-360-E-3
Description:	Violation: Based on a review of the record for Foster Child (FC) FC3 and interview with the regional director. The licensee failed to include the name of the individual whom the child was discharged. Findings: FC was placed with the licensee on 2/12/18 and discharged on 11/26/19. The discharge summary documented in the record failed to list the name of the individual with whom the child was discharged. During an interview with the regional director, it was acknowledged that the required information was not included in the discharge summary.
Plan of Correction:	A section will be added to the discharge summary to indicate the specific name of the legal guardian whom the child is being discharged to.