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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: Nov. 4, 2021

Complaint Related: No

Areas Reviewed:
22VAC40-131 PERSONNEL
22VAC40-131 PROGRAM STATEMENT
22VAC40-131 PROVIDER HOMES
22VAC40-131 CHILDREN'S SERVICES
22VAC40-131 ADDITIONAL REQUIREMENTS FOR SPECIFIC PROGRAMS
63.2 Licensure and Registration Procedures
22VAC40-191 Background Checks for Child Welfare Agencies

Comments:
A monitoring inspection was initiated on 11/4/21 and concluded on 11/08/21. The regional director was contacted by telephone to initiate the inspection. The regional director reported that the current census was 34 children in care and 36 approved provider homes. The inspector emailed the regional director a list of items required to complete the remote documentation review portion of the inspection.

The inspector reviewed 4 children records, and 4 provider home records. Background checks for 2 additional provider homes and 4 staff were reviewed. The regional director and human resources recruiter were interviewed during the inspection.

An exit interview was conducted with the regional director, assistant director of quality improvement and risk management, associate vice president of programs, and human resources recruiter on 11/08/21 at approximately 3:30 pm where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection.

Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:
Standard #: 22VAC40-191-40-D-5
Description: Violation:
Based on review of the record for Provider Home (PH), PH1 and interview with the regional director, the licensee failed to ensure the required background checks were dated no more than 90 days prior to approval.

Findings:
PH1 was approved by the licensee on 7/29/21. PH1?s home study and face sheet documents four household members (OHM) reside in the home that are required to complete background checks.

OHMI?s central registry finding is dated 10/13/19 which is more than 90 days prior to the date of PH1?s approval.

OHM2?s national criminal record check is dated 4/3/17 and OHM2?s criminal record check is dated 5/22/20, which are more than 90 days prior to the date of PH1?s approval.

OHM2?s central registry finding is dated 5/29/20, which is more than 90 days prior to the date of PH1?s approval.

OHM3?s central registry finding is dated 2/8/21, which is more than 90 days prior to the date of PH1?s approval.

OHM4?s central registry finding is dated 10/3/19, which is more than 90 days prior to the date of PH1?s approval.

During an interview with the regional director, it was acknowledged the requirement to complete new background checks for the other household members for PH1?s approval was overlooked.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-191-60-C-1
Description: Violation:
Based on review of background checks for Staff (S) S1 and interview with the regional director and human resources recruiter, the licensee failed to ensure a criminal record check was completed on S1.

Findings:
S1 started her internship with the licensee on 8/23/21.

During the inspection the criminal record check for S1 was requested for review. The licensee did not provide a criminal record check for S1.

During an interview with the regional director, it was acknowledged that a criminal record check was not completed for S1.

Plan of Correction: Not available online. Contact Inspector for more information.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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