VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lutheran Social Services of the National Capital Area
8922 Little River Turnpike
Fairfax, VA 22031
(202) 723-3000

Current Inspector: Kevin Lassiter (804) 241-2093

Inspection Date: March 10, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-131 PERSONNEL 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. A renewal inspection was initiated on 3/10/21. The inspection was concluded on 3/17/21. The agency reports there are currently no children placed. The Program Director was contacted by email to initiate the inspection. The inspector emailed the Program Director a list of items required to complete the inspection. The inspector reviewed documents from 6 personnel records. Background checks for 1 corporate officer and 1 agent were reviewed in compliance with regulations regarding license renewals. An exit interview was conducted on 3/17/21 with the Program Director and the Executive Director. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the agency. Upon receipt of the violation notice, the licensee must develop a plan of correction for each violation. The plan of correction must include the following: 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 non-compliance will be corrected. The licensee has ten (10) calendar days from receipt of the inspection documentation to complete the section entitled "Plan of Correction", sign each page of the Plan of Correction and return it to the Licensing Office. The licensee retains a copy to be posted at the facility. Results of the inspection are subject to public disclosure and will be posted on the VDSS web site within five (5) days, regardless of whether or not the Plan of Correction has been completed.

Violations:

Standard #:	22VAC40-131-160-B-5
Description:	Violation: Based on a review of the performance evaluation for two employees (P-1 an P-2) and an interview with an agency representative, the agency failed to complete annual performance evaluations. Evidence: 1) More than 13 months have passed since P-1 and P-2 received performance evaluations. 2) The agency representative (AR-1) acknowledged that the performance evaluations for P-1 and P-2 were outdated.
Plan of Correction:	Steps to correct non-compliance with standard(s): P-1 and P-2 will complete their performance evaluation within 30 days of this response. Measures to prevent re-occurrence of non-compliance: The agency wide policy for yearly performance evaluations will be enforced by upper management through written policy guidance to managers and yearly written reminders when performance evaluations are due. Person's responsible for implementing and monitoring preventative measures: HR Director Date of Correction: 4/19/2021
Standard #:	22VAC40-191-40-D-1-b
Description:	Violation: Based on a review of the sworn statement submitted by the agency for an employee (P-3) and an interview with an agency representative, the agency failed to obtain a signed sworn statement for P-3 prior to the first day of employment. Evidence: 1) The sworn statement for P-3 was signed 15 days after the first day of employment. 2) The agency representative (AR-1) acknowledged that the sworn statement for P-3 was not obtained prior to the first day of employment.
Plan of Correction:	Steps to correct non-compliance with the standard(s); HR and URM Program Director (PD) will work together to ensure all new hires sign the sworn statement prior to first day of employment. Step 1: HR will forward, collect and review the sworn statement from the new hire for signature before the start date. Step 2: PD will review the new hire's HR file and confirm the sworn statement has been signed before the start date. Measures to prevent re-occurrence of non-compliance: PD will audit the new hire's HR record before their scheduled start date. PD will review the file for all required documents and delay the new hire's start date if the sworn statement has not been signed. Person(s) responsible for implementation and monitoring of preventative measure(s); HR Director and URM Director Date of Correction: effective immediately.