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 15, 2022

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 63.2 General Provisions. 22VAC40-191 Background Checks for Child Welfare Agencies

Comments:

An onsite, unannounced, renewal inspection was conducted on March 15, 2022 from 10:00 am to 2:00 pm. The agency reports 4 children currently placed and 8 approved providers. During this inspection, one foster child record was reviewed and four personnel records were reviewed. Two foster home records were reviewed. Background checks were reviewed for four additional foster families approved since the last inspection. Background checks and references were reviewed for a corporate officer and an agent in compliance with regulations regarding renewal inspections. There were 13 citations for violations of the Standards for Child-Placing Agencies. They were key health and safety standards. 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 #:	22VAC40-131-180-F
Description:	Violation: Based on the review of a foster home record (FH-2) and an interview with an agency representative (AR-1), the agency failed to conduct at least one face to face interview with all individuals that reside in the home of the applicants. Evidence: 1) The certificate of approval contained in the foster home record of FH-2 documented their approval on 2/12/22. Three face to face interviews with each adoptive parent were documented in the homestudy. The homestudy documented a phone call on 1/06/22 with the adult child residing in the home. No face to face interview was documented with the adult child residing in the home. 2) In a preliminary findings interview on 3/15/22, AR-1 acknowledged that there was no face to face visit with each individual residing in the home as required.
Plan of Correction:	Training and Licensing Specialist will be briefed regarding this violation and reminded of the face to face interview requirements when licensing foster homes. Executive Director/Director will not approve home studies and/or licenses if face to face interviews have not been completed with all members of the household. Training and licensing specialist will be required to complete missing face to face interviews prior to approval.
Standard #:	22VAC40-131-200-A-2
Description:	Violation: Based on the review of two foster home records (FH-1 and FH-2) and an interview with an agency representative (AR-1), the agency failed to complete and document all required components of the home studies. Evidence: 1) Certificates of approval contained in the records of FH-1 and FH-2 document approval on 2/11/22 and 2/12/22 respectively. Pre-service training PRIDE certificates documented that both foster families completed PRIDE training prior to their approval. 2) There was no documentation in the files of FH-1 and FH-2 that the pre-service training included the twenty two core competencies required by 22VAC40-131-210.A.1. through 22. 3) In a preliminary findings interview on 3/15/22, AR-1 acknowledged that there was no documentation contained in the foster home files regarding the specific core competencies as required.
Plan of Correction:	A document outlining the 22 core competencies required for pre-service training has been created in order for foster parents to initial and date when they have completed specific competencies following sessions. This completed document will be placed in each foster parent file moving forward.
Standard #:	22VAC40-131-260-A
Description:	Violation: Based on a review of the foster child?s record (FC-1) and an interview with an agency representative (AR-1), the agency failed to complete a social history on each child within 45 days of the date of the child?s placement. Evidence: 1) The "Intake and Preplacement Form" contained in the record of FC-1 documents that the child was placed on 12/21/21. There was no social history contained in the record of FC-1. 2) In a preliminary findings interview on 3/15/22, AR-1 acknowledged that she did not know whether or not a social history had been completed.
Plan of Correction:	Social histories will be completed on each child within 45 days of placement and it will be saved to the child?s online case file. Social Worker will note 45th day after placement on a calendar as a reminder that the social history is required to be completed by that date. Social Work Supervisor will remind Social Worker during each weekly supervision session of the upcoming deadline until the social history is complete and saved into the child?s file. Social Work Supervisor will verify document has been saved to appropriate file. FC-1?s social history was completed during the initial 45 days of placement. Social Worker had not saved the document to the child?s file. Document was saved to the file 3/16/22.
Standard #:	22VAC40-131-280-A
Description:	Violation: Based on a review of the foster child?s record (FC-1) and an interview with an agency representative (AR-1), the agency failed to have a written foster home agreement with the family (FH-3) for each child in care. Evidence: 1) The "Intake and Preplacement Form" contained in the record of FC-1 documents that the child was placed on 12/21/21. There was no foster home agreement contained in the record of FC-1. 2) In a preliminary findings interview on 3/15/22, AR-1 acknowledged that there was no foster home agreement contained in the record and that she did not know if an agreement had been completed.
Plan of Correction:	The foster home agreement was completed at the time of placement, however it was not placed in the child?s record. The agreement has since been placed in the child?s record. Director/Executive Director will conduct monthly audits of children?s records to ensure all required documents are contained in the child?s record. Social worker will place required documents in child?s record within 24 hours of completion.
Standard #:	22VAC40-131-290-E
Description:	Violation: Based on a review of the foster child's record (FC-1) and an interview with an agency representative (AR-1), the child did not have a dental examination. Evidence: 1) The "Intake and Preplacement Form" contained in the record of FC-1 documents that the child was placed on 12/21/21. There was no dental examination contained in the record of FC-1. 2) In a preliminary findings interview on 3/15/22, AR-1 acknowledged that she did not know whether or not a dental examination had been completed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-131-340-A
Description:	Violation: Based on a review of the foster child?s record (FC-1) and an interview with an agency representative (AR-1), the agency failed to develop and implement an individualized service plan for every child accepted for care and service. Evidence: 1) The "Intake and Preplacement Form" contained in the record of FC-1 documents that the child was placed on 12/21/21.There was no service plan contained in the record of FC-1. 2) In a preliminary findings interview on 3/15/22, AR-1 acknowledged that she did not know whether or not a service plan had been completed.
Plan of Correction:	The Social Worker will develop and implement a service plan for every child accepted for care and service. FC-1 has a service plan on record. Social Worker had not saved plan to client?s case record. The plan was saved to the child?s record on 3/16/22. Social Worker will save all documentation related to children in care to his/her case record within 24 hours of completion. Executive Director and/or Director will complete monthly audits of client records to ensure compliance.
Standard #:	22VAC40-131-370-Q
Description:	Violation: Based on a review of the foster child?s record (FC-1) and an interview with an agency representative (AR-1), the narrative case notes for FC-1 were not current within 30 days, documented in the file of the child in chronological order, or signed and dated by the individual making the entry. Evidence: 1) The "Intake and Preplacement Form" contained in the record of FC-1 documents that the child was placed on 12/21/21. The last contact note contained in the file was dated 12/28/21 for FC-1. 2) In a preliminary findings interview on 3/15/22, AR-1 acknowledged that she did not know if the contact notes since 12/28/21 had been completed.
Plan of Correction:	1. The contact notes for FC-1 were up to date, however they were not saved in the online portal. Executive Director and Program Director will conduct regular audits of client files on a monthly basis to ensure documentation is up to date. Social Worker will enter all contact notes in online file to ensure they are saved in real time and no transfer is needed.
Standard #:	22VAC40-191-40-D-1-a
Description:	Violation: Based on a review of an agent record (A-1) and an applicant record (CO-1) and email exchanges with an agency representative (AR-1), the agency failed to obtain a central registry search for an agent/employee. The agency failed to obtain a sworn statement, central registry search, and a criminal history record check for an applicant. Evidence: 1) A-1 and CO-1 were listed on the renewal application received by the department on 3/18/22. In an email on 3/21/22, this licensing specialist requested central registry searches, criminal history record checks, and sworn statements for A-1 and CO-1 from AR-1. 2) No central registry finding was provided for A-1. 3) No sworn statement, criminal history record check, or central registry finding was provided for CO-1. 4) In an email dated 3/30/22, AR-1 verified that CO-1 was appointed on 5/12/21 and A-1 started on 11/30/20. AR-1 stated in an email on 3/31/22, that these background check requests were sent out in the mail on 3/31/22.
Plan of Correction:	Executive Director and/or Director will not allow any agents or applicant to begin work until all necessary background checks have been completed and Executive Director has verified this information with Human Resources Generalist or Director. Executive Director will meet with Director, HR Director, and HR Generalist upon their hiring to review licensing standards/regulations regarding clearances and paperwork including sworn statements for agents and applicants to ensure compliance.
Standard #:	22VAC40-191-40-D-1-b
Description:	Violation: Based on a review of two personnel records (P-2, P-3) and an interview with an agency representative (AR-1) and email exchanges with agency representatives (AR-1 and AR-2), the agency failed to obtain a sworn statement, a central registry finding and a criminal history record check for one employee. The agency failed to obtain a criminal history record check before 30 days of employment ended for a second employee. Evidence: 1) There was no criminal history check, central registry finding, or sworn statement in the personnel file of P-3. 2) The criminal history check results for P-2 were dated seven weeks after P-2 began employment at the agency. 3) In a preliminary findings interview on 3/15/22, AR-1 acknowledged that the background check contained in the record for P-2 was not in compliance with the regulations and that there were no background checks for P-3. 4) An email was sent to AR-2 on 3/21/22 requesting a criminal history check, central registry finding, and sworn statement for P-3. AR-1 stated in an email on 3/31/22, that these background check requests were sent out in the mail on 3/31/22.
Plan of Correction:	Executive Director and/or Director will not allow any personnel or agency representatives to begin work until all necessary background checks and paperwork have been completed and Executive Director has verified this information with Human Resources Generalist or Director. Executive Director will meet with Director, HR Director, and HR Generalist upon their hiring to review licensing standards/regulations regarding clearances and paperwork including sworn statements for all personnel and agency representatives to ensure compliance.
Standard #:	22VAC40-191-40-D-5
Description:	Violation: Based on a review of a personnel record (P-1), an interview with an agency representative (AR-1), and an email exchange with an agency representative (AR-2), the agency accepted a criminal history record report and a central registry finding for P-1 that were dated more than 90 days prior to the date of employment for P-1. Evidence: 1) The criminal history record check and the central registry finding in the personnel file of P-1 were dated more than 6 months prior to P-1's start date. 2) In a preliminary findings interview on 3/15/22, AR-1 clarified the start date and acknowledged that the criminal history check and central registry search were dated more than 6 months prior to the start date of P-1.
Plan of Correction:	Executive Director and/or Director ensure HR Team is in receipt of all regulations that must be followed in regard to timeframes for clearances and start dates. Executive Director will meet with Director, HR Director, and HR Generalist upon their hiring to review and highlight sections licensing standards/regulations regarding clearances and for all personnel and agency representatives to ensure compliance.
Standard #:	22VAC40-191-60-C-1
Description:	Violation: Based on a request for a criminal history check for a volunteer (V-1) and email exchanges with agency representatives (AR-1 and AR-2), the volunteer continued to provide services to the agency when the agency had not obtained a criminal history record check . Evidence: 1) AR-1 forwarded an email to this licensing specialist from V-1 on 3/18/22 to provide additional information following the inspection on 3/15/22. In the email, V-1 was requesting paperwork from a foster family. V-1 was not listed on the staff information sheet. 2) An email was sent to AR-2 on 3/21/22 requesting a criminal history check for V-1. No criminal history check was provided. 3) In an email dated 3/30/22, AR-1 verified that V-1 began volunteer service at the agency on 9/15/21. 4) AR-1 stated in an email on 3/31/22, that the background check request for V-1 was sent out in the mail on 3/31/22.
Plan of Correction:	Executive Director and/or Director will not allow any volunteers to begin work until all necessary background checks have been completed and Executive Director has verified this information with Human Resources Generalist or Director. Executive Director will meet with Director, HR Director, and HR Generalist upon their hiring to review licensing standards/regulations regarding clearances for volunteers to ensure compliance.
Standard #:	22VAC40-191-60-C-2
Description:	Violation: Based on a request for a central registry finding for a volunteer (V-1) and email exchanges with agency representatives (AR-1 and AR-2), the volunteer continued to provide services to the agency when the agency had not obtained a central registry finding. Evidence: 1) AR-1 forwarded an email to this licensing specialist from V-1 on 3/18/22 to provide additional information following the inspection on 3/15/22. In the email, V-1 was requesting paperwork from a foster family. V-1 was not listed on the staff information sheet. 2) An email was sent to AR-2 on 3/21/22 requesting a central registry search for V-1. No central registry search was provided. 3) In an email dated 3/30/22, AR-1 verified that V-1 began volunteer service at the agency on 9/15/21. 4) AR-1 stated in an email on 3/31/22, that the central registry search request for V-1 was sent out in the mail on 3/31/22.
Plan of Correction:	Executive Director and/or Director will not allow any volunteers to begin work until all necessary background checks have been completed and Executive Director has verified this information with Human Resources Generalist or Director. Executive Director will meet with Director, HR Director, and HR Generalist upon their hiring to review licensing standards/regulations regarding clearances for volunteers to ensure compliance. Executive Director will submit clearance results to VA DSS Monitor upon receipt.
Standard #:	63.2-901.1 B-3
Description:	Violation: Based on a review of a foster home record (FH-6) and interview with an agency representative (AR-1), the agency failed to obtain a search of the child abuse and neglect registry maintained by any other state in which the individual has resided in the last five years for an adult child (AC-1) living in the home. Evidence: 1) AC-1 completed a sworn statement dated 9/26/21 documenting that AC-1 had resided in a state other than Virginia within the last five years. 2) There was no a search of the child abuse and neglect registry maintained by the other state contained in the foster home record of FH-6. 3) In a preliminary findings interview on 3/15/22, AR-1 acknowledged that she did not know whether or not a search of the central registry from the other state had been requested for AC-1.
Plan of Correction:	Foster home licenses will not be approved by Director and/or Executive Director without all required paperwork. All required licensing paperwork will be saved to the online shared drive in the foster parent file for review upon request for license approval. Upon a thorough search of former and current employee emails and files, evidence of receipt of the record from the other state of residence (Minnesota) could not be located. Foster parent was able to provide evidence of submission of the request. A new request for child abuse and neglect registry search in the state of Minnesota has been submitted. LSSNCA is awaiting results.