VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Adore Children and Family Services
801 N. Pitt Street
Suite 116
Alexandria, VA 22314
(703) 582-7304

Current Inspector: Irvin Goode (804) 543-5188

Inspection Date: Sept. 9, 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 22VAC40-191 Background Checks for Child Welfare Agencies

Technical Assistance:

Licensing Specialist discussed qualifications for child placing supervisor with the executive director as outlined in 22 VAC40-131-140.E.

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 monitoring inspection was initiated on 09/9/2020 and concluded on 09/21/2020. The executive director was contacted by telephone to initiate the inspection. The agency reported 5 children in care and 11 approved provider homes. The inspector emailed the executive director a list of items required to complete the inspection. The inspector reviewed 2 provider home records, 1 child record and15 staff records. Background checks for 7 additional provider homes were reviewed. Two employees were interviewed. The agency submitted Covid-19 policies and procedures. An exit interview was conducted by telephone on 09/18/2020 at approximately 11:40 am with the executive director and the assistant 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 5 citations for violation 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 #:	22VAC40-131-110
Description:	Violation: Based on a review of documents provided for the inspection, the licensee failed to ensure all information received documented date received. Findings: The medical examination completed on 5/25/20 for FC1 failed to document the date received. The educational degree for Staff (S) S3 failed to document date received. The search of the central registry and criminal record check for S7 failed to document date received.
Plan of Correction:	ADORE will re-train all staff to date documents when they are received. by ADORE staff. ADORE's Compliance manager will ensure all doucments
Standard #:	22VAC40-131-160-B
Description:	Violation: Based on review of S15's record, the licensee failed to ensure a copy of the educational degree was included in the personnel record as required by 22 VAC-40-131-160-B.2. Findings: S15 was hired on 4/9/20. At the time of review, S15's record failed to document a copy of the educational degree/diploma.
Plan of Correction:	ADORE will re-train all recruiters, home study writers and compliance manager to secure latest diplomas from all staff for employment. The Compliance manager will be responsible for ensuring diplomas are in staff files.
Standard #:	22VAC40-131-340-E-4
Description:	Violation: Based on review of the individualized service plan for FC1, the licensee failed to ensure the anticipated targets dates for identified goals in the service plan included the month, day and year. Findings: FC1 was placed with the licensee on 5/25/20. The individualized service plan for FC1 is dated 6/5/20. The service plan documents "ongoing" as the target date for all goals on the service plan.
Plan of Correction:	ADORE will ensure that the target date for ISP goals include the month, day and year. ADORE's clincial director and case managers will be re-trained. ADORE's clinical director will ensure all ISP's target dates include month, day and year.
Standard #:	22VAC40-131-350-B
Description:	Violation: Based on review of the quarterly progress report, medical reports, and contact notes for FC1 and interviews with the executive director and case manager for FC1, the licensee failed to list all medical treatment received and progress made toward each goal identified on the service plan in the quarterly progress report as required by 22 VAC 40-131-350-B-12. Findings: The service plan for FC1 identifies (1) "meeting all developmental milestones and (2) "meet all height and weight milestones and grow in a healthy manner" as goals. The quarterly progress report covering 5/25/20 to 8/23/20 fails to address the progress made on these goals. Contact note for 7/16/20 documents that FC1 had a well child exam on 7/13/20 and a skeletal evaluation is pending. FC1's record documents a well child exam was completed on 8/21/20. None of these medical treatments were listed in the quarterly progress report for the period covering 5/25/20 to 8/23/20. During an interview with the executive director and case manager for FC1 it was acknowledged that FC1 received medical treatment not documented on the quarterly progress report. During the exit interview with the executive director, it was acknowledged that all goals and progress were not documented on the quarterly progress report.
Plan of Correction:	ADORE will revise its quarterly report to include the requirement for listing all medical treatment dates and the progress toward each goal. ADORE' Clinical director will ensure all medical dates and progress made on goals are included in the Quarterly summary.
Standard #:	22VAC40-191-40-D-1-b
Description:	Violation: Based on review of the records for Staff (S) S3, S7 and S15, the licensee failed to ensure background checks were completed as required. Findings: S3 was hired on 4/6/20.The sworn statement for S3 is dated 5/29/20-aftter the first day of employment. S7 was hired on 5/4/20. The search of the central registry for S7 is dated 6/9/20-beyond 30 days of employment. S15 was hired on 4/9/20. The search of the central registry for S15 is dated 5/29/20-beyond 30 days of employment. The criminal record check for S15 is dated 6/3/20-beyond 30 days of employment.
Plan of Correction:	All background checks for staff will be completed prior to employment. (date of Hire)The Compliance manager will be responsible for ensuring background checks are completed.