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: April 5, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN'S SERVICES 22VAC40-191 Background Checks for Child Welfare Agencies

Technical Assistance:

LI, discussed with the executive director contacting the local building code authorities to ensure PH1 is in compliance with relevant state or local laws per, 22VAC40-131-40 due to an additional room being added to the lower level of a provider home.

Comments:

An unannounced complaint inspection was conducted on 4/5/2022 from approximately 10:30 am to 2:55 pm at the office of Adore Children and Family Services located in Alexandria. The complaint related to background checks for individuals residing in a provider home. The agency reported 11 children in care and 20 approved provider homes. The executive director and general compliance manager were available to answer questions throughout the inspection. The inspector reviewed 2 provider home records and interviewed 3 employees. Contact notes for 1 discharged youth were reviewed and one provider was interviewed as part of this inspection. An exit interview was conducted on 4/5/22 at approximately 2:30 pm with the executive director and the general compliance manager to discuss preliminary inspection findings. An acknowledgement form was left with the executive director. A meeting was held with the executive director and general compliance manager via telephone on 4/11/22 to discuss the validity of the complaint and final inspection findings. 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. The complaint is deemed as valid. There were four (4) citations for violation of the Standards for Licensed 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 #:	22VAC40-131-180-N
Complaint related:	No
Description:	Based on review of the record for Provider Home (PH) PH1 and interviews with agency representatives (AR) and Provider (P) P1, the licensee failed to document an addendum to the home study. Findings: PH1?s record documented an updated floor plan that includes an additional downstairs bedroom. A contact note dated 3/9/22 for PH1 and signed by AR3, documents a change in PH1?s family composition. The contact note documents that AR3 informed P1, that background checks are required due to the change in the family composition. During the licensing inspector's interview with Agency Representative (AR) AR1 on 4/5/22, ARI informed licensing inspector, that PH1 was ?on hold?. When asked to explain why PH1 was ?on hold?, ARI stated that PH1 was ?on hold? due to wanting a break and the licensee was attempting to determine what is going on with additional individuals residing in the home. The record for PH1 did not document an addendum to PH1's home study as required to document significant change to PH1's original approval. During the licensing inspector's interview with AR4 on 4/5/22, AR4 acknowledged having a telephone conversation with Provider (P) P1 in PH1 during the week of 3/28/22 and P1 reported that her adult sister continues to reside in the home. During the licensing inspector's interview with Provider (P) P1 on 4/11/22, when asked when the licensee was made aware of her adult sister residing in the home, P1 responded that her sister moved into her home in November 2021, and that AR4 knew her sister and her 2 children were residing in the home. P1 also acknowledged that her sister and 2 children continue to reside in her home.
Plan of Correction:	The CM has been disciplined for failure to complete an addendum to the home study reflecting the change in home and family composition. The home is suspended. The LCM and staff trainer have retrained the CM in the standards and requirements when there is a change in the foster home. The LCM will ensure CM?s maintain all foster homes and files.
Standard #:	22VAC40-131-370-M-12
Complaint related:	No
Description:	Based on review of the record for PH1, the licensee failed to list all names and dates of birth of all members of the household and the relationship of each member to the provider. Findings: A contact note dated 3/9/22 for PH1 and signed by AR3 documents a recent change in PH1?s family composition. PH1?s record documented an updated floor plan that includes an additional downstairs bedroom. During the licensing inspector's interview with AR4 on 4/5/22, AR4 acknowledged having a telephone conversation with Provider (P) P1 in PH1 during the week of 3/28/22 and P1 reported that her adult sister continues to reside in the home. During the licensing inspector's interview with Provider (P) P1 on 4/11/22, when asked when the licensee was made aware of her adult sister residing in the home, P1 responded that her sister moved into her home in November 2021, and that AR4 knew her sister and her 2 children were residing in the home. P1 also acknowledged that her sister and 2 children continue to reside in her home. The face sheet in the record for PH1 did not document the names of PH1's adult sister and 2 children.
Plan of Correction:	The CM was disciplined for failure to maintain the foster parent file. The LCM, CM and Case aides were retrained on maintenance of the foster home file. The LCM will ensure the face sheet of the foster parent files are maintained pursuant to this Standard.
Standard #:	22VAC40-191-40-D-3
Complaint related:	Yes
Description:	Based on review of the record for Provider Home (PH) PH1 and interviews with Provider (P) P1 and Agency Representative, (AR) AR4, the licensee failed to ensure a sworn disclosure statement or affirmation, a search of the central registry and a national criminal background check were completed. Findings: PH1 is a two parent provider home and was approved to provide foster care services by the licensee on 9/16/20. The placement log for PH1, documents a youth was placed with PH1 from 4/30/21 to 3/15/22. A contact note dated 3/9/22 for PH1 and signed by AR3, documents a change in PH1?s family composition. The contact note documents that AR3 informed P1, that background checks are required due to the change in the family composition. During the licensing inspector's interview with Provider (P) P1 on 4/11/22, when asked when the licensee was made aware of her adult sister residing in the home, P1 responded that her sister moved into her home in November 2021 and that AR4 made her aware that background checks would need to be completed. During the licensing inspector's interview with AR4 on 4/5/22, AR4 acknowledged having a telephone conversation with Provider (P) P1 in PH1 during the week of 3/28/22 and P1 reported that her sister continues to reside in the home. The record for PH1 did not document background checks for P1?s adult sister. During the 4/11/22 interview with PH1, it was acknowledged that her sister had not completed background checks and that her sister continues to reside in the home.
Plan of Correction:	The home has been suspended and the CM disciplined for the failure to follow up and secure required background checks for the change in the family composition. The suspension of the home will not be lifted until either background checks are completed or the additional persons leave the home permanently. The Lead Case Manager, all CM?s and Intake coordinator have been retrained to inquire about family composition, document, and follow up when a family has visitors. The Intake Coordinator will notify the LCM and and appropriate CM when they receive information regarding a change in a families composition. CM has been retrained in home visit narrative documentation and quarterly home summary documentation. The staff trainer and compliance director have ensured trainings are complete. The Lead CM and Compliance manager will ensure compliance with this standard.
Standard #:	22VAC40-191-40-D-4-a
Complaint related:	Yes
Description:	Based on review of Provider Home (PH) PH1, and an interview with P1, the licensee failed to ensure a search of the central registry was completed. Findings: PH1 is a two parent provider home and was approved by the licensee to provide foster care services on 9/16/20. The placement log for PH1, documents a youth was placed with PH1 from 4/30/21 to 3/15/22. The face sheet in the record for PH1 documents that Other Household Member (OHM) OHM1 resides in PH1. OHM1 is 15 years of age and at the time of the inspection, the record for PH1 did not document a search of the central registry for OHM1. A contact note dated 3/9/22 for PH1 and signed by AR3, documents a change in PH1?s family composition. The contact note documents that AR3 informed P1, that background checks are required due to the change in the family composition. During the licensing inspector's interview with Provider (P) P1 on 4/11/22, when asked when the licensee was made aware of her adult sister residing in the home, P1 responded that her sister moved into her home in November 2021, and that AR4 made her aware that background checks would need to be completed. P1 also acknowledged that AR4 knew her sister?s 2 children were residing in the home. When asked the ages of her sister?s children, P1 replied 17 and 7 years old. P1 acknowledged that AR4 visited her home on at least 2 occasions where he met her sister and the children. P1?s sister and her 2 children continue to reside in PH1. The record for PH1 did not document a search of the central registry for the 17 year old residing in PH1.
Plan of Correction:	The home has been suspended and the CM disciplined for failure to maintain the foster home and secure required background checks for children over 14. The Lead CM, CM?s and Case Aides have been retrained to add all household members into the MIS along with their dates of birth. The MIS has been adjusted to give an alert 60 days prior to when children turn 14 and 30 days prior to turning 18. They have also been retrained to review the status of family members during home visits and on the Quarterly summary. The Lead CM and Compliance manager will ensure compliance with this standard.