VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cabrini Children's Center: Commonwealth Catholic Charities
2250 Pump Road
Richmond, VA 23233
(804) 362-0063

Current Inspector: Dawn Espelage (540) 759-8852

Inspection Date: May 26, 2020 and May 29, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-151 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 DISASTER OR EMERGENCEY PLANNING

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 May 26, 2020 and concluded on May 29, 2020. The Program Manager was contacted by telephone to initiate the inspection. The Program Manager reported that the current census was 0. The inspector emailed the Program Manager a list of items required to complete the inspection. The inspector reviewed one resident record and three personnel records to include background investigation information, the daily log, progress notes, case management notes, emergency drill documentation, and menus, submitted by the facility to ensure documentation was complete. The Program Manager was interviewed during the inspection. Exit meeting was held with the Program Manager and Program Director via telephone on May 29, 2020. 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. The Licensing Inspector reviewed with the provider COVID-19 Essential Guidance for Children?s Residential Facilities. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return to the Licensing Office within 5 business days from receipt of the inspection documentation. You will need to specify how the deficient practice will be or has been corrected (merely writing the word corrected is not acceptable). Your plan of correction must contain the steps to correct the noncompliance with the standard(s), the measures to prevent the noncompliance from occurring again; and the position responsible for implementing each step and/or monitoring any preventive measure(s). The licensee should retain a copy to be posted at the facility. Results of the inspection documentation are subject to public disclosure and will be posted on the VDSS website within 5 days, regardless of whether the Plan of Correction is completed.

Violations:

Standard #:	22VAC40-151-190-B-1
Description:	Violation: Based on review of the personnel record for Staff S3 and interview with agency representative AR1, a TB (Tuberculosis) screening assessment was not documented. Findings: 1. A TB screening assessment was not documented in the personnel record for S3. 2. During an interview with the Licensing Specialist, AR1 confirmed that a TB screening assessment had not been completed. According to AR1, S3 has not worked in the facility since March 2020 and the TB screening assessment will be completed prior to S3's return to work.
Plan of Correction:	Employee was contacted by Human Resources Manager with instructions to complete the TB assessment. Employee was informed by Program Manager, they could not return to work until the TB assessment was completed. Program Manager discussed process with Human Resources Manager. It is now clear that all employees at the Cabrini Shelter must have a TB assessment before working in facility. Identified employee has appointment to complete the TB assessment.. Test was completed and results will be documented on 6/5/20 Program Manager discussed with Human Resources Manager that TB assessments will be included in all New Employee requirements. Going forward Program Manager will ask for verification from Human Resources Manager that the new employee has completed this process.
Standard #:	22VAC40-151-240-B-9
Description:	Violation: Based on review of the training records for Staff S2 and interview with agency representative AR1, training in suicide prevention, appropriate siting, and good neighbor policies and community relations was not documented. Findings: 1. Training records did not document training in these required regulations. 2. During an interview with the Licensing Specialist, AR1 reported that the training had been completed but was not documented in the training records.
Plan of Correction:	Zoom meeting with Program Manager and Training Coordinator to discuss onboarding of new employees and ensuring training documentation is competed. Going forward >On first day of hire, the employee will meet with Program Manager and Training Coordinator for a training orientation meeting. The training process will be discussed, the trainee will be set up at a work station, and the documentation will be discussed. At the end of each training day the completed documentation will be handed to the Training Coordinator. The Program Manager and Training Coordinator will meet at minimum once per week to discuss the progress and to identify any challenges.Upon completion of all training, the completed documentation will be signed and submitted to Human Resources Manager to be placed in the employee?s personnel file. As to the identified employee in this inspection, she will go back and complete missing training and will submit completed documentation to Program Manager by 6/5/20 . The Program Manager will submit to Training Coordinator and will follow up for verification from Human Resources Manager in one week. March - Just prior to the Pandemic, we established a weekly meeting with all persons involved in case management. During these meetings files will be reviewed for documentation. Zoom meeting with Case Managers, and Program Manager to discuss files reviews and documentation
Standard #:	22VAC40-151-640-E
Description:	Violation: Based on review of the resident's record for resident, R1, and interview with agency representative AR1, reason for discharge was not documented on the face sheet. Findings: 1. Reason for discharge was not documented on R1's face sheet. 2. During an interview with the Licensing Specialist, AR1 confirmed that this information had been omitted from the face sheet.
Plan of Correction:	Just prior to the Pandemic, we established a weekly meeting with all persons involved in case management. During these meetings files will be reviewed for documentation. Zoom meeting with Case Managers, and Program Manager to discuss files reviews and documentation
Standard #:	22VAC40-151-660-F
Description:	Violation: Based on review of the individualized service plan for resident, R1, and interview with agency representative AR1, the plan did not include the signature of the person who developed it. Findings: 1. The service plan did not include the signature of the person who developed it. 2. During an interview with the Licensing Specialist, AR1 confirmed that the signature was missing from the service plan.
Plan of Correction:	Zoom meeting with Case Managers, Administrative Assistant and Program Manager to discuss files reviews and documentation. All completed reports will be printed out and signed by Case Managers and submitted to Program Manager for review and signature. The completed report will be given to Administrative Assistant to be files in the case record. Weekly case management meetings and file reviews. Meetings will include Case Managers and Program Manager at minimum. To begin when children are admitted. Quarterly review of case files by CCC QA Coordinator
Standard #:	22VAC40-151-680-G-1-f
Description:	Violation: Based on review of the discharge summary for resident R1 and interview with agency representative AR1, the signature of the person preparing the discharge summary was not documented. Findings: 1. The discharge summary did not document the signature of the person preparing it. 2. During an interview with the Licensing Specialist, AR1 confirmed that the signature was missing from the discharge summary.
Plan of Correction:	Zoom meeting with Case Managers, Administrative Assistant and Program Manager to discuss files reviews and documentation. All completed reports will be printed out and signed by Case Managers and submitted to Program Manager for review and signature. The completed report will be given to Administrative Assistant to be files in the case record. Weekly case management meetings and file reviews. Meetings will include Case Managers and Program Manager at minimum. To begin when children are admitted. Quarterly review of case files by CCC QA Coordinator