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: Jan. 25, 2024 and Feb. 13, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-151 Administration 22VAC40-151 Residential Environment 22VAC40-151 Programs and Services 22VAC40-151 Programs and Services 22VAC40-151 Disaster or Emergency Planning

Technical Assistance:

Discussed staff development as noted in CRF standard 22 VAC 40-151-250. Discussed housekeeping and maintenance as it pertains to CRF standard 22 VAC 40-151-540.A. Discussed emergency placements as noted in CRF standard 22 VAC 40-151-610.1-3. Discussed information concerning the need for continuing therapeutic interventions as noted in CRF standard 22 VAC 40-151-680.E. Discussed the date the medication was prescribed as noted in CRF standard 22 VAC 40-151-750.F.1. Discussed identification of interventions that may escalate inappropriate behaviors as noted in CRF standard 22 VAC 40-151-800.A.5. Discussed evacuation drills as noted in CRF standard 22 VAC 40-151-990.L.2.

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/25/24 from 11:16 AM ? 11:40 AM - At the facility 1/25/24 from 11:58 AM ? 6:00 PM - At the corporate office 1/26/24 from 10:15 AM ? 8:43 PM - At the facility The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents in care at the beginning of the inspection: 10 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident?s records reviewed: 4 Number of staff records reviewed: 9 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Additional Comments/Discussion: Staff records were reviewed at the corporate office in Richmond on 1/25/24. The Human Resource (HR) Manager was available and accessible during this inspection. A preliminary findings meeting was held with the HR Manager on the same date. A follow-up conversation was held with this staff member on 2/13/24 prior to the exit meeting. An entrance meeting was held on 1/26/24 with the Director of Operations for Children's Residential Services and the Program Manager. The Program Manager and the Program Supervisor were accessible and available during the inspection. The following is a listing of the activities for this inspection: Other documentation reviewed during this inspection included, but was not limited to the following: emergency drill documentation, menus, staff work schedules, the daily log, et cetera. The Program Manager and the Program Supervisor were interviewed at the facility for the preliminary findings meeting held at the facility on 1/26/24. The exit meeting was held on 2/13/24 to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Michele Freeman, Licensing Inspector at (804) 662-7062 or by email at michele.freeman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-151-190-B-1
Description:	Violation: Based upon review of the personnel records for staff, S1 and S3, and interview with staff, the facility failed to obtain the results of a screening assessment for tuberculosis (TB) at the time of hire, which is not older than 30 days. Findings: 1) The personnel record for S1 includes the results for a TB screening assessment, which is 39 days old. Therefore, in comparison with S1?s date of hire, this assessment is older than 30 days. 2) The personnel record for S3 includes the results for a TB screening assessment, which is 73 days old. Therefore, in comparison with S3?s date of hire, this assessment is older than 30 days. 3) During the interview, S11 acknowledged the Licensing Specialist?s findings.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-151-680-G-1
Description:	Violation: Based upon review of discharged resident?s, DR1?s, record, the facility failed to place a comprehensive discharge summary in the resident?s record no later than 30 days after discharge. Findings: 1) The Licensing Specialist stated the discharge summary was not in DR1?s record. 2) Staff, S2, stated it was missing from the record because it had not been completed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-151-730-B
Description:	Violation: Based on review of the information readily accessible to staff for current resident, CR2, and interview with staff, the facility failed to include the following element in the event of an emergency. Findings: 1) 730.B.4.c ? Substance abuse and use was blank. 2) During the interview, staff, S2, confirmed the above-mentioned element is missing from CR2?s readily accessible information.
Plan of Correction:	Not available online. Contact Inspector for more information.