Inspection · 2022-03-15
Date
2022-03-15
Complaint Related
No
Licensing Inspector
Emily Walsh
(757) 404-2575
(757) 404-2575
SHSIA monitoring inspection of an approved subsidy vendor to determine compliance with current subsidy requirements regarding the health and safety of children and to promote quality standards for the children in their care.
No
Areas Reviewed
8VAC20-780 ADMINISTRATION.
8VAC20-780 STAFF QUALIFICATIONS AND TRAINING.
8VAC20-780 Physical plant.
8VAC20-780 STAFFING AND SUPERVISION.
8VAC20-780 PROGRAMS.
8VAC20-780 Special care provisions and emergencies.
8VAC20-780 SPECIAL SERVICES.
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-770 Background Checks (22VAC40-191)
Inspector Notes
An unannounced renewal inspection was conducted on 03/15/2022 from 4:10 pm - 6:30 pm. At the time of entrance there were 14 school age children in care with two staff. Children were observed eating dinner and engaged in various table games/activities. Two children's records were reviewed.
The inspector additionally investigated a self-reported serious injury that occurred on 02/14/2022.
Four staff records were reviewed prior to the inspection at the Blocker Family YMCA where staff records are maintained.
Violations were found in the areas of administration, staff training, special care provisions and emergencies, terms of the license and background checks.
These violations are listed on the violation notice and were reviewed with the program director at the exit interview.
Violations
10Standard 8VAC20-770-60-C-2
Based on record review and interview, the center failed to obtain a central registry finding within 30 days of employment for staff.
Evidence:
1. Staff 1, hire date 10/15/2021, lacks the results of a central registry check.
2. Staff 2, hire date 10/12/2021, lacks the results of a central registry check.
3. Administrative staff confirmed that a central registry check had not been obtained for staff 1 and staff 2.
Evidence:
1. Staff 1, hire date 10/15/2021, lacks the results of a central registry check.
2. Staff 2, hire date 10/12/2021, lacks the results of a central registry check.
3. Administrative staff confirmed that a central registry check had not been obtained for staff 1 and staff 2.
Plan of Correction: A central registry check has been requested for both staff. An email was sent to check the status of both checks on 03/16/2022.
Standard 8VAC20-780-160-A
Based on record review and interview, the center failed to ensure that each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children.
Evidence:
1. Staff 1, hire date 10/15/2021, lacks documentation of a TB screening.
2. Administrative staff confirmed that a TB screening was not on file for staff 1.
Evidence:
1. Staff 1, hire date 10/15/2021, lacks documentation of a TB screening.
2. Administrative staff confirmed that a TB screening was not on file for staff 1.
Plan of Correction: A current TB screening will be obtained and going forward all staff will obtain a TB screening prior to employment - within 30 days.
Standard 8VAC20-780-240-A
Based on record review and interview, the center failed to ensure that staff complete the Virginia Department of Education-sponsored orientation course shall be completed within 90 calendar days of employment.
Evidence:
1. Staff 1, hire date 10/15/2021, has not completed the ten-hour Virginia Preservice Orientation training within 90 days of hire.
a. Administrative staff confirmed that staff 1 had not completed this training.
Evidence:
1. Staff 1, hire date 10/15/2021, has not completed the ten-hour Virginia Preservice Orientation training within 90 days of hire.
a. Administrative staff confirmed that staff 1 had not completed this training.
Plan of Correction: Staff 1 will complete this training.
Standard 8VAC20-780-40-D
Based on review, the center failed to ensure that the license shall be posted in a place conspicuous to the public.
Evidence:
1. The facility failed to post the current license issued by the Virginia Department of Social Services with effective dates of 04/08/2020 - 04/07/2022.
a. The facility had posted the license that expired on 04/07/2020.
Evidence:
1. The facility failed to post the current license issued by the Virginia Department of Social Services with effective dates of 04/08/2020 - 04/07/2022.
a. The facility had posted the license that expired on 04/07/2020.
Plan of Correction: The current license will be posted.
Standard 8VAC20-780-540-C
Based on observation the center failed to ensure that the required first aid kit shall include all required elements.
Evidence:
The first aid kit lacked band-aids.
Evidence:
The first aid kit lacked band-aids.
Plan of Correction: Band aids will be obtained and placed in the first aid kit tomorrow.
Standard 8VAC20-780-540-E
Based on review, the center failed to ensure that there was one working, battery-operated radio in each building used by children.
Evidence:
The battery operated radio was not working as the batteries had expired.
Evidence:
The battery operated radio was not working as the batteries had expired.
Plan of Correction: New batteries will be obtained.
The radio was checked recently and it was working.
The radio was checked recently and it was working.
Standard 8VAC20-780-550-P
Based on record review and staff interviews, the center failed to ensure that the written record of children's serious injuries shall be written on the day of occurrence and contain all required elements.
Evidence:
1. Child 1 obtained a serious injury on 02/14/2022 however, the injury report was not written until 02/16/2022.
2. The injury report for this injury lacked the following required information:
a. A parent signature or second staff signature;
b. The injury report indicated the injury occurred on 02/16/2022 however, the injury occurred on 02/14/2022 according to all staff interviewed;
c. The injury report indicated the parent was notified by telephone call on 02/16/2022 however, staff interviews indicate the parent was notified in-person on 02/14/2022.
Evidence:
1. Child 1 obtained a serious injury on 02/14/2022 however, the injury report was not written until 02/16/2022.
2. The injury report for this injury lacked the following required information:
a. A parent signature or second staff signature;
b. The injury report indicated the injury occurred on 02/16/2022 however, the injury occurred on 02/14/2022 according to all staff interviewed;
c. The injury report indicated the parent was notified by telephone call on 02/16/2022 however, staff interviews indicate the parent was notified in-person on 02/14/2022.
Plan of Correction: All staff have been retrained on correct documentation for injury reports. Going forward, all injuries will be documented on the injury form the day of occurrence.
The parent was notified, via telephone call, after the injury occurred.
The parent was notified, via telephone call, after the injury occurred.
Standard 8VAC20-780-60-A
Based on record review, the center failed to ensure that children's records contain all of the required elements.
Evidence:
1. The enrollment record for child 2 lacked the following required information:
a. The work phone number for one parent's place of employment;
b. The first date of attendance.
2. The enrollment record for child 1 lacked the following required information:
a. The name, address and phone number of a second emergency contact;
b. The first date of attendance.
Evidence:
1. The enrollment record for child 2 lacked the following required information:
a. The work phone number for one parent's place of employment;
b. The first date of attendance.
2. The enrollment record for child 1 lacked the following required information:
a. The name, address and phone number of a second emergency contact;
b. The first date of attendance.
Plan of Correction: Missing information will be added to these enrollment records.
Standard 8VAC20-780-80-A
Based on record review, the center failed to ensure that for each group of children, the center shall maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs.
Evidence:
1. The attendance sheet lacked the time and departure of children in care.
2. The parent sign-in sheet, which serves as an additional attendance record, did not contain the correct days and month.
a. The parent sign-in sheet in use was incorrectly marked for April 2022 rather than the correct month of March 2022.
b. Parent's of children in care had been signing in since March 1, 2022 on a sign-in sheet for April 2022.
Evidence:
1. The attendance sheet lacked the time and departure of children in care.
2. The parent sign-in sheet, which serves as an additional attendance record, did not contain the correct days and month.
a. The parent sign-in sheet in use was incorrectly marked for April 2022 rather than the correct month of March 2022.
b. Parent's of children in care had been signing in since March 1, 2022 on a sign-in sheet for April 2022.
Plan of Correction: The director stated that the parent sign-in sheet had been labeled for April by mistake. A new parent sign-in sheet will be made listing the correct month and dates for March 2022. Additionally, the staff attendance records will begin listing the time of arrival and departure of children.
Standard 8VAC20-820-120-E-2
Based on review, the center failed to post the findings of the most recent inspection of the facility.
Evidence:
1. The findings from the most recent inspection, conducted 03/04/2020, were not posted.
Evidence:
1. The findings from the most recent inspection, conducted 03/04/2020, were not posted.
Plan of Correction: The acknowledgement form was posted however, the actual licensing inspection reports will be posted going forward.