Inspection · 2022-04-11
Date
2022-04-11
Complaint Related
No
Licensing Inspector
Nanette Roberts
(757) 404-2322
(757) 404-2322
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.
8VAC20-770 Background Checks (8VAC20-770)
22.1 Background Checks Code, Carbon Monoxide
Inspector Notes
An unannounced monitoring inspection was conducted on 4/11/22 from 2:15pm - 4:10pm. During the inspection there were 47 children ages five years old through twelve years old in care with 6 staff. Children were observed participating in various activities in the classroom, eating snack, and playing outside. Records were reviewed for five children and three staff. Medication, emergency procedures, and emergency supplies were reviewed during the inspection. Areas of non-compliance are identified on the violation notice and were discussed during the exit interview.
Violations
6Standard 8VAC20-770-60-C-2
Based on a review of five staff records, it was determined that the facility did not deny continued employment of a staff who did not have a search of the central registry finding within 30 days of employment.
Evidence:
1. The record for staff #5 (date of hire 6/18/21) did not contain documentation of a completed search of the central registry finding.
2. Staff #6 (Program Administrator) reviewed the record for the staff #5, and confirmed that the search of the central registry finding has not been received.
Evidence:
1. The record for staff #5 (date of hire 6/18/21) did not contain documentation of a completed search of the central registry finding.
2. Staff #6 (Program Administrator) reviewed the record for the staff #5, and confirmed that the search of the central registry finding has not been received.
Plan of Correction: The facility responded: Staff #5 will complete a search of the central registry since we can not find a completed one.
Standard 8VAC20-780-160-A
Based on a review of five staff records, it was determined that the facility did not ensure that each staff member shall submit documentation of a negative tuberculosis screening. Documentation of the screening shall be submitted no later than 21 days after employment and shall have been completed within 12 months prior to or 21 days after employing.
Evidence:
1. The record for staff #5, working during the inspection, did not contain documentation of a negative tuberculosis screening.
2. Staff #6 (Program Administrator) reviewed the record for staff #5, and confirmed that the documentation of a negative tuberculosis screening had not been received prior to employment.
Evidence:
1. The record for staff #5, working during the inspection, did not contain documentation of a negative tuberculosis screening.
2. Staff #6 (Program Administrator) reviewed the record for staff #5, and confirmed that the documentation of a negative tuberculosis screening had not been received prior to employment.
Plan of Correction: The facility responded: Staff #5 will be sent to complete a TB screening. All new staff will complete a TB screening prior to employment.
Standard 8VAC20-780-160-C
Based on a review of five staff records, it was determined that the facility did not ensure that at least every two years from the date of the first initial screening or testing, staff members shall obtain and submit the results of a follow-up tuberculosis screening.
Evidence:
1. The record for staff #1, contained documentation of TB screening that was dated 2/27/20.
2. Staff #6 (Program Administrator), reviewed the record for staff #1 and confirmed that an updated TB screening had not been received.
Evidence:
1. The record for staff #1, contained documentation of TB screening that was dated 2/27/20.
2. Staff #6 (Program Administrator), reviewed the record for staff #1 and confirmed that an updated TB screening had not been received.
Plan of Correction: The facility responded: Staff #1 will be sent to complete an updated TB screening. All current staff will complete an updated TB screening prior to two years since the last TB screening.
Standard 8VAC20-780-340-D
Based on observation, a review of five staff records and interviews, it was determined that the licensee did not ensure that in each grouping of children at least one staff member who meets the qualifications of a program leader or program director shall be regularly present.
Evidence:
1. Staff #2 working alone with a group of School Age children in a classroom. The record for staff #2 did not contain documentation to demonstrate that staff #2 was Program Leader qualified.
2. Staff #5 working alone with a group of School Age children in a classroom. The record for staff #5 did not contain documentation to demonstrate that staff #5 was Program Leader qualified.
3. Staff #6 (Program Administrator) reviewed the record for the staff #5, and confirmed that staff #5 was not Program Leader qualified.
Evidence:
1. Staff #2 working alone with a group of School Age children in a classroom. The record for staff #2 did not contain documentation to demonstrate that staff #2 was Program Leader qualified.
2. Staff #5 working alone with a group of School Age children in a classroom. The record for staff #5 did not contain documentation to demonstrate that staff #5 was Program Leader qualified.
3. Staff #6 (Program Administrator) reviewed the record for the staff #5, and confirmed that staff #5 was not Program Leader qualified.
Plan of Correction: The facility responded: All staff will not work alone with the children unless they have completed the required training to meet Program Leader qualifications.
Standard 8VAC20-780-530-A
Based on a review of five staff records and interviews, it was determined that the facility did not ensure that there shall be at least one staff in each classroom or area where children are present that has a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care.
Evidence:
1. Staff #3 working alone with a group of School Age children in a classroom. The record for staff #2 did not contain documentation to demonstrate that staff #3 had a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care
2. Staff #5 working alone with a group of School Age children in a classroom. The record for staff #5 did not contain documentation to demonstrate that staff #5 had a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care,
3. Staff #6 (Program Administrator) reviewed the records for the staff #3 and staff #5, and confirmed that staff #3 and staff #5 did not have a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care.
Evidence:
1. Staff #3 working alone with a group of School Age children in a classroom. The record for staff #2 did not contain documentation to demonstrate that staff #3 had a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care
2. Staff #5 working alone with a group of School Age children in a classroom. The record for staff #5 did not contain documentation to demonstrate that staff #5 had a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care,
3. Staff #6 (Program Administrator) reviewed the records for the staff #3 and staff #5, and confirmed that staff #3 and staff #5 did not have a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care.
Plan of Correction: The facility responded: We will ensure that at least one staff in each grouping of children has a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care.
Standard 8VAC20-780-550-D
Based on a review of the emergency drill log and interview, it was determined that the facility did not ensure that a monthly practice evacuation drill is completed.
Evidence:
1. The emergency drill log did not have written documentation to demonstrate that an emergency evacuation drill was completed during the month of March 2022.
2. Staff #6 (Program Administrator) confirmed that there was no emergency evacuation drill completed during the month of March 2022.
Evidence:
1. The emergency drill log did not have written documentation to demonstrate that an emergency evacuation drill was completed during the month of March 2022.
2. Staff #6 (Program Administrator) confirmed that there was no emergency evacuation drill completed during the month of March 2022.
Plan of Correction: The facility responded: We will ensure that a practice emergency drill is completed each month.