Inspection · 2022-11-01
(804) 840-8245
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 (8VAC20-770)
22.1 Background Checks Code, Carbon Monoxide
Inspector Notes
An unannounced monitoring inspection was conducted on-site November 1, 2022 and concluded remotely on November 3, 2022. The director was available during the inspection. There were 37 children present, ranging in ages from 5 years to 12 years, with 3 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of 5 child records and 3 staff records were reviewed.
Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program.
Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to me within 5 business days from today. Please specify how the deficient practice will be or has been corrected. Your plan of correction should contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measures. Please do not use staff names; list staff by positions only.
Violations
5Evidence: 1. The record of staff #2, hired 11/11/21, contained documentation of central registry results dated 12/29/21. Administrator #1 confirmed the results were late.
The program will meet this requirement by using an electronic tracker that shows when the background checks are sent off and due to be returned. This will be monitored and maintained by the Program Manager.
Evidence: 1. The record of child #1, enrolled 7/13/22, contained documentation of immunizations dated 10/31/22.
2. The record of child #4, enrolled 8/9/22, contained documentation of immunizations dated 9/27/22.
This is the responsibility of the Enrollment Coordinator and will be monitored at each site by the Team Leader.
Evidence: 1. The record of staff #2, hired 11/11/21, contained documentation of the Virginia Department of Education sponsored orientation dated 8/15/22.
The center will meet this requirement by using an electronic tracker that shows when orientation was completed for the new hire. It is the responsibility of the program manager to ensure this requirement is met within 90 days of hiring. We will not backdate orientation forms going forward.
Evidence: 1. The record of staff #2, hired 11/11/21, contained documentation of orientation dated 2/17/22. 2. Administrator #1 indicated that staff #2 initially started with the Early Head Start program and submitted another documentation of orientation that was dated 12/6/21.
3. The documentation of orientation was signed and dated as completed on 12/6/21, however, the form completed indicated it was updated in October 2022 and therefore could not have been signed on 12/6/21.
4. Administrator #1 confirmed the form was ?doctored.?
Evidence: 1. The record of staff #3 contained documentation of 4 hours of training from6/13/21 to 6/13/22. 2. Administrator #1 acknowledged the annual training hours were not complete.
The Program Manager will ensure the supporting documentation is filed in the staff file upon updating the training tracker. The training tracker is monitored at least quarterly to ensure staff are getting their 16 hours of annual training.