Inspection · 2022-08-01
Date
2022-08-01
Complaint Related
No
Licensing Inspector
Kelly Adriazola
(804) 840-8245
(804) 840-8245
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 Service
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
Inspector Notes
A mandated inspection along with a focused inspection regarding a self-reported incident received on July 15, 2022 was conducted on August 1, 2022 from 9:50 A.M.-1:00 P.M. There were 27 children present, ranging in ages from 5 years to 11 years of age, with three 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 six child records and ten 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.
If you have any questions please contact the Licensing Inspector at 540-430-9257.
Violations
8Standard 8VAC20-770-60-B
Based on review of staff records, the center failed to ensure that a sworn disclosure statement was signed and on file prior to the first date of employment.
Evidence:
1. Staff #1?s first day of employment was 05/18/2022. The sworn disclosure in the record was dated 05/25/2022.
2. Administration verified the date of employment for Staff #1 and the date on the sworn disclosure statement.
Evidence:
1. Staff #1?s first day of employment was 05/18/2022. The sworn disclosure in the record was dated 05/25/2022.
2. Administration verified the date of employment for Staff #1 and the date on the sworn disclosure statement.
Plan of Correction: Site managers will be reminded that paperwork that needs to be completed by the end of the first day on site. This includes the Sworn Disclosure Statement.
Standard 8VAC20-780-410-5
Based on review of documentation and interview, the center failed to ensure that staff did not withhold food.
Evidence:
1. On 07/13/2022 Staff #8 and Staff #9 withheld a second afternoon snack from Child #1.
2. Staff #2 stated that on 07/13/2022 between 4:30 p.m.-5:00 p.m. approximately three to five children requested a second snack from food that was extra from earlier in the day. Staff #8 and Staff #9 provided the children with a snack. When Child #1 requested a snack, staff #8 and #9 denied him a second snack due to his behavior.
3. Documentation from Staff #10 stated that she met with Staff #8 and Staff #9, and they stated ?they did not withhold afternoon snack, but denied the child the food later in the evening that they looked at as a treat.?
Evidence:
1. On 07/13/2022 Staff #8 and Staff #9 withheld a second afternoon snack from Child #1.
2. Staff #2 stated that on 07/13/2022 between 4:30 p.m.-5:00 p.m. approximately three to five children requested a second snack from food that was extra from earlier in the day. Staff #8 and Staff #9 provided the children with a snack. When Child #1 requested a snack, staff #8 and #9 denied him a second snack due to his behavior.
3. Documentation from Staff #10 stated that she met with Staff #8 and Staff #9, and they stated ?they did not withhold afternoon snack, but denied the child the food later in the evening that they looked at as a treat.?
Plan of Correction: The two staff involved were removed from the schedule and not allowed to finish out their two weeks notice once administration staff met with the parent of the child in question. Additionally, staff have been reminded that food cannot be withheld from children under any circumstance. This will be a regular reminder in staff meetings.
Standard 8VAC20-780-430-I
Based on observation, the center failed to ensure that all personal belongings were labeled with the child?s name.
Evidence:
1. In the baskets in the hallway there was a water bottle that was not labeled with the child?s name. The basket the water bottle was located in was not labeled with the child?s name.
2. In the cafeteria area there were two water bottles on the table that were not labeled with the child?s name.
Evidence:
1. In the baskets in the hallway there was a water bottle that was not labeled with the child?s name. The basket the water bottle was located in was not labeled with the child?s name.
2. In the cafeteria area there were two water bottles on the table that were not labeled with the child?s name.
Plan of Correction: All staff will be re-trained on the requirements and importance of labeling all of the participants food items and how that should be done.
Standard 8VAC20-780-510-B
Based on review of medication, the center failed to ensure that prescription medication shall be given to a child only with written authorization from the parent.
Evidence:
1. Child 1M had a prescription medication, Methlypedine, at the center. The medication authorization form signed by the parent, dated 05/23/2022, was only current for 10 business days, and expired on June 7, 2022. The medication log was reviewed, and the medication had been administered to the child for an additional 32 days, (June 8th-July 29th), without parent or physician authorization.
2. Staff #2 verified that an updated authorization from the parent had not been obtained and the medication had been administered 32 times between June 8, 2022-July 29, 2022.
Evidence:
1. Child 1M had a prescription medication, Methlypedine, at the center. The medication authorization form signed by the parent, dated 05/23/2022, was only current for 10 business days, and expired on June 7, 2022. The medication log was reviewed, and the medication had been administered to the child for an additional 32 days, (June 8th-July 29th), without parent or physician authorization.
2. Staff #2 verified that an updated authorization from the parent had not been obtained and the medication had been administered 32 times between June 8, 2022-July 29, 2022.
Plan of Correction: Staff will be updated on the medication administration policies. Additionally, the forms used by the site will be updated and will be put into circulation immediately for new enrollees and cycled into use for current enrollees as their old forms expire. The new forms will be distinctly separate for parent permission and doctor permission so that staff knows which forms are needed.
Standard 8VAC20-780-510-F
Based on review of medication, the center failed to ensure that medication authorization shall be available to staff during the entire time it is effective.
Evidence:
1. Child 2M had a prescription emergency medication, Albuterol Inhaler, at the center. There was no medication authorization form available to staff. The medication had not been administered.
2. Staff #2 verified that the medication authorization could not be located.
Evidence:
1. Child 2M had a prescription emergency medication, Albuterol Inhaler, at the center. There was no medication authorization form available to staff. The medication had not been administered.
2. Staff #2 verified that the medication authorization could not be located.
Plan of Correction: The OCSACC Operations Manager will visit each site to ensure the medication files are up to date and accessible to those that need access.
Standard 8VAC20-780-510-P
Based on review of medication, the center failed to ensure that when an authorization for medication expires, the parent shall be notified that the medication needs to be picked up within 14 days or the parent must renew the authorization.
Evidence:
1. Child 3M had a prescription emergency medication, ProAir Inhaler, at the center. The medication authorization form signed by the parent, dated 05/18/2022, was only current for 10 business days, and expired on June 2, 2022. The medication had not been administered.
2. Child 1M had a prescription medication, Methlyphedine, on site. The medication authorization form signed by the parent, dated 05/23/2022, was only current for 10 business days, and expired on June 7, 2022. The medication had been given 32 times between June 8, 2022-July 29, 2022.
Evidence:
1. Child 3M had a prescription emergency medication, ProAir Inhaler, at the center. The medication authorization form signed by the parent, dated 05/18/2022, was only current for 10 business days, and expired on June 2, 2022. The medication had not been administered.
2. Child 1M had a prescription medication, Methlyphedine, on site. The medication authorization form signed by the parent, dated 05/23/2022, was only current for 10 business days, and expired on June 7, 2022. The medication had been given 32 times between June 8, 2022-July 29, 2022.
Plan of Correction: All MAT trained staff will be reminded of the policy surrounding expired medication and medication forms. This includes when medication expires, but is still needed for a particular child. Also staff will be reminded that if a medication is not picked up as requested once expired staff is to properly dispose of this medication.
Standard 8VAC20-780-560-F
Based on observation and interview, the center failed to ensure that a menu listing foods to be served for snacks was posted for the most current week.
Evidence:
1. The menu that was posted on the parent board was dated May 2022.
2. Staff #2 verified that there was not a current menu posted, and there had not been one posted for June 2022 or July 2022.
Evidence:
1. The menu that was posted on the parent board was dated May 2022.
2. Staff #2 verified that there was not a current menu posted, and there had not been one posted for June 2022 or July 2022.
Plan of Correction: This situation has been discussed with the Site Manager. Additionally, the Operations Manager will be taking over scheduling snacks for each site at the beginning September and will provide a monthly menu to each Site Manager to post at their respective sites.
Standard 8VAC20-780-560-G
Based on observation, the center failed to ensure that all food brought in from home was clearly labeled with the child?s name and date.
Evidence:
1. In the hallway in a basket there was a Lunchable and a container of mandarin oranges that were not labeled with the child?s name or date.
2. There were three lunchboxes in the hallway that were not labeled with the date.
3. There were two lunchboxes in the hallway that were not labeled with the child?s name.
4. Staff #2 verified that the food and lunchboxes were not labeled with the required information.
Evidence:
1. In the hallway in a basket there was a Lunchable and a container of mandarin oranges that were not labeled with the child?s name or date.
2. There were three lunchboxes in the hallway that were not labeled with the date.
3. There were two lunchboxes in the hallway that were not labeled with the child?s name.
4. Staff #2 verified that the food and lunchboxes were not labeled with the required information.
Plan of Correction: All staff will be re-trained on the requirements and importance of labeling all of the participants food items and how that should be done.