Inspection · 2021-11-03

Date

2021-11-03

Complaint Related

Licensing Inspector

Cindy Horne
(804) 297-4469

Yes

Areas Reviewed

22VAC40-665 INTRODUCTION
22VAC40-665 ADMINISTRATION
22VAC40-665 STAFF QUALIFICATIONS & TRAINING
22VAC40-665 PHYSICAL PLANT
22VAC40-665 STAFFING & SUPERVISION
22VAC40-665 PROGAMS
22VAC40-665 SPECIAL CARE PROVISIONS & EMERGENCIES
22VAC40-665 SPECIAL SERVICES

Inspector Notes

This inspection was conducted by licensing staff using an alternate remote protocol, including telephone contacts, documents review, interviews and a virtual tour of the program.

A subsidy health and safety (SHSI) inspection was initiated on 11/03/2021 and concluded on 11/03/2021. There were 44 children present with seven staff supervising. A licensing inspection was also conducted on this date. Both inspections combined cover subsidy health and safety regulations. Only subsidy requirements that are not covered in licensing standards were reviewed during this supplemental inspection.

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.

Violations

Standard 22VAC40-665-540-A

Based on a review of three staff records and interview, the vendor did not ensure one staff member was evaluated by a health professional and be issued a statement that the individual is determined to be free of communicable tuberculosis (TB) within the required time frame.

Evidence: 1) The TB screening in the record for Staff #1, hired on 07/01/2021, was dated 09/08/2021. Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children. The documentation shall have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician's designee, or an official of the local health department. 2) During interview, a member of management reported the TB screening for Staff #1 was not obtained prior to hire.

Plan of Correction: Per the Vendor: "During the pandemic it was hard to get TB tests. Going forward, the director will ensure all TB tests are done in time."

Standard 22VAC40-665-580-E-1

Based on a review of three staff records and interview, the vendor did not ensure that one staff who works directly with children had current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care within the required time frame.

Evidence: 1) The record for Staff #2, hired on 06/16/2021, does not contain documentation that the staff has current certification in CPR. 2) During interview, a member of management reported Staff #2 does not have current certification in CPR. All staff who work directly with children shall have certification in CPR within 90 days of the date of employment.

Plan of Correction: Per the Vendor: "During the pandemic, classes for CPR/First Aid were not always available. Staff #2 has been enrolled in a class and will be done 11/29/21. The director will make sure to have staff complete first aid and CPR within the 90 day time frame."

Standard 22VAC40-665-580-E-2

Based on a review of three staff records and interview, the vendor did not ensure that one staff who works directly with children had current certification in first aid appropriate to the ages of children in care within the required time frame.

Evidence: 1) The record for Staff #2, hired on 06/16/2021, does not contain documentation that the staff has current certification in first aid. 2) During interview, a member of management reported Staff #2 does not have current certification in first aid. All staff who work directly with children shall have certification in first aid within 90 days of the date of employment.

View original record on Virginia Department of Social Services