Inspection · 2024-10-01
Date
2024-10-01
Complaint Related
No
Licensing Inspector
Morgan Bryson
(540) 270-0057
(540) 270-0057
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
22.1 Early Childhood Care and Education
63.2 Child Abuse & Neglect
During the inspection, the inspector reviewed the areas listed above to include standards found out of compliance during the previous inspection. Unless otherwise noted as a violation within this inspection report, the provider was in compliance with the standards reviewed. If there were any serious injuries or fatalities related to a violation, the details will be included in the description of the violation.
Inspector Notes
An unannounced, on-site monitoring inspection was initiated on 10/1/2024 and completed on 10/1/2024. The on-site inspection began at 12:30pm and ended at 3:30pm. The inspector reviewed compliance in the areas listed above. There were 60 children present and 7 staff. The inspector reviewed 6 children?s records and 5 staff records on site on 10/1/2024. This inspection included document review, a tour of the facility, observations and interviews. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations are documented on the violation notice issued to the program.
Please complete the plan of correction (POC) and date to be corrected sections for each violation cited on the violation notice. Specify how the violation will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on 10/10/2024. A POC submitted after this date will not appear on the public website.
Violations
9Standard 8VAC20-780-160-A
(Repeat Violation) The center is required to obtain documentation of a negative tuberculosis (TB) screening at the time of employment and prior to coming into contact with children.
Staff #4 had no screening documentation and had been employed for two months.
Staff #4 had no screening documentation and had been employed for two months.
Plan of Correction: Immediately ensure that Staff #4 obtains a TB screening and submits the documentation. Review the files of all employees to ensure compliance with TB screening requirements. Incorporate TB screening into the onboarding process, ensuring no employee begins work without the proper documentation. Set up a system to remind employees of upcoming health screenings or documentation that will need renewal. Maintain a medical file audit every quarter to catch any missing documentation early.
Standard 8VAC20-780-240-B
Staff are to complete orientation training prior to working alone with children and no later than 7 days of the date of hire.
Staff #3 was observed working alone with children and does not have documentation of orientation training.
Staff #3 was observed working alone with children and does not have documentation of orientation training.
Plan of Correction: Immediately schedule orientation training for Staff #3 and ensure the completion is documented. Prohibit any staff from working alone with children until orientation is complete. Require all orientation training to be completed and documented within the first week of employment. Implement a digital training log to track completed training for each staff member. Conduct quarterly reviews of training records to ensure all staff are up to date.
Standard 8VAC20-780-260-A
After the first license, annual approval from the health department shall be obtained.
The health inspection is overdue by 17 months.
The health inspection is overdue by 17 months.
Plan of Correction: Schedule the overdue health inspection with the local health department immediately. Ensure the inspection is completed within 30 days. Set annual reminders for scheduling health inspections and make this a mandatory part of the yearly calendar.
Standard 8VAC20-780-440-L
Pillows and comforters shall not be used by children under two years of age.
Child #1, age 19 months, was observed sleeping with a pillow.
Child #1, age 19 months, was observed sleeping with a pillow.
Plan of Correction: Remove the pillow immediately and ensure the child is placed on an approved sleep surface with no additional soft items. Review sleep safety standards with all staff, especially those working with children under two years of age. Provide refresher training on infant/toddler sleep safety every quarter. Post visible reminders of sleep safety guidelines in all rooms where children under two are present. Implement a regular room inspection checklist to ensure compliance with sleep safety regulations.
Standard 8VAC20-780-510-E
The center?s procedures for administering Long term prescription and over-the-counter medication require written authorization from the child?s parent and physician.
There was not written parent and/or physician authorization to administer long term medications to child #4, #5, #7, #8, #9 and child #11.
There was not written parent and/or physician authorization to administer long term medications to child #4, #5, #7, #8, #9 and child #11.
Plan of Correction: Immediately contact parents of the affected children to obtain the required written authorization forms from both the parent and the physician. Ensure all necessary documents are signed and added to the children?s files before administering any further medication. Provide training to staff regarding the requirement for both parental and physician authorization for long-term medications. Implement a monthly audit of all medication forms to ensure authorizations are current. Create a checklist for parents during enrollment or re-enrollment to ensure all required medication forms are completed. Designate a staff member to monitor and update the medication records and notify parents a month before the authorization expires.
Standard 8VAC20-780-510-P
When an authorization for medication expires, the facility shall notify parents that the medication must be picked up within 14 days of the authorization expiring or that a new authorization should be completed.
Medication for Child #7 was onsite, but the medication authorization had expired 4 months ago. Medication for child #10 was onsite, but the medication authorization had expired 1 month ago.
Medication for Child #7 was onsite, but the medication authorization had expired 4 months ago. Medication for child #10 was onsite, but the medication authorization had expired 1 month ago.
Plan of Correction: Immediately contact parents of Child #7 and Child #10 to either renew the authorization or collect the expired medication. Remove any expired medications from the center. Set up a monthly medication audit process to review authorization expiration dates. Notify parents one month before medication authorizations expire, and follow up with reminders two weeks prior. Designate a staff member to oversee medication compliance, including tracking and notifying parents about expiring authorizations.
Standard 8VAC20-780-530-A
At least one staff in each classroom or area where children are present shall have current certification in both CPR and first aid.
Staff #3 was alone with a group of 19 preschool children and was not certified in CPR or first aid.
Staff #3 was alone with a group of 19 preschool children and was not certified in CPR or first aid.
Plan of Correction: Ensure that Staff #3 immediately completes CPR and first aid certification training. Reassign duties until certification is obtained. Verify that all staff members have current CPR and first aid certifications upon hiring and maintain updated certifications through a monitoring system. Schedule and require all staff to attend annual refresher courses. Ensure that there is always at least one certified staff member present in every classroom.
Standard 8VAC20-780-550-D
The center shall implement a monthly practice evacuation drill.
There was no documented evacuation drill in May, June, July and August of 2024.
There was no documented evacuation drill in May, June, July and August of 2024.
Plan of Correction: Schedule and conduct an immediate evacuation drill to ensure compliance for this month. Document the drill, ensuring proper filing. Create an annual drill calendar to ensure that monthly evacuation drills are scheduled and conducted. Designate a staff member responsible for ensuring drill documentation is completed and filed each month. Review drill documentation during monthly staff meetings to ensure compliance
Standard 8VAC20-780-70
(Repeat Violation) Documentation of at least 2 references to character, reputation, and competency are to be checked prior to employment.
Staff #3, who has been actively working at the center for the past week, staff # 4, who has been actively working at the center for 2 months, and staff #5, who has been actively working at the center for 7 months did not have two completed reference verifications on file.
Staff #3, who has been actively working at the center for the past week, staff # 4, who has been actively working at the center for 2 months, and staff #5, who has been actively working at the center for 7 months did not have two completed reference verifications on file.
Plan of Correction: Immediately complete reference checks for staff #3, #4, and #5 and file the required documentation. Review files of all employees to ensure that reference verifications are complete and filed. Update the hiring checklist to include a verification step requiring two references before the start of employment. Create a digital tracking system to monitor compliance with reference checks.