Virginia
Sign in
Back
Tri-County Community Action Agency, Inc. - Boydton

Inspection · 2024-11-04

Date
2024-11-04
Complaint Related
No
Licensing Inspector
Danielle Morrison
(804) 929-3771
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.
20 Access to minor?s records
8VAC20-780 Staff Qualifications and Training.
22.1 Early Childhood Care and Education
8VAC20-780 Physical Plant.
63.2 Child Abuse & Neglect
8VAC20-780 Staffing and Supervision.
8VAC20-790 Introduction
8VAC20-780 Programs.
8VAC20-790 Administration
8VAC20-780 Special Care Provisions and Emergencies
8VAC20-790 Staff Qualifications & Training
8VAC20-780 Special Services.
8VAC20-790 Physical Plant
8VAC20-820 THE LICENSE.
8VAC20-790 Staffing & Supervision
8VAC20-820 THE LICENSING PROCESS.
8VAC20-790 Programs
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-790 Special Care Provisions & Emergencies
8VAC20-770 Background Checks
8VAC20-790 Special Services

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 renewal inspection was initiated on 11/4/2024 and completed on 11/6/2024. The on-site inspection began at 10:20am and ended at 12:10pm. The inspector reviewed compliance in the areas listed above. There were 11 children present and 3 staff. The inspector reviewed 5 children?s records on site and 3 staff records electronically on 11/6/2024. This inspection included document review, tour of the facility, interviews and observations.

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 11/19/2024. A POC submitted after this date will not appear on the public website.

Violations

7
Standard 22.1-289.035-B-3
The center must obtain the results of a central registry search for an employee, within 30 days of employment.

The record for staff #3 contained a central registry background check dated 40 days after their date of employment.
Plan of Correction: The Head Start will collaborate with the Director of Human Resources to ensure central registry background checks are completed within 30 days of employment.
Standard 8VAC20-780-140-A
Physical examinations completed by a physician shall be obtained prior to the first day of attendance or within 30 days after the first day of attendance.

There was a physical examination in the record for child #3 dated 45 days after enrollment. There was a physical examination in the record for child #4 dated 56 days after enrollment.
Plan of Correction: The Health Specialist will ensure that all physical examinations are received prior to or within the first 30 days of each child's attendance as required.
Standard 8VAC20-780-150-B
Immunization records are required to be signed by a physician, his designee, or an official of the local health department.

The immunization records for child #3 and child #4 were not signed.
Plan of Correction: The Health Specialist will ensure that all immunization records received are signed by a physician or health official, as required.
Standard 8VAC20-780-160-A
Each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with the children.

The screening for Staff #1 was completed three weeks after hire and the screening for Staff #3 was completed one day after hire.
Plan of Correction: The Head Start Director will collaborate with the Director of Human Resources to ensure TB screenings are completed prior to newly hired staff coming in contact with children.
Standard 8VAC20-780-200-A
The center shall have a qualified program director or qualified back-up program director who shall regularly be on-site at least 50% of the center?s hours of operation.

Based on interviews with staff, the center does not currently have a program director assigned to the center. Staff reported not having a program director or back-up program director at the center at least 50% of the time.
Plan of Correction: Staff #3 was assigned the role of center director for Boydton Head Start.
Standard 8VAC20-780-550-G
The center shall maintain documentation of emergency evacuation drills that includes all required components.

There was no documentation of emergency evacuation drills for the months of September and October 2024.
Plan of Correction: Management will ensure staff completes the required monthly Fire Evacuation Drills as required by licensing.
Standard 8VAC20-780-560-F
A menu listing food to be served for meals and snacks during the current one-week period shall: be dated; be posted in a location conspicuous to parents or given to parents; list any substituted food; and be kept on file for one week at the center.

The center did not have a menu posted for the week of 11/4/24-11/8/24 during the inspection.
Plan of Correction: Management will ensure staff has all current menus posted with any substitutions documented, as needed.
View original record on Virginia Department of Social Services