Inspection · 2024-07-18
Date
2024-07-18
Complaint Related
Yes
Licensing Inspector
Shahana Green
(571) 423-6735
(571) 423-6735
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
Inspector Notes
An unannounced inspection was initiated on 07/18/2024 and completed on 09/24/2024 in response to a complaint received by the licensing office on 7/15/2024 relating to allegations of Supervision. The inspector reviewed 1 children?s record and 2 staff records on-site on 7/18/2024. This inspection included document review, tour of the facility, and interviews.
The preponderance of evidence gathered during the investigation supports the allegation(s); therefore, the complaint is determined to be valid. Information gathered during the inspection determined non-compliance with applicable standards or law and the violations are documented on the violation notice issued to the program.
Violations
7Standard 8VAC20-780-240-D
Prior to working alone with children and within seven days of the first day of employment, staff shall be provided in writing with the center's information listed in 8VAC20-780-420 A and the procedures outlined in 8VAC20-780-240D1-7.
Evidence:
Management reported procedures for the following are provided verbally, but not in writing, during orientation:
1. Procedures for supervising a child who may arrive after scheduled classes or activities including field trips have begun;
2. Procedures to confirm absence of a child when the child is scheduled to arrive from another program or from an agency responsible for transporting the child to the center;
3. Procedures for identifying where attending children are at all times, including procedures to ensure that all children are accounted for before leaving a field trip site and upon return to the center;
4. Procedures for action in case of lost or missing children, ill or injured children, medical emergencies, and general emergencies;
5. Policy for any administration of medication;
6. Emergency evacuation, relocation, shelter-in-place, and lockdown procedures; and
7. Precautions in transporting children, if applicable.
Evidence:
Management reported procedures for the following are provided verbally, but not in writing, during orientation:
1. Procedures for supervising a child who may arrive after scheduled classes or activities including field trips have begun;
2. Procedures to confirm absence of a child when the child is scheduled to arrive from another program or from an agency responsible for transporting the child to the center;
3. Procedures for identifying where attending children are at all times, including procedures to ensure that all children are accounted for before leaving a field trip site and upon return to the center;
4. Procedures for action in case of lost or missing children, ill or injured children, medical emergencies, and general emergencies;
5. Policy for any administration of medication;
6. Emergency evacuation, relocation, shelter-in-place, and lockdown procedures; and
7. Precautions in transporting children, if applicable.
Plan of Correction: The staff handbook has been updated. The center will ensure staff receive the handbook with the required written information during orientation.
Standard 8VAC20-780-340-A
When staff are supervising children, they shall always ensure their care and protection.
Evidence:
1. On 06/18/2024, Child #1 was left in the restroom without supervision for approximately 1 hour before staff realized the child was missing. The door to the restroom was too heavy for Child #1 to physically open. Child #1 was unable to exit the restroom on her own.
Evidence:
1. On 06/18/2024, Child #1 was left in the restroom without supervision for approximately 1 hour before staff realized the child was missing. The door to the restroom was too heavy for Child #1 to physically open. Child #1 was unable to exit the restroom on her own.
Plan of Correction: The center immediately removed the secondary/interior door in both restrooms to make children more visible to supervising staff. Current policies were reviewed and policies were updated to include requiring staff to sweep each area and check all spaces for children before transitioning to the next location in addition to counting children. Both staff members responsible were immediately terminated. A staff meeting was conducted to explain the incident and review current and updated policies and procedures regarding transitions, restroom breaks, and personal phone use. Additional counts were also implemented by management outside of transition times to encourage consistency.
Standard 8VAC20-780-340-F
Children under 10 years of age always shall be within actual sight and sound supervision of staff.
Evidence:
1. On 6/18/2024, at approximately 12:55pm, Child #1 (age 3 years), was taken to the restroom with the purple group and the green group. One staff member walked with most of the children back to their assigned classroom while one staff member remained outside of the restroom to supervise the rest of the children. The staff member then accompanied two children who exited the restroom back to the classroom.
2.At approximately 2:10pm, both staff in Child #1's classroom discovered Child #1 was missing.
3. Child #1 was found alone, standing in the last stall in the restroom.
4. Child #1 was alone in the restroom for approximately one hour.
Evidence:
1. On 6/18/2024, at approximately 12:55pm, Child #1 (age 3 years), was taken to the restroom with the purple group and the green group. One staff member walked with most of the children back to their assigned classroom while one staff member remained outside of the restroom to supervise the rest of the children. The staff member then accompanied two children who exited the restroom back to the classroom.
2.At approximately 2:10pm, both staff in Child #1's classroom discovered Child #1 was missing.
3. Child #1 was found alone, standing in the last stall in the restroom.
4. Child #1 was alone in the restroom for approximately one hour.
Plan of Correction: The center immediately removed the secondary/interior door in both restrooms to make children more visible to supervising staff. Current policies were reviewed and policies were updated to include requiring staff to sweep each area and check all spaces for children before transitioning to the next location in addition to counting children. Both staff members responsible were immediately terminated. A staff meeting was conducted to explain the incident and review current and updated policies and procedures regarding transitions, restroom breaks, and personal phone use. Additional counts were also implemented by management outside of transition times to encourage consistency.
Standard 8VAC20-780-40-E
The operational responsibilities of the licensee shall include ensuring the center's activities and services are maintained in compliance with the center's own policies and procedures that are required by these standards.
Evidence:
1.Management reported the procedure for accounting for all children during restroom breaks is to count the number of children, verify that all children are present, then transition to the next location. On 6/18/2024 at approximately 12:55pm, children from the purple and green rooms were taken to the restroom. The children were not counted during the transition to leave the restroom and return back to the purple classroom.
2.Management reported it is procedure to complete a head count upon returning to the classroom and again before naptime. On 6/18/2024, additional counts of children were not completed once arriving back to the classroom from the restroom, or before naptime after laying down on the rest mats.
3. Child #1 was left behind in the restroom for approximately one hour before staff realized the child was missing.
Evidence:
1.Management reported the procedure for accounting for all children during restroom breaks is to count the number of children, verify that all children are present, then transition to the next location. On 6/18/2024 at approximately 12:55pm, children from the purple and green rooms were taken to the restroom. The children were not counted during the transition to leave the restroom and return back to the purple classroom.
2.Management reported it is procedure to complete a head count upon returning to the classroom and again before naptime. On 6/18/2024, additional counts of children were not completed once arriving back to the classroom from the restroom, or before naptime after laying down on the rest mats.
3. Child #1 was left behind in the restroom for approximately one hour before staff realized the child was missing.
Plan of Correction: Both staff members were immediately terminated. A staff meeting was conducted to explain the incident and review current and updated policies and procedures regarding transitions, restroom breaks, and personal phone use. Additional counts were also implemented by management outside of transition times to encourage consistency.
Standard 8VAC20-780-50-B
Records and reports on staff shall be maintained and made accessible for two years after separation from employment.
Evidence:
1. Documentation of the original orientation training for Staff #2, who had been working at the center for 3 years, was not available for review.
2. Management stated the original documentation of orientation training was not maintained and had been destroyed.
Evidence:
1. Documentation of the original orientation training for Staff #2, who had been working at the center for 3 years, was not available for review.
2. Management stated the original documentation of orientation training was not maintained and had been destroyed.
Plan of Correction: An additional binder was created to maintain paperwork of terminated employees. Documentation for all current employees will be maintained for at least 2 years following separation of employment.
Standard 8VAC20-780-550-N
The center shall notify the parent immediately if a child is lost.
Evidence:
1.On 6/18/2024, staff discovered Child #1 was lost for approximately one hour. Child #1 was found alone in the restroom at approximately 2:15pm
2.The parent was not notified the child had been lost until pick-up at approximately 5pm.
Evidence:
1.On 6/18/2024, staff discovered Child #1 was lost for approximately one hour. Child #1 was found alone in the restroom at approximately 2:15pm
2.The parent was not notified the child had been lost until pick-up at approximately 5pm.
Plan of Correction: The center will notify parents immediately if a child is lost.
Standard 8VAC20-780-60-A
Children's records are required to contain parental home and employment addresses and phone numbers.
Evidence:
1. The record for Child #1 did not contain the name, telephone number, and address of each parent's places of employment.
Evidence:
1. The record for Child #1 did not contain the name, telephone number, and address of each parent's places of employment.
Plan of Correction: Management will ensure all parents provide the employment information for each enrolled child. An additional form has been created for parents to include the employment information, as the current online enrollment form does not include the information as a requirement.