Inspection · 2023-05-01
Date
2023-05-01
Complaint Related
Yes
Licensing Inspector
Stephanie Reed
(540) 272-6558
(540) 272-6558
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 Staffing and Supervision.
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-770 Background Checks (8VAC20-770)
22.1 Background Checks Code, Carbon Monoxide
Inspector Notes
A complaint inspection was conducted on site on May 1, 2023 from 8:00 A.M.-1:15 P.M., telephone interviews were conducted on May 23, 2023, and the inspection concluded on June 5, 2023. A complaint was received in the Office of Child Care Health & Safety (Valley), on April 27, 2023 in regards to staffing, supervision, ratios, and background checks. The inspector reviewed compliance in the areas of administration, staff records, staffing, ratios, and supervision. One staff record was reviewed, eleven staff were interviewed, time cards, staff schedules, sign-in and sign-out sheets were reviewed, and classroom observations conducted. The information gathered during the investigation does support the allegation, so the complaint is determined to be "valid".
Information gathered during the inspection determines non-compliance with applicable standards or lawn and violations were documented on the violation notice issued to the program.
If you have any questions or concerns please contact the Licensing Inspector at 540-430-9257.
Violations
7Standard 22.1-289.035-B-2
COMPLAINT RELATED
Based on review of staff records, the center failed to ensure that the required national criminal background check was completed prior to the first day of employment.
Evidence:
1. Staff #1?s date of employment was 08/04/2022. There was not documentation of the National Fingerprint background check being completed in the file.
2. Staff #8 verified that Staff #1 was working in the center on 03/28/2023, 03/30/23, 04/03/2023, and 04/04/2023.
3. Two staff revealed during interviews that Staff #1 was counted in ratio and observed working with children alone.
Based on review of staff records, the center failed to ensure that the required national criminal background check was completed prior to the first day of employment.
Evidence:
1. Staff #1?s date of employment was 08/04/2022. There was not documentation of the National Fingerprint background check being completed in the file.
2. Staff #8 verified that Staff #1 was working in the center on 03/28/2023, 03/30/23, 04/03/2023, and 04/04/2023.
3. Two staff revealed during interviews that Staff #1 was counted in ratio and observed working with children alone.
Plan of Correction: A follow-up checklist was created 6/19/2023 and an Admin Only Google Calendar created and sent to all Admin with reminders to check for background checks that need to be sent and to follow up on any checks not received. Included on Heritage Internal New Hire Checklist as of 6/19/2023
Standard 22.1-289.035-B-4
COMPLAINT RELATED & REPEAT
Based on review of staff records, the center failed to ensure that all required out-of-state background checks were completed.
Evidence:
1. Staff #1?s date of employment was 08/04/2022. On the West Virginia Clearance for Access: Registry & Employment Screening, Staff #1 indicated they had lived in two states (West Virginia and Maryland), outside of Virginia within the past five years.
2. There was no documentation of a West Virginia or Maryland Sex Offender name check completed before date of hire.
3. There was not documentation that an out of state central registry finding for Maryland had been completed within 30 days of hire.
4. Staff #8 verified that Staff #1 was working in the center on 03/28/2023, 03/30/23, 04/03/2023, and 04/04/2023. Staff #8 stated they were not aware if the out-of-state background checks had been completed.
5. Two staff revealed during interviews that Staff #1 was counted in ratio and observed working with children alone.
Based on review of staff records, the center failed to ensure that all required out-of-state background checks were completed.
Evidence:
1. Staff #1?s date of employment was 08/04/2022. On the West Virginia Clearance for Access: Registry & Employment Screening, Staff #1 indicated they had lived in two states (West Virginia and Maryland), outside of Virginia within the past five years.
2. There was no documentation of a West Virginia or Maryland Sex Offender name check completed before date of hire.
3. There was not documentation that an out of state central registry finding for Maryland had been completed within 30 days of hire.
4. Staff #8 verified that Staff #1 was working in the center on 03/28/2023, 03/30/23, 04/03/2023, and 04/04/2023. Staff #8 stated they were not aware if the out-of-state background checks had been completed.
5. Two staff revealed during interviews that Staff #1 was counted in ratio and observed working with children alone.
Plan of Correction: Out of State Background Checks - upon hire all states lived in over the last 5 years will be noted by the Director who sent the offer, and checks will begin immediately.
Including Sex Offender Registry Check and Central Registry Checks. Included on Heritage Internal New Hire Checklist as of 6/19/2023
Including Sex Offender Registry Check and Central Registry Checks. Included on Heritage Internal New Hire Checklist as of 6/19/2023
Standard 8VAC20-770-60-B
COMPLAINT RELATED & REPEAT
Based on review of staff records, the center failed to ensure that the sworn disclosure statement included a statement that attested to whether or not the individual has been subject of a founded complaint of child abuse or neglect within or outside the Commonwealth was completed prior to the date of employment.
Evidence:
1. Staff #1?s date of employment was 08/04/2022. The West Virginia disclosure statement on file did not include a statement to attest whether or not the individual has been subject of a founded complaint of child abuse or neglect within or outside the Commonwealth.
2. Staff #8 verified that Staff #1 was working in the center on 03/28/2023, 03/30/23, 04/03/2023, and 04/04/2023.
3. Two staff revealed during interviews that Staff #1 was counted in ratio and observed working with children alone.
Based on review of staff records, the center failed to ensure that the sworn disclosure statement included a statement that attested to whether or not the individual has been subject of a founded complaint of child abuse or neglect within or outside the Commonwealth was completed prior to the date of employment.
Evidence:
1. Staff #1?s date of employment was 08/04/2022. The West Virginia disclosure statement on file did not include a statement to attest whether or not the individual has been subject of a founded complaint of child abuse or neglect within or outside the Commonwealth.
2. Staff #8 verified that Staff #1 was working in the center on 03/28/2023, 03/30/23, 04/03/2023, and 04/04/2023.
3. Two staff revealed during interviews that Staff #1 was counted in ratio and observed working with children alone.
Plan of Correction: Sworn Disclosure is now included in the new hire paperwork and must be completed prior to the first day of employment. On the first day of employment, Admin will check for this document at intake and a 2nd Admin will check that it is complete before orientation. Included on Heritage Internal New Hire Checklist 6/19/2023
Standard 8VAC20-770-60-C-2
COMPLAINT RELATED
Based on review of staff records, the center failed to ensure that a Virginia Central Registry Finding was completed within 30 days of hire.
Evidence:
1. Staff #1?s date of employment was 08/04/2022. There was not a completed Virginia Central Registry Finding on file for Staff #1.
2. Staff #8 verified that Staff #1 was working in the center on 03/28/2023, 03/30/23, 04/03/2023, and 04/04/2023. Staff #8 was not aware if a Virginia Central Registry finding had been completed for Staff #1.
3. Two staff revealed during interviews that Staff #1 was counted in ratio and observed working with children alone.
Based on review of staff records, the center failed to ensure that a Virginia Central Registry Finding was completed within 30 days of hire.
Evidence:
1. Staff #1?s date of employment was 08/04/2022. There was not a completed Virginia Central Registry Finding on file for Staff #1.
2. Staff #8 verified that Staff #1 was working in the center on 03/28/2023, 03/30/23, 04/03/2023, and 04/04/2023. Staff #8 was not aware if a Virginia Central Registry finding had been completed for Staff #1.
3. Two staff revealed during interviews that Staff #1 was counted in ratio and observed working with children alone.
Plan of Correction: A list is currently underway of Employees that are interested in being available to work in both Heritage and the WV center, Children First, if needed. These staff will be required to have all staff file information complete for both VA and WV State Licensing before working in both buildings is a possibility.
- To include:
- Central Registry Check
- Criminal History (Fingerprints)
- TB Screening (Current)
- VA Preservice Training
- To include:
- Central Registry Check
- Criminal History (Fingerprints)
- TB Screening (Current)
- VA Preservice Training
Standard 8VAC20-780-160-A
Based on review of staff records, the center failed to ensure that documentation of a tuberculosis screening or test shall be submitted at the time of employment and prior to coming into contact with children.
Evidence:
Staff #1?s date of employment was 08/04/2022. The tuberculosis screening on file was dated 09/23/2022.
Evidence:
Staff #1?s date of employment was 08/04/2022. The tuberculosis screening on file was dated 09/23/2022.
Plan of Correction: New Staff will not be permitted to work, and orientation will not be scheduled until a TB Screening has been completed and results are received. Included on Heritage Internal New Hire Checklist as of 6/19/2023.
Standard 8VAC20-780-350-B-2
COMPLAINT RELATED
Based on a review of sign-in sheets, timecards, schedule, and interviews, the center failed to ensure that the staff-to-children ratio was always maintained for children that are two years old.
Evidence:
1. Review of sign-in sheets revealed that there were fourteen two-year-olds in attendance on April 19, 2023, that were present between the timeframe of 2:30 P.M.-3:00 P.M. The required ratio is 1:8 for two-year-olds.
2. Review of the schedule and timesheets revealed that one staff member left at 2:29 P.M., and that another staff member did not arrive until 2:50 P.M.
3. Staff interviews confirmed that the required ratio was not maintained for two-year-olds for approximately 30 minutes, around 2:30pm- 3:00pm on April 19. 2023.
Based on a review of sign-in sheets, timecards, schedule, and interviews, the center failed to ensure that the staff-to-children ratio was always maintained for children that are two years old.
Evidence:
1. Review of sign-in sheets revealed that there were fourteen two-year-olds in attendance on April 19, 2023, that were present between the timeframe of 2:30 P.M.-3:00 P.M. The required ratio is 1:8 for two-year-olds.
2. Review of the schedule and timesheets revealed that one staff member left at 2:29 P.M., and that another staff member did not arrive until 2:50 P.M.
3. Staff interviews confirmed that the required ratio was not maintained for two-year-olds for approximately 30 minutes, around 2:30pm- 3:00pm on April 19. 2023.
Plan of Correction: To ensure Staff to child ratio is being maintained and that Staff are in their assigned classrooms, a
Staff attendance sheet has been created and implemented as of June 15th, 2023. Staff will sign in to their classroom, and sign out of their classroom as they leave the room. Staff may not leave the room at any point if they are not in compliance with ratios. Administration will be available for any classroom should they need coverage. Working Interviews will be introduced by Admin to Staff and announced clearly, these individuals will not count toward ratio, and may not be left alone with any child for any reason. All Staff have been verbally given this information, and Admin will closely monitor working staff in the building. The topic will be discussed during July 11th Staff meeting to clarify the purpose of a working interview and their status within the building when present.
Staff attendance sheet has been created and implemented as of June 15th, 2023. Staff will sign in to their classroom, and sign out of their classroom as they leave the room. Staff may not leave the room at any point if they are not in compliance with ratios. Administration will be available for any classroom should they need coverage. Working Interviews will be introduced by Admin to Staff and announced clearly, these individuals will not count toward ratio, and may not be left alone with any child for any reason. All Staff have been verbally given this information, and Admin will closely monitor working staff in the building. The topic will be discussed during July 11th Staff meeting to clarify the purpose of a working interview and their status within the building when present.
Standard 8VAC20-780-70
Based on review of staff records, the center failed to ensure that staff completed the Virginia Department of Education sponsored orientation course within 90 days of employment.
Evidence:
1. The record for Staff #1 showed the date of employment was 08/04/2022 and there was no documentation on file that Staff #1 had completed the orientation training.
2. Staff #8 verified that there was not documentation of the orientation training being completed by Staff #1.
Evidence:
1. The record for Staff #1 showed the date of employment was 08/04/2022 and there was no documentation on file that Staff #1 had completed the orientation training.
2. Staff #8 verified that there was not documentation of the orientation training being completed by Staff #1.
Plan of Correction: A list is currently underway of Employees that are interested in being available to work in both Heritage and the WV center, Children First, if needed. These staff will be required to have all staff file information complete for both VA and WV State Licensing before working in both buildings is a possibility.
- To include:
- Central Registry Check
- Criminal History (Fingerprints)
- TB Screening (Current)
- VA Preservice Training
- To include:
- Central Registry Check
- Criminal History (Fingerprints)
- TB Screening (Current)
- VA Preservice Training