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Millwood School

Inspection · 2024-11-07

Date
2024-11-07
Complaint Related
No
Licensing Inspector
Molly Muscat
(804) 588-2367
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.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
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 renewal inspection was initiated on 11/07/2024 and completed on 12/10/2024. The on-site inspection began at 10:45 am and ended at 12:30 pm. The inspector reviewed compliance in the areas listed above. There were 20 children present and 5 staff. The inspector reviewed 5 children?s records and 5 staff records on-site and reviewed 6 board member records on 12/10/2024.

The 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 11/22/2024. A POC submitted after this date will not appear on the public website.

An amended inspection was sent to the center on 12/17/2024. An updated POC is due by close of business on 12/24/2024.

Violations

9
Standard 22.1-289.035-A
The center is required to have employees undergo a background check every five years.

The most recent central registry check for staff #4 was overdue by 6 months.
Plan of Correction: Central registry for staff #4 has been sent twice. We were told first was sent but we didn't receive it.
Standard 22.1-289.036-A
Repeat Violation
Every applicant for licensure and agent of an applicant for licensure shall undergo a background check every five years.

1. The most recent background checks for agent #4 were overdue by 3 years.
2. The most recent background checks for agent #5 were overdue by 1 year.
Plan of Correction: Both agents were contacted. Agent #4 has since stepped off the Board. Agent #5 has had his background check done.
Standard 22.1-289.036-B-2
Every applicant for licensure and agent of an applicant for licensure shall undergo a background check within 30 days of employment or service.

1. The center did not obtain fingerprints for agent #1 who has been an officer of the board since 2021.
Plan of Correction: Background check for agent #1 has been done.
Standard 8VAC20-770-60-C-2
The center is required to obtain the results of a central registry background check on all agents/board members within 30 days of service.

1. The center did not obtain a central registry background check for agent #1 who has been in service since 2021.

2. The center did not obtain a central registry background check for agent #2 who has been in service since 2021.
Plan of Correction: Central Registry has been submitted for agent #1 & 2.
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 no physical examination in the record of child #2, who has been enrolled for 2 months.
Plan of Correction: Parents have requested from doctor.
Standard 8VAC20-780-160-C
A tuberculosis (TB) screening is required every two years from the last screening.

1. Staff #1 updated screening was due 3 days ago.
2. Staff #2 updated screening was due 15 days ago.
Plan of Correction: Both staff members notified to get screening.
Standard 8VAC20-780-60-A
Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information.

1. The record for child #4, enrolled for 2 months, was missing the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.
Plan of Correction: Parents were notified.
Standard 8VAC20-780-60-A-8
Repeat violation
A written care plan is required for each child with a diagnosed food allergy, to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction.

1. Child #2, who has been enrolled for 2 months, has a diagnosed food allergy and did not have a written care plan in their file.
2. Child #3, who has been enrolled for 2 months, has a diagnosed food allergy and did not have a written care plan in their file.
Plan of Correction: Both families were emailed requesting a copy form their doctor.
Standard 8VAC20-780-90-A
A written agreement between the parent and the center shall be in each child's record by the first day of the child's attendance. The agreement shall be signed by the parent and include an authorization for emergency medical care, a statement that the center will notify the parent when the child becomes ill and must be picked up, and a statement that the parent will inform the center within 24 hours of any communicable diseases within the household.

The record for child #3, enrolled for 2 months, did not contain a signed written parent agreement.
Plan of Correction: Necessary form was emailed to parents.
View original record on Virginia Department of Social Services