Inspection · 2022-10-26
Date
2022-10-26
Complaint Related
No
Licensing Inspector
Jennifer Moore
(540) 430-0384
(540) 430-0384
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.
Yes
Areas Reviewed
8VAC20-790 Subsidy Regulations
Inspector Notes
An unannounced Subsidy Health and Safety inspection (SHSI) was initiated on 10/26/2022 and concluded on 10/31/2022. On Wednesday, October 26, 2022, the inspector was on site from 9:45am to approximately 11:35am. There were 23 children in attendance and a total of six staff directly supervising. Upon arrival, the children were observed in their designated classrooms. The children were participating in a variety of activities. The children were later observed preparing for lunch, taking bathroom breaks, and resting. Staff were observed having positive interactions with the children. All areas of the facility including classrooms, kitchen, hallways, outdoor play area, and bathrooms were inspected. Five children's records and five staff records were reviewed. Additional information was submitted electronically on 10/31/2022.
A code compliance inspection was conducted on the same date as the SHSI supplemental inspection. Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the
program.
Violations
11Standard 8VAC20-790-550-2-a
Based on a review of five staff records and interview, the vendor did not ensure three staff had the results of the Virginia Child Protective Services Central Registry check within 30 days of the individuals beginning employment.
Evidence: 1) The record of Staff #1, employed 09/16/2022, did not contain the results of the
central registry check. 2) The central registry finding in the record of Staff #3, employed 07/15/19, was dated 07/09/20. 3) The record of Staff #5, employed 04/07/22, did not contain the results of the central registry check. 4) During interview, management confirmed the central registry findings were not received within 30 days of employment for Staff #1, Staff #3, and Staff #5. The records did not contain documentation of any further contact with the Office of Background Investigations within 30 days of employment, and the staff members had been continuously employed.
Evidence: 1) The record of Staff #1, employed 09/16/2022, did not contain the results of the
central registry check. 2) The central registry finding in the record of Staff #3, employed 07/15/19, was dated 07/09/20. 3) The record of Staff #5, employed 04/07/22, did not contain the results of the central registry check. 4) During interview, management confirmed the central registry findings were not received within 30 days of employment for Staff #1, Staff #3, and Staff #5. The records did not contain documentation of any further contact with the Office of Background Investigations within 30 days of employment, and the staff members had been continuously employed.
Plan of Correction: In the future, the center will follow up with OBI and document contact if results are not received within 30 days of employment. The center will follow up with OBI about the missing results.
Standard 8VAC20-790-550-2-b
Based on a review of five staff records and interview, the vendor did not obtain satisfactory results of the child abuse and neglect registry from one state in which one staff member had resided in the preceding five years.
Evidence: 1) The record of Staff #1, employed 09/16/22, indicated the staff had resided in a state outside of Virginia in the last five years. The record did not contain the results of the child abuse and neglect registry from that state. 2) During interview, management reported the center did not obtain the required out-of-state background checks for Staff #1. The results should have been requested within 30 days of employments.
Evidence: 1) The record of Staff #1, employed 09/16/22, indicated the staff had resided in a state outside of Virginia in the last five years. The record did not contain the results of the child abuse and neglect registry from that state. 2) During interview, management reported the center did not obtain the required out-of-state background checks for Staff #1. The results should have been requested within 30 days of employments.
Plan of Correction: The out-of-state searches will be completed for Staff #1.
Standard 8VAC20-790-550-2-c
Based on a review of five staff records and interview, the vendor did not obtain the results of a criminal history record information check and sex offender registry check from one state in which the staff member had resided in the preceding five years.
Evidence: 1) The record of Staff #1, employed 09/16/22, indicated the staff had resided in a state outside of Virginia in the last five years. The record did not contain the results of a criminal history record information check or a sex offender registry check from that state. 2) During interview, management reported the center did not obtain the required out-of-state background checks for Staff #1. The criminal history record information check and the sex offender registry should have been obtained prior to employment.
Evidence: 1) The record of Staff #1, employed 09/16/22, indicated the staff had resided in a state outside of Virginia in the last five years. The record did not contain the results of a criminal history record information check or a sex offender registry check from that state. 2) During interview, management reported the center did not obtain the required out-of-state background checks for Staff #1. The criminal history record information check and the sex offender registry should have been obtained prior to employment.
Plan of Correction: The out-of-state searches will be completed for Staff #1.
Standard 8VAC20-790-550-2-f
Based on a review of five staff records and interview, the vendor did not obtain documentation of subsequent background checks conducted every five years for one staff member.
Evidence: 1) The sworn disclosure in the record of Staff #4, employed 09/19/17, expired on 09/19/22. 2) During interview, management reported Staff #4 did not complete a new sworn statement every five years as required.
Evidence: 1) The sworn disclosure in the record of Staff #4, employed 09/19/17, expired on 09/19/22. 2) During interview, management reported Staff #4 did not complete a new sworn statement every five years as required.
Plan of Correction: A new sworn disclosure is on file for Staff #4. In the future, background checks will be repeated every 5 years.
Standard 8VAC20-790-560-A
Based on a review of four staff records and interview, the vendor did not ensure one staff member had documentation of a negative tuberculosis (TB) screening within the required
timeframe.
Evidence: 1) The TB screening in the record of Staff #1, employed 09/16/22, was dated 10/02/22. 2) The record of Staff #5, employed 04/07/22, did not contain documentation of a
negative TB screening. 3) During interview, management confirmed Staff #5 does not have
documentation of a negative TB screening. Documentation of the screening should be submitted at the time of employment and prior to coming into contact with children.
timeframe.
Evidence: 1) The TB screening in the record of Staff #1, employed 09/16/22, was dated 10/02/22. 2) The record of Staff #5, employed 04/07/22, did not contain documentation of a
negative TB screening. 3) During interview, management confirmed Staff #5 does not have
documentation of a negative TB screening. Documentation of the screening should be submitted at the time of employment and prior to coming into contact with children.
Plan of Correction: Staff will submit the missing TB. In the future, staff will be required to provide a negative TB screening within the required timeframe.
Standard 8VAC20-790-580-A
Based on a review of five children's records and interview, the vendor did not obtain documentation that one child had received the immunization required by the State Board of Health before the child attended the center.
Evidence: 1) The immunizations in the record of Child #1, date of attendance 08/08/22, were
dated 09/01/22. 2) During interview, the center acknowledged immunizations for Child #1 were not obtained prior to the child's attendance.
Evidence: 1) The immunizations in the record of Child #1, date of attendance 08/08/22, were
dated 09/01/22. 2) During interview, the center acknowledged immunizations for Child #1 were not obtained prior to the child's attendance.
Plan of Correction: In the future, children will have the required immunizations at the time of attendance. The center will ensure to follow their established procedures for
ensuring children have the required immunizations.
ensuring children have the required immunizations.
Standard 8VAC20-790-600-B
Based on a review of five staff records, the vendor did not ensure two staff who work directly with children completed the Virginia Preservice Training for Child Care Staff within 90 days of employment.
Evidence: 1) The Virginia Preservice Training certificate in the record of Staff #2, employed 12/28/20, was dated 10/28/22. 2) The Virginia Preservice Training certificate in the record of Staff #4, employed 04/07/22, was dated 10/02/22.
Evidence: 1) The Virginia Preservice Training certificate in the record of Staff #2, employed 12/28/20, was dated 10/28/22. 2) The Virginia Preservice Training certificate in the record of Staff #4, employed 04/07/22, was dated 10/02/22.
Plan of Correction: Moving forward, staff will complete the VA Preservice training within 90 days of employment.
Standard 8VAC20-790-600-C
Based on a review of five staff records and interview, the vendor did not ensure one staff completed orientation training prior to the staff member working alone with children and within seven days of the date of employment.
Evidence: 1) The record of Staff #1, employed 09/16/22, contained documentation of orientation training that was dated 09/30/22. 2) During interview, management reported the orientation training was not completed within seven days of the date of employment.
Evidence: 1) The record of Staff #1, employed 09/16/22, contained documentation of orientation training that was dated 09/30/22. 2) During interview, management reported the orientation training was not completed within seven days of the date of employment.
Plan of Correction: Moving forward, staff will receive orientation training within 7 days of employment.
Standard 8VAC20-790-600-F
Based on a review of five staff records and interview, the vendor did not ensure three staff who work directly with children completed at least annually 16 hours of training and staff development activities, to include the department's health and safety update course.
Evidence: 1) The record of Staff #2, employed 12/28/20, contained 14.5 hours of annual training. The department's health and safety update course on file was completed on 10/27/22. The staff did not complete the health and safety update course in 2021.
2) The record of Staff #3, employed 07/15/19, contained 1.5 hours of annual training. The department's health and safety update course on file was completed on 08/03/20. The staff did not complete the health and safety update course in 2021.
3) The record of Staff #4, employed 09/19/17, contained 1.5 hours of annual training. The department's health and safety update course on file was completed on 07/30/20. The staff did not complete the health and safety update course in 2021.
4) During interview, management stated additional training certificates for Staff #2, Staff #3, and Staff #4 could not be located.
Evidence: 1) The record of Staff #2, employed 12/28/20, contained 14.5 hours of annual training. The department's health and safety update course on file was completed on 10/27/22. The staff did not complete the health and safety update course in 2021.
2) The record of Staff #3, employed 07/15/19, contained 1.5 hours of annual training. The department's health and safety update course on file was completed on 08/03/20. The staff did not complete the health and safety update course in 2021.
3) The record of Staff #4, employed 09/19/17, contained 1.5 hours of annual training. The department's health and safety update course on file was completed on 07/30/20. The staff did not complete the health and safety update course in 2021.
4) During interview, management stated additional training certificates for Staff #2, Staff #3, and Staff #4 could not be located.
Plan of Correction: Staff will be required to log all training and to complete 16 hours of annual training. Staff will complete the update training annually.
Standard 8VAC20-790-600-I
Based on interview, the vendor did not ensure there should be at least one staff on duty who has obtained within the last three years instruction in performing a daily health observation of children.
Evidence: During interviews, management was not able to identify a staff member on duty who has obtained within the last three years instruction in daily health observation of children.
Evidence: During interviews, management was not able to identify a staff member on duty who has obtained within the last three years instruction in daily health observation of children.
Plan of Correction: The center will ensure staff receive training and follow the established procedures for daily health observation.
Standard 8VAC20-790-800-A-1
Based on documentation reviewed and interview, the vendor did not ensure the center's evacuation procedures were practiced at least monthly.
Evidence: 1)The emergency response drills reviewed for 2022 did not include a practice evacuation drill for February 2022, July 2022, and August 2022. 2) During interview, management reported an evacuation drill was not practiced during those months.
Evidence: 1)The emergency response drills reviewed for 2022 did not include a practice evacuation drill for February 2022, July 2022, and August 2022. 2) During interview, management reported an evacuation drill was not practiced during those months.
Plan of Correction: Moving forward, evacuation procedures will be practiced monthly.