Inspection · 2023-11-13
Date
2023-11-13
Complaint Related
No
Licensing Inspector
D'Nae Goodwin
(757) 404-3063
(757) 404-3063
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
8VAC20-770 Background Checks (8VAC20-770)
22.1 Background Checks Code, Carbon Monoxide
Inspector Notes
An unannounced monitoring inspection was conducted on 11/13/23 from 2:50pm to 5:00pm. At the time of the inspection there were 33 children in care and 4 staff members. Children were observed arriving to the center, eating snack and engaged in homework activities. Records were reviewed for 5 children while at the facility and 5 staff records were reviewed on 11/15/23 at the central office. Evacuation drills, injury reports, medication and emergency supplies were reviewed during the inspection. The information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice and discussed during the exit interview.
Violations
5Standard 8VAC20-780-160-A
Repeat Violation
Based on a review of 5 staff records, it was determined that the center did not ensure that each staff member shall submit documentation of a negative tuberculosis screening at the time of employment, prior to coming into contact with children.
Evidence:
1. Three out of five records reviewed contained documentation that the tuberculosis screenings were completed after employment began.
a. The tuberculosis screening provided for staff #1, hired on 10/4/23 was dated 10/18/23.
b. The tuberculosis screening provided for staff #4, hired on 9/14/23 was dated 9/22/23.
c. The tuberculosis screening provided for staff #5, hired on 10/20/23 was dated 11/1/23.
Based on a review of 5 staff records, it was determined that the center did not ensure that each staff member shall submit documentation of a negative tuberculosis screening at the time of employment, prior to coming into contact with children.
Evidence:
1. Three out of five records reviewed contained documentation that the tuberculosis screenings were completed after employment began.
a. The tuberculosis screening provided for staff #1, hired on 10/4/23 was dated 10/18/23.
b. The tuberculosis screening provided for staff #4, hired on 9/14/23 was dated 9/22/23.
c. The tuberculosis screening provided for staff #5, hired on 10/20/23 was dated 11/1/23.
Plan of Correction: New employees will have TB screening prior to first day with club members.
Standard 8VAC20-780-190-A
Based on the review of records and interview, it was determined the center did not ensure that the program director meets the required qualifications including education, and/or certification required for the position.
Evidence:
1. The record for staff #2, promoted to the director position in September 2023, did not include documentation to show the staff member met the education or certification requirements for the director position.
2. Staff #6 confirmed the staff member did not currently have the required college degree, college semester hours or completed a certification.
Evidence:
1. The record for staff #2, promoted to the director position in September 2023, did not include documentation to show the staff member met the education or certification requirements for the director position.
2. Staff #6 confirmed the staff member did not currently have the required college degree, college semester hours or completed a certification.
Plan of Correction: Program Director is in the process of enrolling in a certification program. A qualified staff member will take over place as an interim Program Director.
Standard 8VAC20-780-245-L
Based on a review of staff records and interviews, it was determined that the center did not ensure that there was at least one staff member on duty who had obtained within the last three years, instruction in performing the daily health observation (DHO) of children.
Evidence:
1.The records for staff #1 and staff #4 contained daily health observation training that had expired 6/18/2022.
2. Staff #6 confirmed there were no other staff members in the center with current daily health observation training.
Evidence:
1.The records for staff #1 and staff #4 contained daily health observation training that had expired 6/18/2022.
2. Staff #6 confirmed there were no other staff members in the center with current daily health observation training.
Plan of Correction: All staff will complete Daily Health Observation training, to ensure there will always be a trained staff on site. Training is scheduled to be completed by January 2024.
Standard 8VAC20-780-550-P
Based on observation and interviews, it was determined that the facility did not ensure that the center maintain a written record containing all of the required information of children's serious and minor injuries.
Evidence:
1. Five out of five injury reports reviewed did not contain the date the injury occurred.
2. Five out of five injury reports reviewed did not contain the required two signatures.
a. Two injury reports had no signatures.
b.Three injury reports contained only one signature.
Evidence:
1. Five out of five injury reports reviewed did not contain the date the injury occurred.
2. Five out of five injury reports reviewed did not contain the required two signatures.
a. Two injury reports had no signatures.
b.Three injury reports contained only one signature.
Plan of Correction: A new form was completed to ensure the date and time is at the top. Program Director or designated person will review all forms before they are filed to make sure everything is completed.
Standard 8VAC20-780-60-A
Based on review of children?s records and interviews, it was determined that the center did not ensure that each child?s record contains all required information.
Evidence:
1.The record for child #1 did not contain the work phone number and place of employment for each parent who has custody.
2.The records for child #1 and child #3 did not contain the complete emergency contact information for the second emergency contact.
Evidence:
1.The record for child #1 did not contain the work phone number and place of employment for each parent who has custody.
2.The records for child #1 and child #3 did not contain the complete emergency contact information for the second emergency contact.
Plan of Correction: Front desk staff will be retrained in how to accept new application, by signing a check list to ensure documents are completed.