Inspection · 2021-05-25
Date
2021-05-25
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.
No
Areas Reviewed
32.1 Report by person other than physician
54.1-3408 Must be MAT Certified.
63.2 Child Abuse & Neglect
63.2(17) License & Registration Procedures
63.2 Facilities & Programs.
22VAC40-191 Background Checks for Child Welfare Agencies
Inspector Notes
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia.
A code compliance inspection was initiated on 05/25/2021 and concluded on 05/25/2021. The director was contacted by video call to initiate the inspection. There were 56 children present and 11 staff. The inspector emailed the director a list of items required to complete the inspection. The Inspector reviewed 21 staff records submitted by the facility to ensure documentation was complete.
Information gathered during the inspection determined non-compliance(s) with applicable code sections and violations were documented on the violation notice issued to the facility.
The Licensing Inspector has reviewed with the provider COVID-19 Essential Guidance for Child Care programs.
Violations
4Standard 22VAC40-191-40-D-2
Based on staff record review, the center did not ensure 16 of 21 staff records had documentation of central registry results within 30 days of employment and a completed sworn statement or affirmation prior to employment.
Evidence:
1. The record of staff #1 (start date: 9/3/19) had documentation of a completed sworn statement or affirmation dated 1/2/20.
2. The record of staff #2 (start date: 8/22/19) had documentation of central registry results dated 9/27/19 and a completed sworn statement or affirmation dated 1/6/20.
3. The record of staff #3 (start date: 9/3/19) did not had a completed sworn statement or affirmation dated 1/21/20.
4. The record of staff #4 (start date: 9/9/19 and end date: 3/2020) had documentation of a completed sworn statement or affirmation dated 9/11/19.
5. The record of staff #5 (start date: 9/12/19) had documentation of a completed sworn statement or affirmation 1/8/20.
6. The record of staff #6 (start date: 12/5/19) had documentation of central registry results dated 1/13/20 and a completed sworn statement or affirmation dated 1/17/20.
7. The record of staff #7 (start date: 8/21/20) did not have documentation of central registry results and a completed sworn statement or affirmation dated 8/25/20.
8. The record of staff #8 (start date: 8/31/20) did not have documentation of central registry results.
9. The record of staff #9 (start date: 8/29/19) had documentation of central registry results dated 10/4/19.
10. The record of staff #11 (start date: 10/19/20) did not have documentation of central registry results and a completed sworn statement or affirmation dated 10/21/20.
11. The record of staff #12 (start date: 2/10/20) had documentation of central registry results dated 3/11/20.
12. The record of staff #13 (start date: 1/14/21) did not have documentation of central registry results.
13. The record of staff #14 (start date: 11/12/20) had documentation of central registry results dated 4/7/21.
14. The record of staff #16 (start date: 8/24/20) did not have documentation of central registry results.
15. The record of staff #17 (start date: 8/24/20) had documentation of central registry results dated 1/25/21.
16. The record of staff #18 (start date: 8/24/20) did not have documentation of central registry results.
Evidence:
1. The record of staff #1 (start date: 9/3/19) had documentation of a completed sworn statement or affirmation dated 1/2/20.
2. The record of staff #2 (start date: 8/22/19) had documentation of central registry results dated 9/27/19 and a completed sworn statement or affirmation dated 1/6/20.
3. The record of staff #3 (start date: 9/3/19) did not had a completed sworn statement or affirmation dated 1/21/20.
4. The record of staff #4 (start date: 9/9/19 and end date: 3/2020) had documentation of a completed sworn statement or affirmation dated 9/11/19.
5. The record of staff #5 (start date: 9/12/19) had documentation of a completed sworn statement or affirmation 1/8/20.
6. The record of staff #6 (start date: 12/5/19) had documentation of central registry results dated 1/13/20 and a completed sworn statement or affirmation dated 1/17/20.
7. The record of staff #7 (start date: 8/21/20) did not have documentation of central registry results and a completed sworn statement or affirmation dated 8/25/20.
8. The record of staff #8 (start date: 8/31/20) did not have documentation of central registry results.
9. The record of staff #9 (start date: 8/29/19) had documentation of central registry results dated 10/4/19.
10. The record of staff #11 (start date: 10/19/20) did not have documentation of central registry results and a completed sworn statement or affirmation dated 10/21/20.
11. The record of staff #12 (start date: 2/10/20) had documentation of central registry results dated 3/11/20.
12. The record of staff #13 (start date: 1/14/21) did not have documentation of central registry results.
13. The record of staff #14 (start date: 11/12/20) had documentation of central registry results dated 4/7/21.
14. The record of staff #16 (start date: 8/24/20) did not have documentation of central registry results.
15. The record of staff #17 (start date: 8/24/20) had documentation of central registry results dated 1/25/21.
16. The record of staff #18 (start date: 8/24/20) did not have documentation of central registry results.
Plan of Correction: No action required since on file - just not by deadline. Will change filing system. [Director]
Standard 22VAC40-191-40-D-6
Based on staff record review, the center did not ensure that satisfactory fingerprint based national criminal background checks were not dated more than 90 days prior to the date of employment.
Evidence:
1. The record for staff #9 (start date: 8/29/2019) had documentation of fingerprint based national criminal background check dated 10/18/2018.
2. The record of staff #19 (start date: 1/25/2021) had documentation of central registry results dated 9/22/20, fingerprint results dated 9/4/20 and a sworn statement or affirmation dated 9/2/20.
Evidence:
1. The record for staff #9 (start date: 8/29/2019) had documentation of fingerprint based national criminal background check dated 10/18/2018.
2. The record of staff #19 (start date: 1/25/2021) had documentation of central registry results dated 9/22/20, fingerprint results dated 9/4/20 and a sworn statement or affirmation dated 9/2/20.
Plan of Correction: Now I know the deadline. I will implement filing system to check filings. [Director]
Standard 63.2(17)-1720.1-B-2
Based on staff record review, the center did not ensure 18 of 21 staff records had documentation of fingerprint based national criminal history search results prior to employment.
Evidence:
1. The record of staff #1 (start date: 9/03/19) had documentation of fingerprint based national criminal history search results dated 9/4/19.
2. The record of staff #4 (start date: 9/09/19) did not have documentation of fingerprint based national criminal history search results.
3. The record of staff #6 (start date: 12/5/19) had documentation of fingerprint based national criminal history search results dated 12/12/19.
4. The record of staff #7 (start date: 8/21/20) had documentation of fingerprint based national criminal history search results dated 8/25/20.
5. The record of staff #8 (start date: 8/31/20) did not have documentation of fingerprint based national criminal history search results.
6. The record of staff #11 (start date: 10/19/20) did not have documentation of fingerprint based national criminal history search results.
7. The record of staff #12 (start date: 2/10/20) had documentation of fingerprint based national criminal history search results dated 2/13/20.
8. The record of staff #13 (start date: 1/14/21) did not have documentation of fingerprint based national criminal history search results.
9. The record of staff #14 (start date: 11/12/20) did not have documentation of fingerprint based national criminal history search results.
10. The record of staff #15 (start date: 3/2/21) did not have documentation of fingerprint based national criminal history search results.
11. The record of staff #16 (start date: 8/24/20) did not have documentation of fingerprint based national criminal history search results.
12. The record of staff #17 (start date: 8/24/20) had documentation of fingerprint based national criminal history search results dated 9/2/20.
13. The record of staff #18 (start date: 8/24/20) did not have documentation of fingerprint based national criminal history search results.
Evidence:
1. The record of staff #1 (start date: 9/03/19) had documentation of fingerprint based national criminal history search results dated 9/4/19.
2. The record of staff #4 (start date: 9/09/19) did not have documentation of fingerprint based national criminal history search results.
3. The record of staff #6 (start date: 12/5/19) had documentation of fingerprint based national criminal history search results dated 12/12/19.
4. The record of staff #7 (start date: 8/21/20) had documentation of fingerprint based national criminal history search results dated 8/25/20.
5. The record of staff #8 (start date: 8/31/20) did not have documentation of fingerprint based national criminal history search results.
6. The record of staff #11 (start date: 10/19/20) did not have documentation of fingerprint based national criminal history search results.
7. The record of staff #12 (start date: 2/10/20) had documentation of fingerprint based national criminal history search results dated 2/13/20.
8. The record of staff #13 (start date: 1/14/21) did not have documentation of fingerprint based national criminal history search results.
9. The record of staff #14 (start date: 11/12/20) did not have documentation of fingerprint based national criminal history search results.
10. The record of staff #15 (start date: 3/2/21) did not have documentation of fingerprint based national criminal history search results.
11. The record of staff #16 (start date: 8/24/20) did not have documentation of fingerprint based national criminal history search results.
12. The record of staff #17 (start date: 8/24/20) had documentation of fingerprint based national criminal history search results dated 9/2/20.
13. The record of staff #18 (start date: 8/24/20) did not have documentation of fingerprint based national criminal history search results.
Plan of Correction: We will have employees that have not had fingerprints done to do ASAP. I will create a different filing system to be reminded they cannot start until prints are on file. [Director] will be responsible.
Standard 63.2(17)-1720.1-B-4
Based on record review, the center did not ensure one of twenty one staff records contained documentation of criminal history record results, a sex offender registry check results and a child abuse and neglect search request from any state in which the individual has resided in the past five years.
Evidence:
1. The record of staff #11 (start date: 1/13/2021) did not have documentation of sex offender registry check results and a child abuse and neglect search request from any state in which the individual has resided in the past five years.
2. The Sworn Statement or Affirmation for staff #21 indicated that the staff has lived in one other state within the past five years.
Evidence:
1. The record of staff #11 (start date: 1/13/2021) did not have documentation of sex offender registry check results and a child abuse and neglect search request from any state in which the individual has resided in the past five years.
2. The Sworn Statement or Affirmation for staff #21 indicated that the staff has lived in one other state within the past five years.
Plan of Correction: Will get documents from DSS for her to fill out. I will be more aware of past living. [Director] is responsible.