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Ms. Deanna Southern

Inspection · 2024-03-26

Date
2024-03-26
Complaint Related
No
Licensing Inspector
Rebecca Forestier
(540) 309-2835
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

8VAC20-800 ADMINISTRATION
8VAC20-800 PERSONNEL
8VAC20-800 HOUSEHOLD MEMBERS
8VAC20-800 PHYSICAL HEALTH OF CAREGIVERS AND HOUSEHOLD MEMBERS
8VAC20-800 CAREGIVER TRAINING
8VAC20-800 PHYSICAL EQUIPMENT AND ENVIRONMENT
8VAC20-800 CARE OF CHILDREN
8VAC20-800 PREVENTING THE SPREAD OF DISEASE
8VAC20-800 EMERGENCIES
8VAC20-800 NUTRITION
8VAC20-770 BACKGROUND CHECKS
22.1 BACKGROUND CHECKS, CODE, CARBON MONOXIDE

Inspector Notes

An unannounced monitoring inspection was conducted on 03/26/2024. There were 12 non-resident children and 1 resident child, ages 8 months-5 years, totaling 31 points, and 3 caregivers present during the inspection. The inspector reviewed compliance in the areas of administration, personnel, household members, caregiver training, physical environment and equipment, care of children, preventing the spread of disease, emergencies, nutrition, and background checks. A total of 5 children?s records and 5 caregiver records were reviewed. The children were observed in organized group activities and in free choice play. The inspector arrived for the inspection at 9:00 am and departed at 10:45 am.

Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the provider.

Violations

5
Standard 22.1-289.035-A
REPEAT VIOLATION

Based on record review, the provider failed to ensure that all caregivers shall undergo a background check in accordance with the Code of Virginia prior to employment and every five years thereafter.

Evidence: The most recent search of the central registry for Caregiver 4 was dated 12/12/2018; there was not a follow-up search of the central registry obtained by 12/12/2023.
Plan of Correction: Will use the portal to submit the request.
Standard 22.1-289.035-B-2
Based on document review, the provider failed to ensure that no person shall be hired for compensated employment prior to the facility obtaining an employment eligibility letter upon the completion of a fingerprint background check as required by the Code of Virginia.

Evidence:
1. The record for Caregiver 3 contained a documented hire date of 11/02/2023; the employment eligibility letter for Caregiver 3 was dated 11/09/2023.
2. The record for Caregiver 5 contained a documented hire date of 11/08/2023; the employment eligibility letter for Caregiver 5 was dated 11/09/2023.
Plan of Correction: Will make completing fingerprints part of the application/interview/hiring process.
Standard 8VAC20-770-60-B
Based on record review, the provider failed to ensure that an employee must not be employed until the agency has the person?s completed sworn statement or affirmation.

Evidence: The record for Caregiver 5 contained a documented hire date of 11/08/2023. The sworn statement in the record for Caregiver 5 was dated 11/09/2023.
Plan of Correction: Will make completing the sworn statement part of the application/interview/hiring process.
Standard 8VAC20-770-60-C-2
Based on record review, the provider failed to obtain the findings from a search of the central registry within 30 days of employment.

Evidence:
1. The record for Caregiver 3 contained a documented hire date of 11/02/2023. The search of the central registry for Caregiver 3 was dated 01/26/2024.
2. The record for Caregiver 5 contained a documented hire date of 11/08/2023. There was not a search of the central registry available for Caregiver 5.
Plan of Correction: Will start using the portal to submit requests.
Standard 8VAC20-800-170-A
Based on record review, the provider failed to obtain from each caregiver at the time of hire, a report documenting the absence of tuberculosis in a communicable form.

Evidence:
1. The record for Caregiver 3 contained a documented hire date of 11/02/2023. The tuberculosis screening/test was dated 11/08/2023.
2. The record for Caregiver 5 contained a documented hire date of 11/08/2023. The tuberculosis screening/test was dated 11/09/2023.
Plan of Correction: Will make getting a TB test part of the application/interview/hiring process.
View original record on Virginia Department of Social Services