Inspection · 2022-11-29
Date
2022-11-29
Complaint Related
No
Licensing Inspector
Jaime Harris
(804) 807-3278
(804) 807-3278
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
8VAC20-770 Background Checks
20 Access to minor's records
22.1 Early Childhood Care and Education
32.1 Report by person other than physician
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced renewal inspection was conducted on Tuesday, November 29, 2022 from 10:30am to approximately 2:15pm. There were a total of 53 children in care in the direct care of 11 staff members. During the inspection, the children and staff were observed participating in a variety of activities. Staff were observed having positive interactions with the children. All areas of the facility including classrooms, kitchen, hallways, playground, and bathrooms were inspected. The center is equipped with toys and supplies and items were available to the children. The required postings were reviewed and found to be in compliance. During the inspection, five children's records and five staff records were reviewed.
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
7Standard 22.1-289.035-B-4
Based on a review of five staff records and interview, the center did not obtain satisfactory results of the child abuse and neglect registry from any other state in which one individual has resided in the preceding five years.
Evidence: 1) The record of Staff #4, employed on 09/22/22, indicated the staff resided in a state outside of Virginia within the last five years. The record did not contain the results of the child abuse and neglect registry from that state within 30 days of employment. 2) During interview, management reported the out-of-state child abuse and neglect registry for Staff #4 had not been obtained.
Evidence: 1) The record of Staff #4, employed on 09/22/22, indicated the staff resided in a state outside of Virginia within the last five years. The record did not contain the results of the child abuse and neglect registry from that state within 30 days of employment. 2) During interview, management reported the out-of-state child abuse and neglect registry for Staff #4 had not been obtained.
Plan of Correction: The request will be sent this afternoon and verification that it was submitted will be sent to licensing within 10 days.
Standard 8VAC20-770-60-B
Based on a review of five staff records and interview, the center did not ensure one staff had a completed sworn statement or affirmation prior to employment.
Evidence: 1) The record of Staff #1, employed 09/06/22, did not contain a completed sworn statement or affirmation. 2) During interview, management reported Staff #1 completed the sworn statement, but it could not be located during the inspection.
Evidence: 1) The record of Staff #1, employed 09/06/22, did not contain a completed sworn statement or affirmation. 2) During interview, management reported Staff #1 completed the sworn statement, but it could not be located during the inspection.
Plan of Correction: A new sworn statement will be completed today. In the future, documentation will be maintained in the staff record as required.
Standard 8VAC20-770-60-C-2
Based on a review of five staff records and interview, the center did not ensure that five staff members had a central registry finding within 30 days of employment.
Evidence: 1) The record of Staff #1, employed 09/06/22, did not contain the results of the central registry finding.
2) The central registry finding in the record of Staff #2, employed 06/28/22, was dated 08/12/22.
3) The central registry finding in the record of Staff #3, employed 06/28/22, was dated 08/12/22.
4) The record of Staff #4, employed 09/22/22, did not contain the results of the central registry finding.
5) The record of Staff #5, employed 09/26/22, did not contain the results of the central registry finding.
6) During interview, management confirmed the central registry findings were not received within 30 days of employment for Staff #1, Staff #2, Staff #3, Staff #4, and Staff #5. The records did not contain documentation of any further contact with the Office of Background Investigations, and the staff members had been continuously employed.
Evidence: 1) The record of Staff #1, employed 09/06/22, did not contain the results of the central registry finding.
2) The central registry finding in the record of Staff #2, employed 06/28/22, was dated 08/12/22.
3) The central registry finding in the record of Staff #3, employed 06/28/22, was dated 08/12/22.
4) The record of Staff #4, employed 09/22/22, did not contain the results of the central registry finding.
5) The record of Staff #5, employed 09/26/22, did not contain the results of the central registry finding.
6) During interview, management confirmed the central registry findings were not received within 30 days of employment for Staff #1, Staff #2, Staff #3, Staff #4, and Staff #5. The records did not contain documentation of any further contact with the Office of Background Investigations, and the staff members had been continuously employed.
Plan of Correction: Management will follow up with the Office of Background Investigation (OBI) and will provide updates to licensing within 10 days. In the future, the center will follow up with OBI and will maintain documentation when the central registry finding is not received within 30 days of employment.
Standard 8VAC20-780-160-A
Based on a review of five staff records, the center did not ensure three staff members had documentation of a negative tuberculosis (TB) screening within the required timeframes.
Evidence: 1) The TB screening in the record of Staff #2, employed 06/28/22, was dated 03/19/22. The documentation should have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician's designee, or an official of the local health department.
2) The record for Staff #4, employed 09/22/22, and the record for Staff #5, employed 09/26/22, did not contain documentation of a negative tuberculosis screening. Documentation of the screening should be submitted at the time of employment and prior to coming into contact with children.
Evidence: 1) The TB screening in the record of Staff #2, employed 06/28/22, was dated 03/19/22. The documentation should have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician's designee, or an official of the local health department.
2) The record for Staff #4, employed 09/22/22, and the record for Staff #5, employed 09/26/22, did not contain documentation of a negative tuberculosis 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 #4 has an appointment to obtain a TB screening on 12/13/22. Moving forward, staff will have to present a TB screening prior to employment and it cannot be more than 30 days prior to employment.
Standard 8VAC20-780-240-A
Based on a review of five staff records and interview, the center did not ensure one staff member completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.
Evidence: 1) The record for Staff #3, employed 06/28/22, did not contain documentation of the Virginia Department of Education-sponsored orientation course. 2) During interview, management reported Staff #3 has not completed the training.
Evidence: 1) The record for Staff #3, employed 06/28/22, did not contain documentation of the Virginia Department of Education-sponsored orientation course. 2) During interview, management reported Staff #3 has not completed the training.
Plan of Correction: Staff #3 will complete the training by the end of next week. Moving forward, staff will have to complete the training within 90 days of employment.
Standard 8VAC20-780-550-D
Based on a review of documents and interview, the center did not implement a monthly practice evacuation drill.
Evidence: 1) The licensing inspector reviewed the emergency drill log for the year 2022. The last practice evacuation drill was documented on 05/02/22. 2) During interview, management reported there have not been monthly practice evacuation drills since May 2022.
Evidence: 1) The licensing inspector reviewed the emergency drill log for the year 2022. The last practice evacuation drill was documented on 05/02/22. 2) During interview, management reported there have not been monthly practice evacuation drills since May 2022.
Plan of Correction: An evacuation drill will be conducted this afternoon and monthly moving forward. The drills will be documented as required.
Standard 8VAC20-780-70
Based on a review of five staff records and interview, the center did not ensure five staff records contained the required information.
Evidence: 1) The following staff records did not contain documentation that two or more references as to character and reputation as well as competency were checks before employment.: Staff #1 (employed 09/06/22), Staff #2 (employed 06/28/22), Staff #3 (employed 06/28/22), and Staff #5 (employed 09/26/22).
2) The record of Staff #4, employed 09/22/22, was missing a second reference.
3) During interview, management acknowledged the references were not obtained for each staff member prior to employment.
Evidence: 1) The following staff records did not contain documentation that two or more references as to character and reputation as well as competency were checks before employment.: Staff #1 (employed 09/06/22), Staff #2 (employed 06/28/22), Staff #3 (employed 06/28/22), and Staff #5 (employed 09/26/22).
2) The record of Staff #4, employed 09/22/22, was missing a second reference.
3) During interview, management acknowledged the references were not obtained for each staff member prior to employment.
Plan of Correction: The missing references will be obtained by the end of the week. Moving forward, all references will be obtained prior to employment.