Inspection · 2023-06-05
Date
2023-06-05
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 monitoring inspection was initiated on Monday, June 5, 2023 to determine the center's compliance with licensing standards. The inspection concluded on Tuesday, June 13, 2023. On June 5, the inspector was on site from 10:35am to approximately 3:25pm. There were a total of 82 children present in the direct care of 12 staff members. The center's owner assisted the inspector throughout the inspection. Upon the inspector's arrival, the children and staff were observed in their respective classrooms. The children were observed during transitions, during free-play, and teacher-led activities. The center is equipped with age-appropriate materials and equipment for the children's use. Staff were engaged with the children and offered guidance when needed. The areas where children receive care were inspected and found to be in compliance. The required postings were observed. Medication is administered and medications and authorizations were reviewed. During the inspection, eight children's records and eight staff records were reviewed. On June 13, the inspector was on-site from 9:45am to approximately 10:50am reviewing records. Additional documentation was submitted electronically on June 6 and on June 13, 2023.
Information gathered during the inspections determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program.
Violations
8Standard 22.1-289.035-B-2
Based on a review of eight staff records and interview, the center did not obtain the satisfactory results of a national fingerprint-based criminal record search within the required timeframe.
Evidence: 1) The record of Staff #5, employed on 08/08/22, contained the results of a national fingerprint-based criminal record search that were completed on 09/07/21.
2) During interview, a member of management reported Staff #5 was previously employed as a contractor on 09/13/21 and new fingerprints were not obtained upon employment on 08/08/22. The results of the national fingerprint-based criminal record search are required to be obtained no more than 90 days prior to employment.
Evidence: 1) The record of Staff #5, employed on 08/08/22, contained the results of a national fingerprint-based criminal record search that were completed on 09/07/21.
2) During interview, a member of management reported Staff #5 was previously employed as a contractor on 09/13/21 and new fingerprints were not obtained upon employment on 08/08/22. The results of the national fingerprint-based criminal record search are required to be obtained no more than 90 days prior to employment.
Plan of Correction: The staff member will obtain updated fingerprints. In the future, new fingerprints will be required upon employment if they are more than 90 days old.
Standard 8VAC20-770-60-C-2
Based on a review of eight staff records and interview, the center did not ensure two staff had a central registry finding within 30 days of employment.
Evidence: 1) The central registry finding in the record of Staff #5, employed on 08/08/22, was dated 10/19/22.
2) The central registry finding in the record of Staff #8, employed on 05/31/22, was dated 07/07/22.
3) During interview, a member of management confirmed the central registry results for Staff #5 and Staff #8 were not received within 30 days of employment. 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 central registry finding in the record of Staff #5, employed on 08/08/22, was dated 10/19/22.
2) The central registry finding in the record of Staff #8, employed on 05/31/22, was dated 07/07/22.
3) During interview, a member of management confirmed the central registry results for Staff #5 and Staff #8 were not received within 30 days of employment. 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: Corrected. In the future, the center will follow up and document any contact with the Office of Background Investigations to ensure deadlines are met if a central registry is not returned within 30 days of employment.
Standard 8VAC20-780-160-A
Based on a review of eight staff records and interview, the center did not ensure two staff members submitted documentation of a negative tuberculosis (TB) screening within the required timeframes.
Evidence: 1) The TB screenings in the record of Staff #3, employed on 04/24/23, were completed on 02/10/23 and 05/30/23.
2) The TB screening in the record of Staff #5, employed on 08/08/22, was completed on 09/10/21.
3) During interview, a member of management confirmed the TB screenings for Staff #3 and Staff #5 were not completed within the required timeframes.
Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children. The documentation shall 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.
Evidence: 1) The TB screenings in the record of Staff #3, employed on 04/24/23, were completed on 02/10/23 and 05/30/23.
2) The TB screening in the record of Staff #5, employed on 08/08/22, was completed on 09/10/21.
3) During interview, a member of management confirmed the TB screenings for Staff #3 and Staff #5 were not completed within the required timeframes.
Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children. The documentation shall 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.
Plan of Correction: In the future, staff will obtain a negative TB screening at the time of employment. The TB screening will not be accepted if it was completed more than 30 days prior to employment.
Standard 8VAC20-780-240-A
Based on a review of eight staff records and interview, the center did not ensure two staff completed the Virginia Department of Education-sponsored (VDOE) orientation course within 90 calendar days of employment.
Evidence: 1) The VDOE orientation course in the record of Staff #5, employed on 08/08/22, was completed on 01/01/23.
2) The VDOE orientation course in the record of Staff #8, employed on 05/31/22, was completed on 06/12/23.
3) During interview, a member of management confirmed Staff #5 and Staff #8 did not complete the VDOE orientation course within 90 calendar days of employment.
Evidence: 1) The VDOE orientation course in the record of Staff #5, employed on 08/08/22, was completed on 01/01/23.
2) The VDOE orientation course in the record of Staff #8, employed on 05/31/22, was completed on 06/12/23.
3) During interview, a member of management confirmed Staff #5 and Staff #8 did not complete the VDOE orientation course within 90 calendar days of employment.
Plan of Correction: Corrected. In the future, staff will complete the DOE orientation within 90 days of employment.
Standard 8VAC20-780-245-A
Based on a review of eight staff records and interview, the center did not ensure two staff completed annually a minimum of 16 hours of training appropriate to the age of children in care.
Evidence: 1) The record of Staff #4, employed on 03/26/21, contained a total of 13 hours of annual training from 03/2022-03/2023.
2) The record of Staff #7, employed on 12/28/18, contained a total of 9 hours of annual training from 12/2021-12/2022.
3) During interview, a member of management confirmed the center did not have further documentation of other training completed by Staff #4 or Staff #7.
Evidence: 1) The record of Staff #4, employed on 03/26/21, contained a total of 13 hours of annual training from 03/2022-03/2023.
2) The record of Staff #7, employed on 12/28/18, contained a total of 9 hours of annual training from 12/2021-12/2022.
3) During interview, a member of management confirmed the center did not have further documentation of other training completed by Staff #4 or Staff #7.
Plan of Correction: In the future, staff will ensure to print out and provide documentation of trainings as they occur to ensure all annual training is properly tracked and documentation is available when needed.
Standard 8VAC20-780-510-G
Based on a review of eight medications and interview, the center did not ensure one medication was labeled with the name of the medication, the dosage amount, and the time or times to be given.
Evidence: 1) A prescription medication was observed for Child #8. The medication was in a plastic bag and did not contain the name of the medication, the dosage amount, and the time or times to be given.
2) During interview, a member of management stated the medication should not have been accepted in a plastic bag without the required information.
Evidence: 1) A prescription medication was observed for Child #8. The medication was in a plastic bag and did not contain the name of the medication, the dosage amount, and the time or times to be given.
2) During interview, a member of management stated the medication should not have been accepted in a plastic bag without the required information.
Plan of Correction: The medication was returned to the parent and the original box was requested to ensure all the required information is at the center along with the medication and authorizations.
Standard 8VAC20-780-510-P
Based on a review of documentation, observation, and interview, the center did not ensure that when an authorization for medication expires, the parent shall be notified that the medication needs to be picked up within 14 days or the parent must renew the authorization. Medications that are not picked up by the parent within 14 days will be disposed of by the center by either dissolving the medication down the sink or flushing it down the toilet.
Evidence: 1) Two prescription medications were observed for Child #11. The authorization to administer one medication expired on 05/06/23 and the authorization to administer the second medication expired on 05/2023.
2) During interview, a member of management confirmed the parent did not renew the authorization and did not pick up the medication within 14 days.
Evidence: 1) Two prescription medications were observed for Child #11. The authorization to administer one medication expired on 05/06/23 and the authorization to administer the second medication expired on 05/2023.
2) During interview, a member of management confirmed the parent did not renew the authorization and did not pick up the medication within 14 days.
Plan of Correction: The expired authorizations and medications were returned to the parent. A renewed authorization was requested.
Standard 8VAC20-780-530-A
Based on observation, a review of records, and interview, the center did not ensure at least one staff in each classroom or area where children are present shall have current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care.
Evidence: 1) Staff #3, employed on 04/24/23, was the only staff member present in the Toddler classroom on 05/31/23.
2) The record of Staff #3 did not contain documentation that the staff has current certification in CPR and first aid.
3) During interview, a member of management confirmed Staff #3 does not have current certification in CPR and first aid.
Evidence: 1) Staff #3, employed on 04/24/23, was the only staff member present in the Toddler classroom on 05/31/23.
2) The record of Staff #3 did not contain documentation that the staff has current certification in CPR and first aid.
3) During interview, a member of management confirmed Staff #3 does not have current certification in CPR and first aid.
Plan of Correction: The Toddler classroom now has an assistant that is certified in CPR and first aid. The lead teacher will obtain the required certification. The center will ensure all classrooms and areas where children receive care have a staff member with current certification in CPR and first aid.