Inspection · 2022-08-24
Date
2022-08-24
Complaint Related
No
Licensing Inspector
Rene Old
(757) 404-1784
(757) 404-1784
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.
8VAC20-820 THE LICENSE.
8VAC20-770 Background Checks (8VAC20-770)
Inspector Notes
An unannounced monitoring inspection was conducted on 08/24/2022 from 1:50 pm - 5:20 pm. At the time of the tour there were 179 school age children present with 18 staff. Children were observed eating afternoon snack, engaged in closing games in the gathering area and during departure. Records were reviewed for three children and two staff.
Information gathered during the inspection determined non-compliances with applicable standards or law and violations were documented on the violation notice issued to the program.
Violations
15Standard 8VAC20-770-60-C-2
Based on record review, the center failed to ensure that staff have have a central registry finding within 30 days of employment or volunteer service.
Evidence:
1. Staff 1, hire date 11/15/2021, lacks a central registry finding.
2. Staff 2, hire date 06/07/2022, lacks a central registry finding.
3. Staff 3, hire date 06/01/2022, lacks a central registry finding.
3. Administrative staff confirmed that a central registry finding was not on file for these staff.
Evidence:
1. Staff 1, hire date 11/15/2021, lacks a central registry finding.
2. Staff 2, hire date 06/07/2022, lacks a central registry finding.
3. Staff 3, hire date 06/01/2022, lacks a central registry finding.
3. Administrative staff confirmed that a central registry finding was not on file for these staff.
Plan of Correction: Central Registry audit has been conducted going into the Before and After care season. To ensure that all staff records are completed and up to date
Standard 8VAC20-780-160-A
Based on record review and interview, the center failed to ensure that each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children.
Evidence:
1. Staff 1, hire date 11/15/2021, lacked documentation of a TB screening.
a. Staff 1 was observed caring for a group of children during the inspection.
2. Staff 3, hire date 06/01/2022, lacked documentation of a TB screening.
a. Staff 3 was observed caring for a group of children during the inspection.
2. Administrative staff confirmed that a TB screening was not on file for staff 1and staff 3.
Evidence:
1. Staff 1, hire date 11/15/2021, lacked documentation of a TB screening.
a. Staff 1 was observed caring for a group of children during the inspection.
2. Staff 3, hire date 06/01/2022, lacked documentation of a TB screening.
a. Staff 3 was observed caring for a group of children during the inspection.
2. Administrative staff confirmed that a TB screening was not on file for staff 1and staff 3.
Plan of Correction: Tuberculosis Screening audit has been conducted going into the Before and After Care season. To ensure that all staff records are completed and up to date.
Standard 8VAC20-780-270-A
Based on observation, the center failed to ensure that areas and equipment of the center shall be maintained in a safe condition.
Evidence:
1. A child was observed playing on the floor, in the camp office, directly beside a window blind cord that was dangling down the wall onto the floor.
a. This is an entanglement hazard.
2. An extension cord was observed placed on the floor, running the length of the classroom, located across from the camp office. This extension cord had been placed through a closed window and extended outside down the side of the building and on the ground. The cord was plugged into a golf cart charger which was sitting on the ground.
a. This is a trip hazard and a fire safety hazard.
Evidence:
1. A child was observed playing on the floor, in the camp office, directly beside a window blind cord that was dangling down the wall onto the floor.
a. This is an entanglement hazard.
2. An extension cord was observed placed on the floor, running the length of the classroom, located across from the camp office. This extension cord had been placed through a closed window and extended outside down the side of the building and on the ground. The cord was plugged into a golf cart charger which was sitting on the ground.
a. This is a trip hazard and a fire safety hazard.
Plan of Correction: Leadership team will have a sign in and out sheet to ensure that all equipment is locked away before and after camp.
Standard 8VAC20-780-340-A
Based on observation, the center failed to ensure that when staff are supervising children, they shall always ensure their care, protection, and guidance.
Evidence:
1. Two children were observed talking and socializing at the grassy area on the side of the classrooms. No staff were present to supervise these children.
a. The inspector brought the unsupervised children to the attention of administrative staff who confirmed they were not aware these children had left the group.
Evidence:
1. Two children were observed talking and socializing at the grassy area on the side of the classrooms. No staff were present to supervise these children.
a. The inspector brought the unsupervised children to the attention of administrative staff who confirmed they were not aware these children had left the group.
Plan of Correction: Leadership will have proper protocol training on how to supervise children and while being placed in different scenarios to ensure the staff is prepared during operational hours.
Standard 8VAC20-780-340-F
Based on observation, the center failed to ensure that children under 10 years of age always shall be within actual sight and sound supervision of staff.
Evidence:
1. Between 3:38 pm and 3:40 pm the inspector observed four children walk unattended from the camp outdoor gathering area to the parking lot where their parent's were waiting at pick up car pool.
a. There were no staff in the parking lot to ensure these children arrived safely to the correct parent nor were any staff within sight and sound supervision of the children once they left the outdoor gathering area.
b. The outdoor gathering area is located behind the camp office and staff can not see beyond the sidewalk area of the camp office.
Evidence:
1. Between 3:38 pm and 3:40 pm the inspector observed four children walk unattended from the camp outdoor gathering area to the parking lot where their parent's were waiting at pick up car pool.
a. There were no staff in the parking lot to ensure these children arrived safely to the correct parent nor were any staff within sight and sound supervision of the children once they left the outdoor gathering area.
b. The outdoor gathering area is located behind the camp office and staff can not see beyond the sidewalk area of the camp office.
Plan of Correction: Leadership will conduct more hands-on training on sight and sound during operational hours as camp. With different scenarios to make sure staff are prepared for different challenges.
Standard 8VAC20-780-400-B
Based on observation, the center failed to ensure that behavioral guidance shall be constructive in nature, age and stage appropriate, and shall be intended to redirect children to appropriate behavior and resolve conflicts.
Evidence:
1. Staff 1 who was identified as the program leader for a group of 27 five year old children was heard stating , " Y'all aren't listening" several times to the children in a voice tone that was loud and negative.
a. The inspector was siting inside of an office and overheard staff 1 from an open window.
b. Staff 1 continued to admonish the children, in a loud voice, several more times until told by the program director that her manner of speaking to the children was inappropriate.
Evidence:
1. Staff 1 who was identified as the program leader for a group of 27 five year old children was heard stating , " Y'all aren't listening" several times to the children in a voice tone that was loud and negative.
a. The inspector was siting inside of an office and overheard staff 1 from an open window.
b. Staff 1 continued to admonish the children, in a loud voice, several more times until told by the program director that her manner of speaking to the children was inappropriate.
Plan of Correction: Leadership will have proper protocol training on how to speak to the campers during the start of camp and having weekly staff meetings.
Standard 8VAC20-780-430-K
Based on observation, the center failed to ensure that provision shall be made for an individual place for each child's personal belongings.
Evidence:
The inspector observed approximately 45 backpacks & lunch containers stored in a heap on the floor of the classroom located across form the camp office.
Evidence:
The inspector observed approximately 45 backpacks & lunch containers stored in a heap on the floor of the classroom located across form the camp office.
Plan of Correction: Leadership will conduct a walk through to relocate the area for lunch containers and backpacks.
Standard 8VAC20-780-510-G
Based on medication review, the center failed to ensure that edication shall be labeled with the child's name, the name of the medication, the dosage amount, and the time or times to be given.
Evidence:
1. A loose inhaler, for child 3, was observed stored in a plastic bag inside of the locked medication box.
a. The bag was labeled with the child's name however, the medication lacked any name label, dosage amount and times to be given.
2. A loose epi pen, for child 4, was observed stored in a plastic bag inside of the locked medication box.
a. The bag was labeled with the child's name however, the medication lacked any name label, dosage amount and times to be given.
Evidence:
1. A loose inhaler, for child 3, was observed stored in a plastic bag inside of the locked medication box.
a. The bag was labeled with the child's name however, the medication lacked any name label, dosage amount and times to be given.
2. A loose epi pen, for child 4, was observed stored in a plastic bag inside of the locked medication box.
a. The bag was labeled with the child's name however, the medication lacked any name label, dosage amount and times to be given.
Plan of Correction: Medication specialists that assist with medication during the camp season will have a weekly checklist to ensure that specific drugs have their original labeled container.
Standard 8VAC20-780-510-I
Based on medication review, the center failed to ensure that drugs that were dispensed from a pharmacy shall be maintained in the original, labeled container.
Evidence:
1. Two prescription medications for child 3 and child 4 were received into the facility without the original prescription label.
Evidence:
1. Two prescription medications for child 3 and child 4 were received into the facility without the original prescription label.
Plan of Correction: Medication specialists that assist with medication during camp season will have a weekly checklist to ensure that specific drugs have their original labeled container.
Standard 8VAC20-780-550-G
Based on record review, the center failed to maintain documentation of emergency shelter-in-place, and lockdown drills.
Evidence:
The emergency log for the facility lacked documentation of any shelter-in-place or lockdown practice drills for the months of June, July and August 2022.
Evidence:
The emergency log for the facility lacked documentation of any shelter-in-place or lockdown practice drills for the months of June, July and August 2022.
Plan of Correction: Leadership staff will document shelter in place and lockdown drills in licensing binder. Conducting weekly audits to ensure that information is up to date.
Standard 8VAC20-780-550-P
Based on record review, the center failed to ensure that the written record of children's serious and minor injuries in which entries are made the day of occurrence include all of the required elements.
Evidence:
1. A review of 20 injury reports found the following required information lacking:
a. One report lacked a staff and parent signature or two staff signatures;
b. Three injury reports lacked a parent signature or a second staff signature;
c. Ten injury reports lacked the date and or time the parent was notified;
d. Four reports lacked documentation of any future action to prevent recurrence of the injury;
e. Four injury reports lacked documentation of how the parent was notified.
Evidence:
1. A review of 20 injury reports found the following required information lacking:
a. One report lacked a staff and parent signature or two staff signatures;
b. Three injury reports lacked a parent signature or a second staff signature;
c. Ten injury reports lacked the date and or time the parent was notified;
d. Four reports lacked documentation of any future action to prevent recurrence of the injury;
e. Four injury reports lacked documentation of how the parent was notified.
Plan of Correction: During the start of camp season staff will have knowledge on how to fill out campers incident reports and have hands-on training with leadership staff to ensure that no steps missed.
Standard 8VAC20-780-560-G
Based on observation, the center failed to ensure that children's lunch containers shall be clearly dated.
Evidence:
Ten of ten lunch containers reviewed lacked a current date.
Evidence:
Ten of ten lunch containers reviewed lacked a current date.
Plan of Correction: Lunch tags will be created and laminated every Sunday before each week of camp.
Standard 8VAC20-780-60-A
Based on record review and interview, the center failed to ensure that each center shall maintain and keep at the center a separate record for each child enrolled which shall contain all of the required elements.
Evidence:
1. There was no enrollment record available for child 1 who was in care during the inspection.
2. The enrollment record for child 2 lacked documentation of a second emergency contact and verification of age and identity.
3. Administrative staff verified that an enrollment record could not be located for child 1 and that information was incomplete for child 2.
Evidence:
1. There was no enrollment record available for child 1 who was in care during the inspection.
2. The enrollment record for child 2 lacked documentation of a second emergency contact and verification of age and identity.
3. Administrative staff verified that an enrollment record could not be located for child 1 and that information was incomplete for child 2.
Plan of Correction: Children's records audit has been conducted going into the Before and After Care season. To ensure that all staff records are completed and up to date.
Standard 8VAC20-780-70
Based on record review, the center failed to ensure that staff records contain all of the required elements:
Evidence:
1. The record for staff 1, hire date 11/15/2021, lacked the following required documentation:
a. Documentation to demonstrate the individual possesses the education, certification, and experience required by the job position, and orientation training required prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities.
b. Documentation of job title however, staff 1 identified herself as a program leader during the inspection.
2. Administrative staff stated the file for staff 3 could not be located.
a. Staff 3 was working in the summer camp program during the inspection.
Evidence:
1. The record for staff 1, hire date 11/15/2021, lacked the following required documentation:
a. Documentation to demonstrate the individual possesses the education, certification, and experience required by the job position, and orientation training required prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities.
b. Documentation of job title however, staff 1 identified herself as a program leader during the inspection.
2. Administrative staff stated the file for staff 3 could not be located.
a. Staff 3 was working in the summer camp program during the inspection.
Plan of Correction: Staff record audit has been conducted going into the Before and After Care season. To ensure that all staff records are completed and up to date.
Standard 8VAC20-820-120-E-2
Based on observation, the center failed to ensure that the findings of the most recent inspection of the facility were posted on the premises of the facility.
Evidence:
1. The most recent violation notice and inspection summary for the 07/11/2022 monitoring inspection were not posted on the facility parent board.
a. The inspection reports for the 08/25/2021 inspection were posted.
Evidence:
1. The most recent violation notice and inspection summary for the 07/11/2022 monitoring inspection were not posted on the facility parent board.
a. The inspection reports for the 08/25/2021 inspection were posted.
Plan of Correction: Licensing checklist has been created to make sure all licensing standards are followed during the camp season. The checklist will be conducted every week.