Inspection · 2023-09-11
Date
2023-09-11
Complaint Related
No
Licensing Inspector
Nicole Scott
(804) 588-2372
(804) 588-2372
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.
Yes
Areas Reviewed
8VAC20-790 Physical Plant
32.1 Report by person other than physician
8VAC20-790 Staffing & Supervision
63.2 Child abuse and neglect
8VAC20-790 Programs
8VAC20-790 Introduction
8VAC20-790 Special Care Provisions & Emergencies
8VAC20-790 Administration
8VAC20-790 Special Services
8VAC20-790 Staff Qualifications & Training
Inspector Notes
Licensing Inspector conducted an unannounced Monitor Subsidy (SHSI) Inspection on September 11, 2023. There were 17 children ages 12 months to 3 years old present under the direct care of 3 staff. The Licensing Inspector reviewed 5 children?s records and 3 staff records, along with any requested program records submitted by the facility to determine if required documentation was complete.
An unannounced Religiously Exempt Code Inspection was conducted on the same date as the SHSI inspection; the two inspections combined cover all subsidy health and safety requirements. Only subsidy requirements that are not covered in Code requirements were reviewed during this inspection.
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.
If you have any questions about this inspection, please contact Monique Anderson, Licensing Inspector at 540.309.2397 or monique.anderson@doe.virginia.gov.
Violations
13Standard 8VAC20-790-530-B
Based on documentation review, the Vendor failed to maintain a written hard copy record of daily attendance that documents the arrival and departure of each child in care as it occurs.
EVIDENCE:
Written hard copy of daily attendance was unavailable.
EVIDENCE:
Written hard copy of daily attendance was unavailable.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-540-B
Based on record review, the Vendor failed to ensure each child?s record included all the requirements per the standard.
EVIDENCE:
1. Record for Child #1 did not include the employers name, address, and work phone for Parent/Guardian #1.
2. Record for Child #2 did not include the employers work phone for Parent #1.
3. Record for Child #3 did not include the employers address and work phone for Parent #1 and Parent #2.
EVIDENCE:
1. Record for Child #1 did not include the employers name, address, and work phone for Parent/Guardian #1.
2. Record for Child #2 did not include the employers work phone for Parent #1.
3. Record for Child #3 did not include the employers address and work phone for Parent #1 and Parent #2.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-550-1
Based on record review, the Vendor failed to keep a record containing the date of employment, address, and verification of age for each staff person.
EVIDENCE:
1. Record for Staff #1 did not include the date of employment, address, or verification of age.
2. Record for Staff #2 did not include the date of employment, address, or verification of age.
3. Record for Staff #3 did not include the date of employment, address, or verification of age.
EVIDENCE:
1. Record for Staff #1 did not include the date of employment, address, or verification of age.
2. Record for Staff #2 did not include the date of employment, address, or verification of age.
3. Record for Staff #3 did not include the date of employment, address, or verification of age.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-560-A
Based on record review, the Vendor failed to ensure each staff person is evaluated by a health professional and issued a statement that the individual is determined to be free of communicable tuberculosis (TB) submitted at the time of employment and completed prior to coming into contact with children.
EVIDENCE:
1. Record for Staff #1 did not include documentation of a TB test. Staff #1 was observed working on the day of the inspection.
2. Record for Staff #2 did not include documentation of a TB test. Staff #2 was observed working on the day of the inspection.
3. Record for Staff #3 did not include documentation of a TB test. Staff #3 was observed working on the day of the inspection.
EVIDENCE:
1. Record for Staff #1 did not include documentation of a TB test. Staff #1 was observed working on the day of the inspection.
2. Record for Staff #2 did not include documentation of a TB test. Staff #2 was observed working on the day of the inspection.
3. Record for Staff #3 did not include documentation of a TB test. Staff #3 was observed working on the day of the inspection.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-600-C
Based on record review, the Vendor failed to ensure each staff person completes center orientation training prior to the staff member working alone with children and within seven days of the date of employment.
EVIDENCE:
1. Record for Staff #1 did not include documentation on orientation training on the facility specific topics. Staff #1 was observed working on the day of the inspection.
2. Record for Staff #2 did not include documentation on orientation training on the facility specific topics. Staff #2 was observed working on the day of the inspection.
3. Record for Staff #3 did not include documentation on orientation training on the facility specific topics. Staff #3 was observed working on the day of the inspection.
EVIDENCE:
1. Record for Staff #1 did not include documentation on orientation training on the facility specific topics. Staff #1 was observed working on the day of the inspection.
2. Record for Staff #2 did not include documentation on orientation training on the facility specific topics. Staff #2 was observed working on the day of the inspection.
3. Record for Staff #3 did not include documentation on orientation training on the facility specific topics. Staff #3 was observed working on the day of the inspection.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-600-D-1
Based on record review, the Vendor failed to ensure all staff who work directly with children completes CPR certification within 90 days of hire.
EVIDENCE:
1. Record for Staff #1 did not include documentation of CPR certification. Licensing Inspector observed Staff #1 working during the previous inspection (9/03/2022).
2. Record for Staff #2 did not include documentation of CPR certification. Licensing Inspector observed Staff #2 working during the previous inspection.
EVIDENCE:
1. Record for Staff #1 did not include documentation of CPR certification. Licensing Inspector observed Staff #1 working during the previous inspection (9/03/2022).
2. Record for Staff #2 did not include documentation of CPR certification. Licensing Inspector observed Staff #2 working during the previous inspection.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-600-D-2
Based on record review, the Vendor failed to ensure all staff who work directly with children completes First aid certification within 90 days of hire.
EVIDENCE:
1. Record for Staff #1 did not include documentation of First Aid certification. Licensing Inspector observed Staff #1 working during the previous inspection (9/03/2022).
2. Record for Staff #2 did not include documentation of First Aid certification. Licensing Inspector observed Staff #2 working during the previous inspection.
EVIDENCE:
1. Record for Staff #1 did not include documentation of First Aid certification. Licensing Inspector observed Staff #1 working during the previous inspection (9/03/2022).
2. Record for Staff #2 did not include documentation of First Aid certification. Licensing Inspector observed Staff #2 working during the previous inspection.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-600-I
Based on record review, the Vendor failed have at least one staff person on duty who has obtained within the last three years instruction in performing a daily health observation of children.
EVIDENCE:
There were no staff present during the inspection who has received Daily Health Observation of children training.
EVIDENCE:
There were no staff present during the inspection who has received Daily Health Observation of children training.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-630-A
Based on observation, the Vendor failed to keep areas and equipment of the center, inside and outside in a clean, safe and operable condition.
EVIDENCE:
The wrought iron handrail on the entrance steps were missing multiple slats on the top platform level (approximately 12 feet from the ground level) creating a fall hazard.
EVIDENCE:
The wrought iron handrail on the entrance steps were missing multiple slats on the top platform level (approximately 12 feet from the ground level) creating a fall hazard.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-640-A
Based on observation, the Vendor failed to keep hazardous substances in a locked place using a safe locking method that prevents access by children.
EVIDENCE:
Licensing Inspector observed unlocked hazardous cleaning agents at the outside entrance of the center. Agents were accessible to the children in care.
EVIDENCE:
Licensing Inspector observed unlocked hazardous cleaning agents at the outside entrance of the center. Agents were accessible to the children in care.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-790-A
Based on documentation review, the Vendor failed to have a written emergency preparedness plan.
EVIDENCE:
An emergency preparedness plan was unavailable.
EVIDENCE:
An emergency preparedness plan was unavailable.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-800-A-2
Based on documentation review, the Vendor failed to ensure shelter-in-place procedures are practiced twice a year.
EVIDENCE:
The provider did not have documentation of an annual shelter-in-place drill completed.
EVIDENCE:
The provider did not have documentation of an annual shelter-in-place drill completed.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-800-A-3
Based on inspection, the Vendor failed to ensure lockdown procedures are practiced at least annually.
EVIDENCE:
The provider did not have documentation of an annual lockdown emergency drill.
EVIDENCE:
The provider did not have documentation of an annual lockdown emergency drill.
Plan of Correction: Not available online. Contact Inspector for more information.