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Bon Secours - St. Francis Medical Center

Inspection · 2021-09-28

Date
2021-09-28
Complaint Related
No
Licensing Inspector
Danielle Morrison
(804) 929-3771
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

22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 PHYSICAL PLANT.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 PROGRAMS.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-185 SPECIAL SERVICES.
22VAC40-80 THE LICENSE.
22VAC40-80 THE LICENSING PROCESS.
22VAC40-191 Background Checks (22VAC40-191)

Inspector Notes

This inspection was conducted by licensing staff using an alternate remote protocol, including telephone contacts, documents review, and interviews.

A renewal inspection was initiated on September 28, 2021 and concluded on September 29, 2021. The director was contacted by telephone and a virtual inspection was conducted. There were 59 children present, ranging in ages from 3 months to 4 years, with 12 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of 4 child records,4 staff records, and 4 board members 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.

Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to me within 5 business days from today. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measures. Please do not use staff names; list staff by positions only.

Violations

1
Standard 22VAC40-185-160-B
Based on a review of four staff member's records and interview, the center failed to obtain an acceptable form of documentation of tuberculosis screening for one record.
Evidence: 1. The record of Staff #1 contained documentation of a tuberculosis screening that was not signed by a physician, physician's designee or an official of the local health department. 2. Administration acknowledged the screening was not signed.
Plan of Correction: Corrected on site
View original record on Virginia Department of Social Services