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Bon Secours - St. Francis Medical Center

Inspection · 2022-03-02

Date
2022-03-02
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

8VAC20-780 ADMINISTRATION.
8VAC20-780 STAFF QUALIFICATIONS AND TRAINING.
8VAC20-780 STAFFING AND SUPERVISION.
8VAC20-780 PROGRAMS.
8VAC20-780 Special care provisions and emergencies.
8VAC20-780 SPECIAL SERVICES.
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.

Inspector Notes

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

A monitoring inspection was initiated on March 2, 2022 and concluded on March 3, 2022. The director was contacted by telephone and a virtual inspection was conducted. There were 70 children present, ranging in ages from 7 months to 5 years, with 13 staff supervising. The inspector reviewed compliance in the areas of administration, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of 4 child records and 4 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.

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. Please specify how the deficient practice will be or has been corrected. Your plan of correction should 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 8VAC20-780-140-B
Based on a review of children records on March 3, 2022, the center did not ensure a physical exam that was completed prior to a child's first date of attendance was not dated within 3 months prior to attendance for a child that 16 months old at the time of enrollment.
Evidence: Child #2 was 16 months of age on their first date of enrollment on 11/12/21 and documentation of the physical exam was dated 7/22/21.
Plan of Correction: Prior to the child's start date, we will be sure that the physical examination is within the required timeframe for the age of the child.
View original record on Virginia Department of Social Services