Inspection · 2022-08-16
Date
2022-08-16
Complaint Related
No
Licensing Inspector
Stephanie Reed
(540) 272-6558
(540) 272-6558
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
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
Inspector Notes
A mandated inspection along with a focused inspection regarding a self-report received on August 10, 2022 was initiated on 08/16/2022 and was concluded on 8/18/2022. There were 48 children present, ranging in ages from 4 months to 5 years old, with 15 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 6 child records and 6 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.
If you have any questions or concerns, please contact the Licensing Inspector at (804) 629-3923.
Violations
10Standard 22.1-289.035-B-4
The center failed to complete an out-of-state abuse and neglect registry check within 30 days of employment.
Evidence:
1. Staff #1?s start date was 3/24/22. Staff #1 indicated on the sworn statement that they had resided in another state within the past 5 years.
2. Staff #9 confirmed that the out-of-state background check was sent and that it had not been sent within 30 days of employment.
Evidence:
1. Staff #1?s start date was 3/24/22. Staff #1 indicated on the sworn statement that they had resided in another state within the past 5 years.
2. Staff #9 confirmed that the out-of-state background check was sent and that it had not been sent within 30 days of employment.
Plan of Correction: Admin will ensure out of state CPS checks are sent out within a timely manner. The Central History and Sexual Abuse completed result was in employees file.
Sent 8/17/2022 I requested from Licensing the agency code and RID code requested by the NY Agency. Code was not given and I was told to send the report and wait or a response and search for another form.
Sent 8/17/2022 I requested from Licensing the agency code and RID code requested by the NY Agency. Code was not given and I was told to send the report and wait or a response and search for another form.
Standard 8VAC20-770-60-C-2
Based on review of records and interviews, the center failed to ensure that all staff members had central registry results on file by the end of the 30th day of employment.
1. Staff #1?s first day of employment was 3/24/2022. A completed central check was not in the staff member?s file.
2. Staff #9 confirmed that the center did not have central registry results on file for Staff #1.
1. Staff #1?s first day of employment was 3/24/2022. A completed central check was not in the staff member?s file.
2. Staff #9 confirmed that the center did not have central registry results on file for Staff #1.
Plan of Correction: Admin will ensure all background checks are sent out within 30 days and followed up on. This has been sent twice waiting for results. *Documentation in the employee's file.
Standard 8VAC20-780-160-A
Based on review of records and interviews, the center failed to ensure that each staff member completed a tuberculosis screening within 30 days prior to employment.
Evidence:
1. Staff #3?s start date was 7/21/22. Staff #3?s TB screen was dated 4/27/22.
2. Staff #9 confirmed that Staff #3?s TB screen was completed more than 30 days prior to hire.
Evidence:
1. Staff #3?s start date was 7/21/22. Staff #3?s TB screen was dated 4/27/22.
2. Staff #9 confirmed that Staff #3?s TB screen was completed more than 30 days prior to hire.
Plan of Correction: Admin will ensure T.B. Testing is within 30 day range.
Licensing Inspector stated there was nothing to do except make sure the staff member renewal within 2 years. Test was completed on 4-27-2022.
Licensing Inspector stated there was nothing to do except make sure the staff member renewal within 2 years. Test was completed on 4-27-2022.
Standard 8VAC20-780-240-A
Based on review of records and interviews, the center failed to ensure that each staff member completed the Virginia Department of Education sponsored orientation with 90 calendar days of employment.
Evidence:
1. Staff #5?s start date was 2/22/22. There was no documentation that the staff member had completed the Virginia Department of Education sponsored orientation.
2. Staff #9 confirmed that the staff member had not completed the Virginia Department of Education sponsored orientation within 90 days of employment.
Evidence:
1. Staff #5?s start date was 2/22/22. There was no documentation that the staff member had completed the Virginia Department of Education sponsored orientation.
2. Staff #9 confirmed that the staff member had not completed the Virginia Department of Education sponsored orientation within 90 days of employment.
Plan of Correction: Admin will ensure staff complete 10 hour Educational Training within 90 days. Staff member completed 3 hour update training ahead of the 10 hour training.
Standard 8VAC20-780-240-E
Based on review of records and interviews, the center failed to ensure that each employee had orientation training in first aid and cardiopulmonary resuscitation (CPR) within 30 days of employment.
Evidence:
1. Staff #6?s first day of employment was 2/24/22. There was no record of CPR or First Aid orientation on file.
2. Staff #7?s first day of employment was 1/21/22.There was no record of CPR or First Aid orientation on file.
3. Staff #9 confirmed that neither staff member had orientation in CPR or First Aid within the first 30 days of employment.
Evidence:
1. Staff #6?s first day of employment was 2/24/22. There was no record of CPR or First Aid orientation on file.
2. Staff #7?s first day of employment was 1/21/22.There was no record of CPR or First Aid orientation on file.
3. Staff #9 confirmed that neither staff member had orientation in CPR or First Aid within the first 30 days of employment.
Plan of Correction: Admin will ensure each classroom as at least one employee with CPR/First Aid. Employees did have orientation First Aid/CPR.
Standard 8VAC20-780-260-B
Based on interviews, the center failed to provide annual approval from the health department.
Evidence:
1. The date of the center?s last health inspection was 1/31/21.
2. Staff #9 confirmed that a health inspection had not been completed since 1/31/21.
Evidence:
1. The date of the center?s last health inspection was 1/31/21.
2. Staff #9 confirmed that a health inspection had not been completed since 1/31/21.
Plan of Correction: The Director has been in touch with the Health Department. Letter was given that they were running behind. Director spoke with inspector again on the 19th. Inspector stated he would be out soon. No date given! Spoke with him on the 19th.
Standard 8VAC20-780-40-J
Based on interviews and review of records, the center failed to ensure that the injury prevention plan was updated at least annually.
Evidence:
1. The date of the last update of the injury prevention plan was 7/21/21.
2. Staff #9 confirmed that the injury prevention plan had not been updated since 7/21/21
Evidence:
1. The date of the last update of the injury prevention plan was 7/21/21.
2. Staff #9 confirmed that the injury prevention plan had not been updated since 7/21/21
Plan of Correction: Admin will ensure that the plan is updated yearly. Completed while the inspector was at the school.
Standard 8VAC20-780-450-A
Based on observation and interviews, the center failed to ensure that children had a top and bottom over on their cots.
Evidence:
1. In Classroom #1, two children were observed having only a top cover on their cots.
2. Staff #4 confirmed the children did not have a bottom cover on their cot.
Evidence:
1. In Classroom #1, two children were observed having only a top cover on their cots.
2. Staff #4 confirmed the children did not have a bottom cover on their cot.
Plan of Correction: Admin will review with the staff the requirements regarding linens at nap time.
Standard 8VAC20-780-530-A-1
Based on review of records and interviews, the center failed to ensure that there was at least one staff member in each classroom that had current certification in cardiopulmonary resuscitation (CPR).
Evidence:
1. In Classroom #1, Staff #3 and #6 were present. The records for these staff did not contain documentation to show that either of the staff had ever been certified in CPR. Staff # 9 confirmed that neither staff member had current CPR certification.
2. In Classroom #7, Staff #7 and #8 were present. The records for these staff did not contain documentation to show that either of the staff had ever been certified in CPR. Staff # 9 confirmed that neither staff member had current CPR certification.
Evidence:
1. In Classroom #1, Staff #3 and #6 were present. The records for these staff did not contain documentation to show that either of the staff had ever been certified in CPR. Staff # 9 confirmed that neither staff member had current CPR certification.
2. In Classroom #7, Staff #7 and #8 were present. The records for these staff did not contain documentation to show that either of the staff had ever been certified in CPR. Staff # 9 confirmed that neither staff member had current CPR certification.
Plan of Correction: Admin will ensure that CPR/First Aid is complete within 90 days of hire. COA has a CPR/First Aid orientation within the first week of training.
Standard 8VAC20-780-530-A-2
Based on review of records and interviews, the center failed to ensure that there was at least one staff member in each classroom that had current certification in first aid.
Evidence:
1. In Classroom #1, Staff #3 and #6 were present. Neither had current first aid certification on file. Staff #9 confirmed that neither staff member had current first aid certification.
2. In Classroom #7, Staff #7 and #8 were present. Neither had current first aid certification on file. Staff #9 confirmed that neither staff member had current first aid certification.
Evidence:
1. In Classroom #1, Staff #3 and #6 were present. Neither had current first aid certification on file. Staff #9 confirmed that neither staff member had current first aid certification.
2. In Classroom #7, Staff #7 and #8 were present. Neither had current first aid certification on file. Staff #9 confirmed that neither staff member had current first aid certification.
Plan of Correction: Admin will ensure one staff member will be in each room with CPR/First Aid.
Admin will all rooms have one employee at all times with CPR/First Aid. Employees did have orientation First Aid/CPR.
Admin will all rooms have one employee at all times with CPR/First Aid. Employees did have orientation First Aid/CPR.