Inspection · 2022-10-24
Date
2022-10-24
Complaint Related
No
Licensing Inspector
Michelle Argenbright
(540) 848-4123
(540) 848-4123
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.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-770 Background Checks (8VAC20-770)
22.1 Background Checks Code, Carbon Monoxide
Inspector Notes
An unannounced monitoring inspection was conducted on-site October 24, 2022. The director was available during the inspection. There were 23 children present, ranging in ages from 3 years to 6 years, with 7 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 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
10Standard 22.1-289.035-B-4
Based on a review of staff records and interview on October 24, 2022, the center failed to obtain the results of an out-of-state child abuse and neglect registry for each employee who has resided in any other state in the preceding five years.
Evidence: The record of staff #4, hired 7/1/22, did not contain documentation of an out-of-state child abuse and neglect registry check. Staff #4 indicated living out-of-state in the previous five years on staff #4's sworn disclosure statement. Staff #5 confirmed the check was not complete.
Evidence: The record of staff #4, hired 7/1/22, did not contain documentation of an out-of-state child abuse and neglect registry check. Staff #4 indicated living out-of-state in the previous five years on staff #4's sworn disclosure statement. Staff #5 confirmed the check was not complete.
Plan of Correction: The Business Manager is auditing all records and following up with central registry about the employees we have not received results for yet.
Standard 8VAC20-770-60-B
Based on a review of staff records on October 24, 2022, the center did not obtain a sworn statement from each staff prior to employment.
Evidence: The record of staff #3, hired 5/17/22, did not contain documentation of a sworn statement.
Evidence: The record of staff #3, hired 5/17/22, did not contain documentation of a sworn statement.
Plan of Correction: The employee has submitted an update form with signature
Standard 8VAC20-770-60-C-2
Based on a review of staff records and interview on October 24, 2022, the center failed to ensure that each staff record reviewed contained a central registry finding within 30 days of employment.
Evidence: 1. The record of staff #2, hired 8/4/22, did not contain documentation of a central registry result. 2. The record of staff #3, hired 5/7/22, did not contain documentation of a central registry result. 3. Staff #5 acknowledged the central registries were not complete.
Evidence: 1. The record of staff #2, hired 8/4/22, did not contain documentation of a central registry result. 2. The record of staff #3, hired 5/7/22, did not contain documentation of a central registry result. 3. Staff #5 acknowledged the central registries were not complete.
Plan of Correction: The Business Manager is auditing all records and following up with Central Registry about the employees we have not received results for yet.
Standard 8VAC20-780-160-A
Based on a review of staff records and interview on October 24, 2022, the center failed to ensure that each staff submit documentation of a negative tuberculosis screening at the time of employment and prior to coming in contact with children.
Evidence: 1. The record of staff #2, hired 8/4/22, did not contain documentation of a negative tuberculosis screening. 2. The record of staff #3, hired 5/17/22, did not contain documentation of a negative tuberculosis screening. 3. The record of staff #4, hired 7/1/22, contained documentation of a negative tuberculosis screening dated 8/25/22. 4. Per staff #5, each of these staff have been continuously in contact with children. 5. Staff #5 confirmed there was no tuberculosis screening for staff #2 and staff #3 and that the screening for staff #4 was late.
Evidence: 1. The record of staff #2, hired 8/4/22, did not contain documentation of a negative tuberculosis screening. 2. The record of staff #3, hired 5/17/22, did not contain documentation of a negative tuberculosis screening. 3. The record of staff #4, hired 7/1/22, contained documentation of a negative tuberculosis screening dated 8/25/22. 4. Per staff #5, each of these staff have been continuously in contact with children. 5. Staff #5 confirmed there was no tuberculosis screening for staff #2 and staff #3 and that the screening for staff #4 was late.
Plan of Correction: All staff who were due for TB screening completed it on August 25th but we did not receive complete documentation. We have given staff until 11/30/22 to submit documentation.
Standard 8VAC20-780-240-A
Based on a review of staff records and interview on October 24, 2022, the center failed to ensure that staff complete the Virginia Department of Education sponsored orientation course within 90 calendar days of employment.
Evidence: The records of staff #3 (hired 5/17/22) and staff #4 (hired 7/1/22) did not contain documentation of the Virginia Department of Education sponsored orientation. Staff #5 confirmed it was not completed.
Evidence: The records of staff #3 (hired 5/17/22) and staff #4 (hired 7/1/22) did not contain documentation of the Virginia Department of Education sponsored orientation. Staff #5 confirmed it was not completed.
Plan of Correction: All relevant employees have been notified and will complete their training by 11/30/22.
Standard 8VAC20-780-245-A
Based on a review of staff records and interview on October 24, 2022, the center failed to obtain an annual minimum of 16 hours of training appropriate to the age of children in care for each staff.
Evidence: 1. The record of staff #1 contained documentation of 7 hours of training from September 1, 2021 to September 1, 2022. 2. Staff #5 confirmed the hours were not complete.
Evidence: 1. The record of staff #1 contained documentation of 7 hours of training from September 1, 2021 to September 1, 2022. 2. Staff #5 confirmed the hours were not complete.
Plan of Correction: This was more of a documentation issue. We will implement the DOE stock form to improve our documentation of PD hours.
Standard 8VAC20-780-500-C
Based on observation and an interview on October 24, 2022, the center failed to ensure toilet chairs were emptied promptly and cleaned and sanitized after each use.
Evidence: A toilet training chair located in the Marigold bathroom (ages 3-5) containing urine a was observed at 1:05pm. The children were observed eating lunch during this time. At 1:11pm the toilet chair still contained the urine. Staff #5 confirmed the toilet chair contained urine and that it had not been emptied and cleaned and sanitized.
Evidence: A toilet training chair located in the Marigold bathroom (ages 3-5) containing urine a was observed at 1:05pm. The children were observed eating lunch during this time. At 1:11pm the toilet chair still contained the urine. Staff #5 confirmed the toilet chair contained urine and that it had not been emptied and cleaned and sanitized.
Plan of Correction: This was corrected immediately.
Standard 8VAC20-780-550-E
Based on a review of records and interview on October 24, 2022, the center did not ensure to implement a minimum of two shelter-in-place practice drills per year for the most likely to occur scenarios.
Evidence: 1. There documentation of one shelter-in-place drill for 2021 dated 11/16/21. 2. Staff #5 confirmed second shelter-in-place drill was not completed.
Evidence: 1. There documentation of one shelter-in-place drill for 2021 dated 11/16/21. 2. Staff #5 confirmed second shelter-in-place drill was not completed.
Plan of Correction: We are planning a shelter in place drill in November.
Standard 8VAC20-780-550-F
Based on a review of the log for procedures for emergencies and interview on October 24, 2022, the center failed to ensure lockdown procedures are practiced at least annually.
Evidence: There was no documentation of a lockdown drill being practiced for 2021. Staff #5 confirmed the lockdown drill was not practiced in 2021.
Evidence: There was no documentation of a lockdown drill being practiced for 2021. Staff #5 confirmed the lockdown drill was not practiced in 2021.
Plan of Correction: We are planning a lock down drill in December.
Standard 8VAC20-780-70
Based on a review of records and interview on October 24, 2022, the center failed to ensure that each staff record contained all required information.
Evidence: 1. The record of staff #2, hired 8/4/22, did not contain documentation of a completed staff orientation. 2. The record of staff #3, hired 5/17/22, did not contain documentation of a completed staff orientation. 3. The record of staff #4, hired 7/1/22, did not contain documentation of a completed staff orientation. 4. Staff #5 stated the orientations were complete but not in the record. 5. The record of staff #3, hired 5/17/22, did not contain the name, address, and phone number of a person to be notified in an emergency.
Evidence: 1. The record of staff #2, hired 8/4/22, did not contain documentation of a completed staff orientation. 2. The record of staff #3, hired 5/17/22, did not contain documentation of a completed staff orientation. 3. The record of staff #4, hired 7/1/22, did not contain documentation of a completed staff orientation. 4. Staff #5 stated the orientations were complete but not in the record. 5. The record of staff #3, hired 5/17/22, did not contain the name, address, and phone number of a person to be notified in an emergency.
Plan of Correction: We will be adopting the VA DOE stock form to ensure proper documentation. All staff received orientation throughout the week of 8/22-8/25 but our documentation is not aligned with licensing. We will incorporate the stock form to document the orientation staff received that week.