Inspection · 2023-07-19
Date
2023-07-19
Complaint Related
No
Licensing Inspector
LaTasha Smith
(804) 588-2362
(804) 588-2362
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 Introduction
8VAC20-790 Administration
8VAC20-790 Staff Qualifications & Training
8VAC20-790 Physical Plant
8VAC20-790 Staffing & Supervision
8VAC20-790 Programs
8VAC20-790 Special Care Provisions & Emergencies
8VAC20-790 Special Services
Inspector Notes
A Subsidy Health and Safety Inspection was initiated and concluded on Wednesday, July 19, 2023. On July 19, the inspector was on site from 11:10am to approximately 2:00pm. There were 24 children present and four staff members directly supervising. Upon arrival, the children were observed preparing for lunch and rest time. A group of children was on a field trip, but were later observed returning to the center and preparing for lunch. The staff were observed having positive interactions with the children. All areas of the facility including classrooms, hallways, the playground, and bathrooms were inspected. A total of five children's records and five staff records were reviewed.
A code compliance inspection was conducted on this date. Both inspections combined cover subsidy health and safety regulations. Only subsidy requirements that are not covered in the code compliance inspection were reviewed during the supplemental inspection. 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.
Violations
8Standard 8VAC20-790-550-2-a
Based on a review of five staff records, the vendor did not ensure two staff had the satisfactory results of the fingerprint-based national criminal background check prior to employment.
Evidence: 1) The fingerprint-based national criminal background check in the record of Staff #1, employed on 07/03/23, was completed on 07/06/23.
2) The record of Staff #5, employed on 06/27/22, did not contain the results of the fingerprint-based national criminal background check.
3) During interview, a member of management acknowledged the results of the fingerprint-based national criminal background check for Staff #1 were obtained after the staff started employment. Management acknowledged the results of the fingerprint-based national criminal background check for Staff #5 were not obtained at the time of employment.
Evidence: 1) The fingerprint-based national criminal background check in the record of Staff #1, employed on 07/03/23, was completed on 07/06/23.
2) The record of Staff #5, employed on 06/27/22, did not contain the results of the fingerprint-based national criminal background check.
3) During interview, a member of management acknowledged the results of the fingerprint-based national criminal background check for Staff #1 were obtained after the staff started employment. Management acknowledged the results of the fingerprint-based national criminal background check for Staff #5 were not obtained at the time of employment.
Plan of Correction: In the future, the vendor will ensure the fingerprint-based national criminal background check results are obtained prior to staff beginning employment.
Standard 8VAC20-790-550-2-f
Based on a review of five staff records and interview, the vendor did not ensure one staff had documentation of subsequent background check conducted every five years.
Evidence: 1) The results of the fingerprint-based national criminal background check in the record of Staff #3, employed on 01/04/14, were dated 03/29/18. A subsequent fingerprint-based national criminal background check should have been conducted no later than 03/29/23.
2) During interview, a member of management confirmed the subsequent background check for Staff #3 was not conducted every five years as required.
Evidence: 1) The results of the fingerprint-based national criminal background check in the record of Staff #3, employed on 01/04/14, were dated 03/29/18. A subsequent fingerprint-based national criminal background check should have been conducted no later than 03/29/23.
2) During interview, a member of management confirmed the subsequent background check for Staff #3 was not conducted every five years as required.
Plan of Correction: The staff member will schedule an appointment to conduct the subsequent fingerprint-based national criminal background check. In the future, all required background checks will be conducted every five years as required.
Standard 8VAC20-790-560-A
Based on a review of five staff records and interview, the vendor did not ensure two staff were evaluated by a health professional and be issued a statement that the individuals were determined to be free of communicable tuberculosis (TB) within the required time frame. Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children. The documentation shall have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician's designee, or an official of the local health department.
Evidence: 1) The TB test in the record of Staff #1, employed on 07/03/23, was completed on 01/18/23.
2) The record of Staff #5, employed on 06/27/22, does not contain documentation that the staff has been determined to be free of communicable TB.
3) During interview, a member of management confirmed the TB test in the record of Staff #1 was completed more than 30 days prior to the date of employment. Management acknowledged Staff #5 does not have the documentation of a negative TB screening on file.
Evidence: 1) The TB test in the record of Staff #1, employed on 07/03/23, was completed on 01/18/23.
2) The record of Staff #5, employed on 06/27/22, does not contain documentation that the staff has been determined to be free of communicable TB.
3) During interview, a member of management confirmed the TB test in the record of Staff #1 was completed more than 30 days prior to the date of employment. Management acknowledged Staff #5 does not have the documentation of a negative TB screening on file.
Plan of Correction: In the future, the vendor will ensure TB screenings/testing are date no more than 30 days prior to the date of employment. Staff #5 will provide a current TB screening/testing by next week.
Standard 8VAC20-790-600-B
Based on a review of five staff records, the vendor did not ensure one staff who works directly with children complete the Virginia Preservice Training for Child Care Staff within the first 90 days of employment.
Evidence: 1) The record of Staff #5, employed on 06/27/22, did not contain documentation that the staff completed the Virginia Preservice Training for Child Care Staff.
2) During interview, a member of management confirmed Staff #5 has not completed the Virginia Preservice Training for Child Care Staff to date.
Evidence: 1) The record of Staff #5, employed on 06/27/22, did not contain documentation that the staff completed the Virginia Preservice Training for Child Care Staff.
2) During interview, a member of management confirmed Staff #5 has not completed the Virginia Preservice Training for Child Care Staff to date.
Plan of Correction: The staff member will start working on the training and provide documentation of completion as soon as possible. In the future, all staff will be required to complete the Virginia Preservice Training within 90 days of employment, regardless of whether or not they are seasonal employees.
Standard 8VAC20-790-600-D-1
Based on a review of five staff records and interview, the vendor did not ensure one staff who works directly with children had current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care within 90 days of the date of employment.
Evidence: 1) The record of Staff #5, employed on 06/27/22, did not contain documentation that the staff has current certification in CPR.
2) During interview, a member of management reported Staff #5 does not have current certification in CPR and the training was not completed within 90 days of the date of employment.
Evidence: 1) The record of Staff #5, employed on 06/27/22, did not contain documentation that the staff has current certification in CPR.
2) During interview, a member of management reported Staff #5 does not have current certification in CPR and the training was not completed within 90 days of the date of employment.
Plan of Correction: The staff member will complete CPR and first aid training as soon as possible. In the future, all staff will have current CPR and first aid certification within 90 days of employment.
Standard 8VAC20-790-600-D-2
Based on a review of five staff records and interview, the vendor did not ensure one staff who works directly with children had current certification in first aid appropriate to the ages of children in care within 90 days of the date of employment.
Evidence: 1) The record of Staff #5, employed on 06/27/22, did not contain documentation that the staff has current certification in first aid.
2) During interview, a member of management reported Staff #5 does not have current certification in first aid and the training was not completed within 90 days of the date of employment.
Evidence: 1) The record of Staff #5, employed on 06/27/22, did not contain documentation that the staff has current certification in first aid.
2) During interview, a member of management reported Staff #5 does not have current certification in first aid and the training was not completed within 90 days of the date of employment.
Plan of Correction: The staff member will complete CPR and first aid training as soon as possible. In the future, all staff will have current CPR and first aid certification within 90 days of employment.
Standard 8VAC20-790-600-F
Based on a review of five staff records and interview, the vendor did not ensure one staff who works directly with children completed the department's health and safety update course annually.
Evidence: 1) The record of Staff #5, employed on 06/27/22, did not contain documentation that the staff completed the department's health and safety update course. The course should have been completed no later than 06/27/23.
2) During interview, a member of management acknowledged Staff #5 did not complete the health and safety update course annually as required.
Evidence: 1) The record of Staff #5, employed on 06/27/22, did not contain documentation that the staff completed the department's health and safety update course. The course should have been completed no later than 06/27/23.
2) During interview, a member of management acknowledged Staff #5 did not complete the health and safety update course annually as required.
Plan of Correction: The staff member will complete the annual health and safety update training. In the future, all staff will complete the training annually.
Standard 8VAC20-790-800-A-1
Based on a review of documentation and interview, the vendor did not ensure the evacuation procedures were practiced at least monthly.
Evidence: 1) The emergency response drill log was reviewed. The most recently documented evacuation drill was dated 04/11/23.
2) During interview, a member of management reported the evacuation procedures were not practiced in May 2023 or June 2023.
Evidence: 1) The emergency response drill log was reviewed. The most recently documented evacuation drill was dated 04/11/23.
2) During interview, a member of management reported the evacuation procedures were not practiced in May 2023 or June 2023.
Plan of Correction: Moving forward, all emergency response drills will be conducted as required. The July evacuation drill will be conducted no later than 7/31/23.