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Grace Covenant Presbyterian Church

Inspection · 2024-01-26

Date
2024-01-26
Complaint Related
No
Licensing Inspector
Molly Muscat
(804) 588-2367
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

22.1 Religious Exempt; Background Checks Code; Carbon Monoxide
8VAC20-790 Staff Qualifications & Training
32.1 Report by person other than physician
8VAC20-790 Physical Plant
54.1 Must be MAT Certified.
8VAC20-790 Staffing & Supervision
63.2 Child abuse and neglect
8VAC20-790 Programs
8VAC20-770 Background Checks
8VAC20-790 Special Care Provisions & Emergencies
8VAC20-790 Introduction
8VAC20-790 Special Services
8VAC20-790 Administration

Inspector Notes

An unannounced code compliance inspection was initiated on 01/26/24. The inspector was on site on 01/26/24 from approximately 10:30 am until 01:30 pm. There were 77 children present, ranging in ages from four months to five years, with 16 staff supervising.

The children were observed playing outside, getting diapers changed, and preparing for and eating lunch. Staff were observed having positive interactions with the children. All areas of the facility including classrooms, kitchen, hallways, outdoor play area, and bathrooms were inspected. Eight children's records and eight 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, sign, and return it to me within 5 business days from today, 02/15/2024. 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 measure(s).

Violations

5
Standard 22.1-289.031-B-1
Based on observation, the center failed to establish and implement procedures to ensure that staff and children wash their hands after diapering.
Evidence: Staff #2 was observed changing a child's diaper. Staff #2 did not wash her hands or the child's hands after the diaper change.
Plan of Correction: Staff are and will be closely monitored to ensure proper diaper changing procedures are followed by each and every staff member. This is and will be spoken more about during training and orientation of staff. Each staff not following proper diaper changing procedures will be written up. These observations will be done by the Assistant Director.
Standard 22.1-289.031-B-7
Based on interview, the center failed to ensure that all incidents involving serious physical injury to or death of children attending the child day center are reported to the Superintendent. Reports of serious physical injuries, which shall include any physical injuries that require an emergency referral to an offsite health care profession or treatment in a hospital, shall be submitted annually.
Evidence:
1. Interviews and documentation review revealed that on 04/04/23 child #1 sustained an injury that required an outside medical emergency referral to an offsite health care profession.
2. Interviews with administration revealed that the center did not report this injury to the Superintendent annually because they were not aware that this was a requirement.
3. The last annual filing packet was submitted by the religious institution on 10/24/23 and additional filing documentation was submitted on 11/30/263, 12/6/23, 12/21/23, and 01/17/24. The documentation did not include documentation of a child requiring outside medical treatment.
Plan of Correction: GCCDC Admin team will continue recording and documenting any and all injuries sustained at GCCDC facilities. Furthermore, will begin to report any and all serious physical injuries to the Superintendent. GCCDC will begin to keep incident reports based on birthdays and file according to birthday and age range. If a child sustains a serious physical injury at GCCDC and requires outside medical attention, the Admin team will obtain documents from parent about summary visits. Staff in each classroom will now be required to file their incident reports by each Friday of each week. Operations Manager will be in charge of signing and filing those reports under the supervision of the Director.
Standard 22.1-289.035-A
Based on record review, the center failed to obtain the results of a fingerprint based national criminal record search every five years.
Evidence: The record for staff #5, date of employment 12/17/18, contained fingerprint results dated 12/11/18. An updated fingerprint based criminal record check was due on or before 12/11/2023.
Plan of Correction: National finger-print background check will be completed before start date and redone every 5 years. Each year, the Admin team will list everyone who needs a new background check and will ensure those staff receive and complete valid checks. Director will be in charge of these reviews and corrections once a year.
Standard 22.1-289.035-B-2
Based on a review of eight staff records, the center did not ensure one staff had 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 #7, employed on 08/08/22, was dated 10/17/22.
Plan of Correction: National finger-print background check will be completed before start date. Every 6 months, the Admin team will ensure staff files are valid and in line with VA Licensing code. Director will be in charge of these reviews and corrections.
Standard 8VAC20-770-40-D-2
Repeat Violation
Based on record review, the center failed to obtain a sworn statement before the first day of employment and the results of a central registry background check within 30 days of employment.
Evidence:
1. The record for staff #2, date of employment 12/21/23, contained a sworn statement dated 01/04/24.
2. The record for staff #6, date of employment 06/01/22, contained the results of a central registry check dated 01/07/23.
3. The record for staff #7, date of employment 08/08/22, did not contain the results of a central registry search.
Plan of Correction: Staffing files will be maintained and ensured all documents will be completed before start date. GCCDC Admin team will ensure all staffing documents have the correct dates and correct background checks before staff officially starts at GCCDC. Central Registry's will be filled out during the hiring process and will be sent off before start date. Every 6 months, the Admin team will ensure Central Registries are valid and in line with VA Licensing code. Director will be in charge of these reviews and corrections.
View original record on Virginia Department of Social Services