Inspection · 2021-08-17
Date
2021-08-17
Complaint Related
No
Licensing Inspector
Nanette Roberts
(757) 404-2322
(757) 404-2322
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
22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 PHYSICAL PLANT.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 PROGRAMS.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-185 SPECIAL SERVICES.
22VAC40-191 Background Checks (22VAC40-191)
63.2 Child Abuse & Neglect
63.2(17) License & Registration Procedures
63.2 Facilities & Programs.
Inspector Notes
This inspection was conducted by licensing staff using an alternate remote protocol, including telephone contacts, documents review, interviews and a virtual tour of the program. A monitoring inspection was initiated on 8/17/21 and concluded on 8/18/21. The director was contacted by telephone and a virtual inspection was conducted. There were 85 children present with 11 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 5 child records and 16 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.
Violations
11Standard 22VAC40-185-130-A
Based on a review of five children's records, it was determined that the facility did not ensure that the center obtains documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center.
Evidence:
1. There was no immunization record for child #3 available for viewing during the inspection..
2. Staff #17 (Program Administrator) confirmed there was no immunization record for child #3 available for viewing during the inspection.
Evidence:
1. There was no immunization record for child #3 available for viewing during the inspection..
2. Staff #17 (Program Administrator) confirmed there was no immunization record for child #3 available for viewing during the inspection.
Plan of Correction: The facility responded: The Child Care facility at Taylor Bend Family YMCA will ensure that each child in attendance has received immunizations before the child attends the center.
Standard 22VAC40-185-140-A
Based on a review of five children's records, it was determined that the facility did not ensure that each child in attendance had a completed physical within one month of attendance.
Evidence:
1. The record for child #1 did not contain a physical examination.
2. There was no physical examination for child #3 available for viewing during the inspection..
3. Staff #17 (Program Administrator) confirmed there was no physical examination available for viewing during the inspection for child #1 and child #3.
Evidence:
1. The record for child #1 did not contain a physical examination.
2. There was no physical examination for child #3 available for viewing during the inspection..
3. Staff #17 (Program Administrator) confirmed there was no physical examination available for viewing during the inspection for child #1 and child #3.
Plan of Correction: The facility responded: The Child Care facility at Taylor Bend Family YMCA will ensure that each child in attendance has a completed physical within one month of attendance.
Standard 22VAC40-185-160-A
Based on a review of 16 staff records, it was determined that the facility did not ensure that each staff member shall submit documentation of a negative tuberculosis screening. Documentation of the screening shall be submitted no later than 21 days after employment and shall have been completed within 12 months prior to or 21 days after employing.
Evidence:
1. The record for staff #2 (date of hire 3/11/21) did not contain documentation of a negative tuberculosis screening.
2. The record for staff #5 (date of hire 6/28/21) did not contain documentation of a negative tuberculosis screening.
3. The record for staff #6 (date of hire 3/11/21) did not contain documentation of a negative tuberculosis screening. .
4. The record for staff #7 (date of hire 1/11/21) contained documentation of a negative tuberculosis screening that was dated 6/9/21.
5. The record for staff #8 (date of hire 6/17/21) did not contain documentation of a negative tuberculosis screening.
6. The record for staff #10 (date of hire 7/6/21) did not contain documentation of a negative tuberculosis screening.
7. The record for staff #11 (date of hire 2/19/21) contained documentation of a negative tuberculosis screening that was dated 7/28/21.
8. The record for staff #13 (date of hire 4/12/21) contained documentation of a negative tuberculosis screening, but it was not dated.
9. The record for staff #16 (date of hire 6/10/21) did not contain documentation of a negative tuberculosis screening.
10. Staff #17 (Program Administrator) confirmed that the documentation of a negative tuberculosis screening was not completed within 21 days of employment for all the staff listed above.
Evidence:
1. The record for staff #2 (date of hire 3/11/21) did not contain documentation of a negative tuberculosis screening.
2. The record for staff #5 (date of hire 6/28/21) did not contain documentation of a negative tuberculosis screening.
3. The record for staff #6 (date of hire 3/11/21) did not contain documentation of a negative tuberculosis screening. .
4. The record for staff #7 (date of hire 1/11/21) contained documentation of a negative tuberculosis screening that was dated 6/9/21.
5. The record for staff #8 (date of hire 6/17/21) did not contain documentation of a negative tuberculosis screening.
6. The record for staff #10 (date of hire 7/6/21) did not contain documentation of a negative tuberculosis screening.
7. The record for staff #11 (date of hire 2/19/21) contained documentation of a negative tuberculosis screening that was dated 7/28/21.
8. The record for staff #13 (date of hire 4/12/21) contained documentation of a negative tuberculosis screening, but it was not dated.
9. The record for staff #16 (date of hire 6/10/21) did not contain documentation of a negative tuberculosis screening.
10. Staff #17 (Program Administrator) confirmed that the documentation of a negative tuberculosis screening was not completed within 21 days of employment for all the staff listed above.
Plan of Correction: The facility responded: The facility responded: The Child Care facility at Taylor Bend Family YMCA will ensure that each staff member will submit documentation of a negative tuberculosis screening. Documentation of a negative TB screening has to be completed prior to the staff?s start date and must be less than 30 days old.
Standard 22VAC40-185-160-C
Based on a review of 16 staff records, it was determined that the facility did not ensure that at least every two years from the date of the first initial screening or testing, staff members shall obtain and submit the results of a follow-up tuberculosis screening.
Evidence:
1. The record for staff #9, contained documentation of TB screening that was dated 7/22/19.
2. Staff #17 (Program Administrator), reviewed the record for staff #39and confirmed that an updated TB screening had not been received.
Evidence:
1. The record for staff #9, contained documentation of TB screening that was dated 7/22/19.
2. Staff #17 (Program Administrator), reviewed the record for staff #39and confirmed that an updated TB screening had not been received.
Plan of Correction: The facility responded: The Child Care facility at Taylor Bend Family YMCA will ensure that each staff will have an update TB screening from the date of the first initial screening or testing, staff will obtain and follow up with tuberculosis screening.
Standard 22VAC40-185-550-D
Based on a review of the emergency drill log and interview, it was determined that the facility did not ensure that a monthly practice evacuation drill is completed.
Evidence:
1. The emergency drill log did not have written documentation to demonstrate that an emergency evacuation drill was completed during the months of March 2021, April 2021, May 2021, June 2021, and July 2021. The last entry for a completed emergency evacuation drill was for February 2021.
2. Staff #17 (Program Administrator) confirmed that there was no emergency evacuation drill completed during the months of March 2021, April 2021, May 2021, June 2021, and July 2021.
Evidence:
1. The emergency drill log did not have written documentation to demonstrate that an emergency evacuation drill was completed during the months of March 2021, April 2021, May 2021, June 2021, and July 2021. The last entry for a completed emergency evacuation drill was for February 2021.
2. Staff #17 (Program Administrator) confirmed that there was no emergency evacuation drill completed during the months of March 2021, April 2021, May 2021, June 2021, and July 2021.
Plan of Correction: The facility responded: The Child Care facility at Taylor Bend Family YMCA will ensure that a monthly practice evacuation drill is completed and recorded.
Standard 22VAC40-185-60-A
Based on a review of five children's records and interview, it was determined that the facility did not ensure that they maintain and keep at the center a complete record for each child enrolled that contains all required information.
Evidence
1. There was no record available for viewing during the inspection for child #3.
2. Staff #17 (Program Director) confirmed that there was no record for child #3.
Evidence
1. There was no record available for viewing during the inspection for child #3.
2. Staff #17 (Program Director) confirmed that there was no record for child #3.
Plan of Correction: The facility responded: The Child Care facility at Taylor Bend Family YMCA will ensure that all children?s files will have the required documentation in them for enrollment (application, immunizations, physical, written agreement, proof of identity)
Standard 22VAC40-185-70-A
Based on a review of 16 staff records and interviews, it was determined that the facility did not ensure that a staff record is kept for each person with all of the required information.
Evidence:
1. The record for staff #3 date of hire 8/13/21) did not include documentation of orientation training.
2. The record for staff #5 date of hire 6/28/21) did not include documentation of orientation training.
3. The record for staff #6 date of hire 6/18/21) did not include documentation of orientation training.
4. The record for staff #3 date of hire 8/13/21) did not include documentation that two or more references as to character and reputation as well as competency were checked before employment and did not include documentation of orientation training.
5. The record for staff #14 date of hire 6/9/21) did not include documentation of orientation training.
6. The record for staff #16 date of hire 6/10/21) did not include documentation that two or more references as to character and reputation as well as competency were checked before employment and did not include documentation of orientation training.
7. Staff #17 (Program Administrator) confirmed that records for the staff listed above were not complete.
Evidence:
1. The record for staff #3 date of hire 8/13/21) did not include documentation of orientation training.
2. The record for staff #5 date of hire 6/28/21) did not include documentation of orientation training.
3. The record for staff #6 date of hire 6/18/21) did not include documentation of orientation training.
4. The record for staff #3 date of hire 8/13/21) did not include documentation that two or more references as to character and reputation as well as competency were checked before employment and did not include documentation of orientation training.
5. The record for staff #14 date of hire 6/9/21) did not include documentation of orientation training.
6. The record for staff #16 date of hire 6/10/21) did not include documentation that two or more references as to character and reputation as well as competency were checked before employment and did not include documentation of orientation training.
7. Staff #17 (Program Administrator) confirmed that records for the staff listed above were not complete.
Plan of Correction: The facility responded: The Child Care facility at Taylor Bend Family YMCA will ensure that staff records will contain all required documentation for each staff (orientation training and references,)
Standard 22VAC40-191-60-B
Based on a review of 16 staff records, it was determined that the facility did not ensure that the facility did not ensure that an employee must not be employed until a sworn statement or affirmation has been completed.
Evidence:
1. The record for staff #1 (date of hire 6/15/21) contained a sworn statement or affirmation that was dated 6/16/21.
2. The record for staff #3 (date of hire 8/13/21) did not contain a sworn statement or affirmation.
3. The record for staff #5 (date of hire 6/28/21) contained a sworn statement or affirmation that was dated 8/19/21.
4. The record for staff #7 (date of hire 1/11/21) contained a sworn statement or affirmation that was dated 8/20/21.
5. The record for staff #10 (date of hire 7/6/21) contained a sworn statement or affirmation that was dated 8/13/21.
6. The record for staff #11 (date of hire 2/9/21) contained a sworn statement or affirmation that was dated 3/1/21.
7. The record for staff #12 (date of hire 6/4/21) contained a sworn statement or affirmation that was dated 6/16/21.
8. The record for staff #14 (date of hire 6/9/21) contained a sworn statement or affirmation that was dated 6/16/21.
9. The record for staff #16 (date of hire 6/10/21) contained a sworn statement or affirmation that was dated 6/16/21.
10. Staff #17 (Program Administrator) confirmed the the sworn statement or affirmation was not completed prior to the first day of employment for the staff listed above.
Evidence:
1. The record for staff #1 (date of hire 6/15/21) contained a sworn statement or affirmation that was dated 6/16/21.
2. The record for staff #3 (date of hire 8/13/21) did not contain a sworn statement or affirmation.
3. The record for staff #5 (date of hire 6/28/21) contained a sworn statement or affirmation that was dated 8/19/21.
4. The record for staff #7 (date of hire 1/11/21) contained a sworn statement or affirmation that was dated 8/20/21.
5. The record for staff #10 (date of hire 7/6/21) contained a sworn statement or affirmation that was dated 8/13/21.
6. The record for staff #11 (date of hire 2/9/21) contained a sworn statement or affirmation that was dated 3/1/21.
7. The record for staff #12 (date of hire 6/4/21) contained a sworn statement or affirmation that was dated 6/16/21.
8. The record for staff #14 (date of hire 6/9/21) contained a sworn statement or affirmation that was dated 6/16/21.
9. The record for staff #16 (date of hire 6/10/21) contained a sworn statement or affirmation that was dated 6/16/21.
10. Staff #17 (Program Administrator) confirmed the the sworn statement or affirmation was not completed prior to the first day of employment for the staff listed above.
Plan of Correction: The facility responded: The Child Care facility at Taylor Bend Family YMCA will ensure that all employees will complete a sworn statement prior to the day that staff is hired.
Standard 22VAC40-191-60-C-2
Based on a review of 16 staff records, it was determined that the facility did not deny continued employment of a staff who did not have a search of the central registry finding within 30 days of employment.
Evidence:
1. The record for staff #5 (date of hire 6/28/21) did not contain documentation of a completed search of the central registry finding.
2. The record for staff #6 (date of hire 6/18/21) did not contain documentation of a completed search of the central registry finding.
3. The record for staff #7 (date of hire 1/11/21) contained documentation of a completed search of the central registry finding that was dated 6/21/21.
4. The record for staff #8 (date of hire 6/17/21) did not contain documentation of a completed search of the central registry finding.
5. The record for staff #10 (date of hire 7/6/21) did not contain documentation of a completed search of the central registry finding.
6. Staff #17 (Program Administrator) confirmed that the search of the central registry finding has not been received within 30 days of employment for the staff listed above.
Evidence:
1. The record for staff #5 (date of hire 6/28/21) did not contain documentation of a completed search of the central registry finding.
2. The record for staff #6 (date of hire 6/18/21) did not contain documentation of a completed search of the central registry finding.
3. The record for staff #7 (date of hire 1/11/21) contained documentation of a completed search of the central registry finding that was dated 6/21/21.
4. The record for staff #8 (date of hire 6/17/21) did not contain documentation of a completed search of the central registry finding.
5. The record for staff #10 (date of hire 7/6/21) did not contain documentation of a completed search of the central registry finding.
6. Staff #17 (Program Administrator) confirmed that the search of the central registry finding has not been received within 30 days of employment for the staff listed above.
Plan of Correction: The facility responded: The Childcare facility at Taylor Bend Family YMCA will ensure that all staff will have a central registry search done with results within 30 days of employment.
Standard 63.2(17)-1720.1-B-2
Based on a review of 16 staff records, it was determined that the facility did not ensure that an employee is allowed to begin employment without a completed national criminal history record check (finger printing).
Evidence:
1. The record for staff #1 (date of hire 6/15/21) contained documentation of a completed national criminal history record check (finger printing) that was dated 6/20/21.
2. The record for staff #3 (date of hire 8/13/21) did not contain documentation of a completed national criminal history record check (finger printing).
3. The record for staff #5 (date of hire 6/28/21) did not contain documentation of a completed national criminal history record check (finger printing).
4. The record for staff #6 (date of hire 6/18/21) did not contain documentation of a completed national criminal history record check (finger printing).
5. The record for staff #7 (date of hire 1/11/21) contained documentation of a completed national criminal history record check (finger printing) that was dated 6/21/21.
6. The record for staff #8 (date of hire 6/17/21) did not contain documentation of a completed national criminal history record check (finger printing).
7. The record for staff #10 (date of hire 7/6/21) contained documentation of a completed national criminal history record check (finger printing) that was dated 8/20/21.
8. The record for staff #11 (date of hire 2/19/21) contained documentation of a completed national criminal history record check (finger printing) that was dated 3/18/21.
9. The record for staff #12 (date of hire 6/4/21) contained documentation of a completed national criminal history record check (finger printing) that was dated 6/21/21.
10. The record for staff #14 (date of hire 6/9/21) contained documentation of a completed national criminal history record check (finger printing) that was dated 7/7/21.
11. The record for staff #16 (date of hire 6/10/21) did not contain documentation of a completed national criminal history record check (finger printing).
12. Staff #17 (Program Administrator) reviewed the records listed above and confirmed that she had not received the results of the finger print background check (finger printing) for the staff prior to employment.
Evidence:
1. The record for staff #1 (date of hire 6/15/21) contained documentation of a completed national criminal history record check (finger printing) that was dated 6/20/21.
2. The record for staff #3 (date of hire 8/13/21) did not contain documentation of a completed national criminal history record check (finger printing).
3. The record for staff #5 (date of hire 6/28/21) did not contain documentation of a completed national criminal history record check (finger printing).
4. The record for staff #6 (date of hire 6/18/21) did not contain documentation of a completed national criminal history record check (finger printing).
5. The record for staff #7 (date of hire 1/11/21) contained documentation of a completed national criminal history record check (finger printing) that was dated 6/21/21.
6. The record for staff #8 (date of hire 6/17/21) did not contain documentation of a completed national criminal history record check (finger printing).
7. The record for staff #10 (date of hire 7/6/21) contained documentation of a completed national criminal history record check (finger printing) that was dated 8/20/21.
8. The record for staff #11 (date of hire 2/19/21) contained documentation of a completed national criminal history record check (finger printing) that was dated 3/18/21.
9. The record for staff #12 (date of hire 6/4/21) contained documentation of a completed national criminal history record check (finger printing) that was dated 6/21/21.
10. The record for staff #14 (date of hire 6/9/21) contained documentation of a completed national criminal history record check (finger printing) that was dated 7/7/21.
11. The record for staff #16 (date of hire 6/10/21) did not contain documentation of a completed national criminal history record check (finger printing).
12. Staff #17 (Program Administrator) reviewed the records listed above and confirmed that she had not received the results of the finger print background check (finger printing) for the staff prior to employment.
Plan of Correction: The facility responded: The Child Care facility at Taylor Bend Family YMCA will ensure that all employees will have a national criminal history record (fingerprinting) prior to the day that staff is hired.
Standard 63.2(17)-1720.1-B-4
Based on a review of 16 staff records, it was determined that the facility did not ensure that they obtain a copy of the results of a criminal history record information check, a sex offender registry check, and a search of the child abuse and neglect registry or equivalent registry from any state in which the staff has resided in the preceding five years.
Evidence:
1. The record for staff #2 (date of hire 3/11/21) did not contain documentation of a completed sex offender search for North Carolina and a search of the central registry finding from North Carolina. The sworn statement indicated staff #2 had previously lived in North Carolina within the last 5 years.
2. Staff #17 (Program Administrator) review the record for the staff #2 and confirmed that the sex offender search for the state of North Carolina and the search of the central registry finding from the state of North Carolina in which staff #2 previously resided in has not been received.
Evidence:
1. The record for staff #2 (date of hire 3/11/21) did not contain documentation of a completed sex offender search for North Carolina and a search of the central registry finding from North Carolina. The sworn statement indicated staff #2 had previously lived in North Carolina within the last 5 years.
2. Staff #17 (Program Administrator) review the record for the staff #2 and confirmed that the sex offender search for the state of North Carolina and the search of the central registry finding from the state of North Carolina in which staff #2 previously resided in has not been received.
Plan of Correction: The facility responded: The Child Care facility at Taylor Bend Family YMCA will obtain copies of the results of all employees criminal history record check, a sex offender registry check, and a search of the child abuse and neglect registry or equivalent registry from any state the employee has resided in the preceding five years.