Inspection · 2022-07-25
Date
2022-07-25
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
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)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced renewal inspection was conducted on 7/25/22 from 9:55am - 1:15pm. During the inspection there were 108 children ages five years old through twelve years old in care with 15 staff. Children were observed participating in various activities in the classrooms, playing outside, swimming, and eating lunch. Records were reviewed for ten children and 15 staff during the inspection. Medication, emergency procedures and emergency supplies were reviewed during the inspection. Information gathered during the inspection determined noncompliance with applicable standards or law and violations were documented on the violation notice issued to the program, and were discussed during the exit interview.
Violations
9Standard 8VAC20-770-60-C-2
Based on a review of 15 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 #2 (date of hire 8/6/21) did not contain documentation of a completed search of the central registry finding.
2. The record for staff #3 (date of hire 6/6/22) did not contain documentation of a completed search of the central registry finding.
3. The record for staff #4 (date of hire 6/3/22) did not contain documentation of a completed search of the central registry finding.
4. The record for staff #5 (date of hire 6/7/22) did not contain documentation of a completed search of the central registry finding.
5. The record for staff #6 (date of hire 6/17/22) did not contain documentation of a completed search of the central registry finding.
6. The record for staff #6 (date of hire 9/21/21) did not contain documentation of a completed search of the central registry finding.
7. The record for staff #9 (date of hire 1/11/17) did not contain documentation of a completed search of the central registry finding.
8. The record for staff #11 (date of hire 3/28/22) did not contain documentation of a completed search of the central registry finding.
9. The record for staff #12 (date of hire 6/9/22) did not contain documentation of a completed search of the central registry finding.
10. The record for staff #15 (date of hire 6/11/22) did not contain documentation of a completed search of the central registry finding.
11. Staff #2 (Program Director) confirmed that there was not a search of the central registry finding available for viewing during the inspection for the staff listed above.
Evidence:
1. The record for staff #2 (date of hire 8/6/21) did not contain documentation of a completed search of the central registry finding.
2. The record for staff #3 (date of hire 6/6/22) did not contain documentation of a completed search of the central registry finding.
3. The record for staff #4 (date of hire 6/3/22) did not contain documentation of a completed search of the central registry finding.
4. The record for staff #5 (date of hire 6/7/22) did not contain documentation of a completed search of the central registry finding.
5. The record for staff #6 (date of hire 6/17/22) did not contain documentation of a completed search of the central registry finding.
6. The record for staff #6 (date of hire 9/21/21) did not contain documentation of a completed search of the central registry finding.
7. The record for staff #9 (date of hire 1/11/17) did not contain documentation of a completed search of the central registry finding.
8. The record for staff #11 (date of hire 3/28/22) did not contain documentation of a completed search of the central registry finding.
9. The record for staff #12 (date of hire 6/9/22) did not contain documentation of a completed search of the central registry finding.
10. The record for staff #15 (date of hire 6/11/22) did not contain documentation of a completed search of the central registry finding.
11. Staff #2 (Program Director) confirmed that there was not a search of the central registry finding available for viewing during the inspection for the staff listed above.
Plan of Correction: The facility responded: The search of the central registry has been submitted for all of the staff. We will check the status and if they have not been received, the staff will complete a new request.
Standard 8VAC20-770-70-A
Based on a review of 15 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 #1 did not include documentation that orientation training had been completed.
2. The record for staff #4 did not include documentation that two or more references as to character and reputation as well as competency were checked before employment.
3. The record for staff #5 did not include documentation that orientation training had been completed.
4. The record for staff #11 did not include documentation that orientation training had been completed.
5. The record for staff #15 did not include documentation that orientation training had been completed.
6. Staff #2 (Program Director) confirmed that the records for the staff listed above were not complete.
Evidence:
1. The record for staff #1 did not include documentation that orientation training had been completed.
2. The record for staff #4 did not include documentation that two or more references as to character and reputation as well as competency were checked before employment.
3. The record for staff #5 did not include documentation that orientation training had been completed.
4. The record for staff #11 did not include documentation that orientation training had been completed.
5. The record for staff #15 did not include documentation that orientation training had been completed.
6. Staff #2 (Program Director) confirmed that the records for the staff listed above were not complete.
Plan of Correction: The facility responded: The missing documentation will be added to each staff record.
Standard 8VAC20-780-140-A
Based on a review of ten 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. Staff #2 (Program Director) confirmed that the record for child #1 did not contain a physical examination.
Evidence:
1. The record for child #1 did not contain a physical examination.
2. Staff #2 (Program Director) confirmed that the record for child #1 did not contain a physical examination.
Plan of Correction: The facility responded: The parents of child #1 will be asked to provide a copy of the most current physical examination.
Standard 8VAC20-780-160-A
Based on a review of 15 staff records, it was determined that the facility did not ensure that each staff member shall submit documentation of a negative tuberculosis screening prior to employment beginning.
Evidence:
1. The record for staff #3 (date of hire 6/6/22) contained documentation of a negative tuberculosis screening that was dated 6/16/22.
2. Based on a review of five staff records, it was determined that the facility did not ensure that each staff member shall submit documentation of a negative tuberculosis screening prior to employment beginning
3. The record for staff #5 (date of hire 6/7/22) contained documentation of a negative tuberculosis screening that was dated 6/28/22.
4. The record for staff #12 did not contain documentation of a negative tuberculosis screening.
5. The record for staff #15 (date of hire 6/11/22) contained documentation of a negative tuberculosis screening that was dated 6/23/22.
Staff #6 (Program Administrator) reviewed the record for staff #5, and confirmed that the documentation of a negative tuberculosis screening had not been received prior to employment.
Evidence:
1. The record for staff #3 (date of hire 6/6/22) contained documentation of a negative tuberculosis screening that was dated 6/16/22.
2. Based on a review of five staff records, it was determined that the facility did not ensure that each staff member shall submit documentation of a negative tuberculosis screening prior to employment beginning
3. The record for staff #5 (date of hire 6/7/22) contained documentation of a negative tuberculosis screening that was dated 6/28/22.
4. The record for staff #12 did not contain documentation of a negative tuberculosis screening.
5. The record for staff #15 (date of hire 6/11/22) contained documentation of a negative tuberculosis screening that was dated 6/23/22.
Staff #6 (Program Administrator) reviewed the record for staff #5, and confirmed that the documentation of a negative tuberculosis screening had not been received prior to employment.
Plan of Correction: The facility responded: Staff will be sent to complete a TB screening. All new staff will have to complete a TB screening prior to employment.
Standard 8VAC20-780-340-D
Based on observation, a review of 15 staff records and interviews, it was determined that the licensee did not ensure that in each grouping of children at least one staff member who meets the qualifications of a program leader or program director shall be regularly present.
Evidence:
1. The Licensing Inspector observed nine groups of children during the inspection. Eight of those groups of children did not contain a staff that was qualified as a Program Leader.
2. Staff #2 (Program Director) reviewed the records for the staff working, and was unable to provide documentation during the inspection that any of the staff in that grouping of children were qualified. Program Leader qualified.
Evidence:
1. The Licensing Inspector observed nine groups of children during the inspection. Eight of those groups of children did not contain a staff that was qualified as a Program Leader.
2. Staff #2 (Program Director) reviewed the records for the staff working, and was unable to provide documentation during the inspection that any of the staff in that grouping of children were qualified. Program Leader qualified.
Plan of Correction: The facility responded: We will ensure that there is a Program leader qualified staff in each grouping of children. The documentation to demonstrate each staff is qualified will be placed in their record.
Standard 8VAC20-780-510-I
Based on a review of the medication being stored at the facility, it was determined that the facility did not ensure that in order to administer prescription medication, the center has obtained written authorization from a parent or guardian.
Evidence:
1. The written authorization for the medication for child #11 was not signed by the parent.
2. There was no written authorization for the medication for child #12.
3. Staff #2 (Program Director) confirmed that there was medication listed above did not have written authorization from the parent to be given.
Evidence:
1. The written authorization for the medication for child #11 was not signed by the parent.
2. There was no written authorization for the medication for child #12.
3. Staff #2 (Program Director) confirmed that there was medication listed above did not have written authorization from the parent to be given.
Plan of Correction: The facility responded: A medication authorization will be completed by the parent . Medication will not be accepted unless a medication authorization is completed.
Standard 8VAC20-780-510-P
Based on a review of the medication being stored at the center, it was determined that the licensee did not ensure that when an authorization expires, the parent shall be notified that the medication needs to be picked up within 14 days or the parent must renew the authorization.
Evidence:
1. The long term medication authorization for child #13 expired on 6/1/22, but the medication (Albuterol inhaler) was still at the center.
2. Staff #2 (Program director) confirmed that the medication for child #13 had been present in the center for more than 14 days since the expiration of the written authorization.
Evidence:
1. The long term medication authorization for child #13 expired on 6/1/22, but the medication (Albuterol inhaler) was still at the center.
2. Staff #2 (Program director) confirmed that the medication for child #13 had been present in the center for more than 14 days since the expiration of the written authorization.
Plan of Correction: The facility responded: The medication for child #13 will be returned to the parent or a new medication authorization will be completed.
Standard 8VAC20-780-530-A
Based on a review of eleven staff records and interviews, it was determined that the facility did not ensure that there shall be at least one staff in each classroom or area where children are present that has a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care.
Evidence:
1. The Licensing Inspector observed nine groups of children during the inspection. Seven of those groups of children did not contain a staff that had a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care.
2. Staff #2 (Program Director) confirmed that staff in each of these seven groups did not have a
current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care available for viewing during the inspection.
Evidence:
1. The Licensing Inspector observed nine groups of children during the inspection. Seven of those groups of children did not contain a staff that had a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care.
2. Staff #2 (Program Director) confirmed that staff in each of these seven groups did not have a
current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care available for viewing during the inspection.
Plan of Correction: The facility responded: We will ensure that there is a staff in each grouping of children that has a current certification in CPR/First Aid.
Standard 8VAC20-780-560-G
Based on observation and interviews, it was determined that the licensee did not ensure that when food is brought from home it is labeled with the child's name and date.
Evidence:
1. The Licensing Inspector observed that the lunch boxes that the children had brought from home were not labeled with their name and the date.
2. Staff #6 (Program Director) confirmed that all of the lunch boxes used by the children at the facility were not labeled with their name or the date.
Evidence:
1. The Licensing Inspector observed that the lunch boxes that the children had brought from home were not labeled with their name and the date.
2. Staff #6 (Program Director) confirmed that all of the lunch boxes used by the children at the facility were not labeled with their name or the date.
Plan of Correction: The facility responded: All lunchboxes will be labeled with the child's name and the date.