Inspection · 2024-07-29
Date
2024-07-29
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.
8VAC20-770 Background Checks (8VAC20-770)
22.1 Background Checks Code, Carbon Monoxide
Inspector Notes
An unannounced, on-site renewal inspection was initiated on 7/29/24 and completed on 7/29/24, as a part of the licensure period. The on-site inspection began at 12:00pm and ended at 2:45pm. The inspector reviewed compliance in the areas listed above. There were 119 children present and 12 staff. The inspector reviewed 5 children?s records and 5 staff records on-site. This inspection included document review, tour of the facility, interviews, observations, and measurements. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations are documented on the violation notice issued to the program.
Please complete the plan of correction (POC) and date to be corrected sections for each violation cited on the violation notice. Specify how the deficient practice will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on 8/13/24. A POC submitted after this date will not appear on the public website.
Violations
7Standard 8VAC20-780-160-C
Repeat Violation
Based on a record review of 5 staff records it was determined that the center did not ensure that at least every two years from the date of the initial screening or testing, staff members shall obtain and submit the results of a follow-up tuberculosis screening as stated.
Evidence:
1.There was no documentation of an updated TB screening for staff #3. The last TB screening was dated 6/23/2022.
a.The Director confirmed the TB was not updated.
Based on a record review of 5 staff records it was determined that the center did not ensure that at least every two years from the date of the initial screening or testing, staff members shall obtain and submit the results of a follow-up tuberculosis screening as stated.
Evidence:
1.There was no documentation of an updated TB screening for staff #3. The last TB screening was dated 6/23/2022.
a.The Director confirmed the TB was not updated.
Plan of Correction: Directors will complete monthly audits on staff files to ensure that any requirements expiring are renewed so that each staff member remains in compliance.
Standard 8VAC20-780-210-A
Repeat Violation
Based on record review and interview, it was determined the center did not ensure that staff in program leader positions met all the requirements.
Evidence:
1.Documentation in the record for staff # 2 (date of hire 5/3/24) indicated the staff member was a program leader however, the record did not contain documentation of the required education, programmatic experience or training hours required for a program leader position. Staff #2 was supervising 18, 8?9-year-old children during the inspection.
a.There was no proof of the required education (diploma, degree, transcript or certificate) in the record.
b.The record contained 20.5 hours of training; this was less than the required 24 hours.
c.The record did not contain documentation of previous experience.
2.Documentation in the record for staff # 5 (date of hire 6/4/24) indicated the staff member was a program leader however, the record did not contain documentation of the required programmatic experience or training hours required for a program leader position. Staff #5 was supervising 22, 8?9-year-old children with two additional staff members.
a.The record contained 14 hours of training; this was less than the required 24 hours.
b.The record contained no documentation of previous experience.
3.The Director confirmed that the documentation in the records for staff #2 and staff #5 did not meet the program leader qualification requirements.
Based on record review and interview, it was determined the center did not ensure that staff in program leader positions met all the requirements.
Evidence:
1.Documentation in the record for staff # 2 (date of hire 5/3/24) indicated the staff member was a program leader however, the record did not contain documentation of the required education, programmatic experience or training hours required for a program leader position. Staff #2 was supervising 18, 8?9-year-old children during the inspection.
a.There was no proof of the required education (diploma, degree, transcript or certificate) in the record.
b.The record contained 20.5 hours of training; this was less than the required 24 hours.
c.The record did not contain documentation of previous experience.
2.Documentation in the record for staff # 5 (date of hire 6/4/24) indicated the staff member was a program leader however, the record did not contain documentation of the required programmatic experience or training hours required for a program leader position. Staff #5 was supervising 22, 8?9-year-old children with two additional staff members.
a.The record contained 14 hours of training; this was less than the required 24 hours.
b.The record contained no documentation of previous experience.
3.The Director confirmed that the documentation in the records for staff #2 and staff #5 did not meet the program leader qualification requirements.
Plan of Correction: Directors will maintain accurate records including updating qualifications and training logs
Standard 8VAC20-780-260-B
Based on a review of documentation and interview, it was determined that the facility did not ensure that an annual approval from the health department shall be provided.
Evidence:
1.The most recent annual health inspection report available for viewing during the inspection was dated 7/17/23.
a.The Director confirmed the annual inspection from the health department had not been completed.
Evidence:
1.The most recent annual health inspection report available for viewing during the inspection was dated 7/17/23.
a.The Director confirmed the annual inspection from the health department had not been completed.
Plan of Correction: Directors will ensure that all licensed requirements including the annual health
inspection is updated annually. Health inspection was completed after licensing inspector visited
inspection is updated annually. Health inspection was completed after licensing inspector visited
Standard 8VAC20-780-350-B-5
Based on observation and interviews the center did not ensure that the staff-child-ratio of 1:18 for children school age eligible up to 9 years was maintained.
Evidence:
1.When the inspector entered the classroom with the Director, staff #6 was observed alone, supervising 19 children ages 7?8-year-old. Based on the ages of the children two staff members were required.
a.The Director confirmed the classroom was out of ratio.
Evidence:
1.When the inspector entered the classroom with the Director, staff #6 was observed alone, supervising 19 children ages 7?8-year-old. Based on the ages of the children two staff members were required.
a.The Director confirmed the classroom was out of ratio.
Plan of Correction: Director will make sure that ratios are maintained at all times.
Standard 8VAC20-780-510-I
Repeat Violation
Based on record review and interviews, it was determined the center did not ensure that all of the requirements for administration of prescription medications were obtained.
Evidence:
1.The emergency medication for child #6 and child #7 was not in the original box with the child identified on the prescription label.
a. The Director confirmed the medications were not in the original boxes and did not have the prescription labels.
Based on record review and interviews, it was determined the center did not ensure that all of the requirements for administration of prescription medications were obtained.
Evidence:
1.The emergency medication for child #6 and child #7 was not in the original box with the child identified on the prescription label.
a. The Director confirmed the medications were not in the original boxes and did not have the prescription labels.
Plan of Correction: MAT trained staff will only accept medication in the original packaging.
Standard 8VAC20-780-550-D
Repeat Violation
Based on record reviews and interviews, it was determined that the center did not ensure that the center shall implement a monthly practice evacuation drill.
Evidence:
1.There was no documentation of an emergency evacuation practice drill conducted in June.
a.The Director confirmed June was not documented.
Based on record reviews and interviews, it was determined that the center did not ensure that the center shall implement a monthly practice evacuation drill.
Evidence:
1.There was no documentation of an emergency evacuation practice drill conducted in June.
a.The Director confirmed June was not documented.
Plan of Correction: Drills will be completed monthly.
Standard 8VAC20-780-60-A
Repeat Violation
Based on review of children?s records and interviews, it was determined that the center did not ensure that each child?s record contains all required information, including first and last days of attendance.
Evidence:
1.The records for child #1, child#2, child#3, cjild#4, child #5 did not contain documentation of the children?s actual last day of attendance.
a.All 5 children?s records reflected start dates of 7/22/24 and last day of attendance as 7/26/24 however the children were in care on 7/29/24.
b.The Director confirmed 7/26/24 was not the last day of attendance for child #1, #2, #3, #4, #5.
Based on review of children?s records and interviews, it was determined that the center did not ensure that each child?s record contains all required information, including first and last days of attendance.
Evidence:
1.The records for child #1, child#2, child#3, cjild#4, child #5 did not contain documentation of the children?s actual last day of attendance.
a.All 5 children?s records reflected start dates of 7/22/24 and last day of attendance as 7/26/24 however the children were in care on 7/29/24.
b.The Director confirmed 7/26/24 was not the last day of attendance for child #1, #2, #3, #4, #5.
Plan of Correction: Director will complete a weekly audit when printing all child
records to ensure that all information is correctly documented as
required.
records to ensure that all information is correctly documented as
required.