Inspection · 2025-01-16
(571) 835-4718
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.
20 Access to minor's records
22.1 Background Checks Code, Carbon Monoxide 54.1 Provider must be MAT certified to administer prescription medication.
63.2 Child abuse and neglect
Inspector Notes
An unannounced, on-site monitoring inspection was conducted on 1/16/25 from 9:04 am to 10:45am. The inspector reviewed compliance in the areas listed above. There were 28 children present and 4 staff. The inspector reviewed 4 children?s records and 4 staff records on-site.
This inspection included document review, tour of the facility, interviews, and observations.
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 violation will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on 1/29/25. A POC submitted after this date will not appear on the public website.
Violations
4Child #2 has an emergency medication on supply that the center has agreed to administer if needed, but none of the staff on site have completed the training required to administer the emergency medication.
EpiPen Jr. as part of policy. The parent handbook has been updated to clearly
state that Auvi-Q devices and any other devices not covered in the MAT training will not be accepted for administration at the center.
1. At 9:04 am, there were a total of twenty-six children present with three staff members. Two of the twenty-six children were two years old.
2. Between 9:04 am to 9:35 am, the children were observed as one large group, handwashing and eating morning snack in the large room.
3. At 9:35 am, the group was divided, and 8 children including the two year old children were taken into another room by Staff # 1.The center did not meet the ratio requirement for 31 minutes.
The center's medication administration policy did not include procedures to ensure that outdated medication is not used.
In addition, NES has developed a new Medication Expiration and Disposal Form
to enhance accountability and support compliance with medication management
procedures.
1. Child #1's medication authorization expired over four months ago, and the medication also expired over four months ago.
2. Child #2's medication authorization expired over 16 months ago, and the medication expired over 13 months ago.
3. The staff present were not aware that the authorizations and medications had expired. Child # 1 and Child # 2's parents were not notified; and the center did not dispose of the medications after 14 days of authorization expiration.
On 1/16/2025, following an inspection, the parent was contacted again and reminded that a new medication and the form was required. The expired
medication was sent home. Child 2's parent was informed that their child's
medication had expired, however,the parent did not confirm whether a replacement would be provided. The expired medication was mistakenly stored
in the back of the cabinet rather than returned or discarded. On 1/16/2025, following the inspection, the parent was contacted to inform them that the
expired medication would be sent home. The parent was also advised that if they wished for their child to have medication available on-site, they would need to provide an unexpired EpiPen along with updated form. As a corrective action, staff were retrained on the proper procedures for handling and disposing of medications. Additionally, a new Medication Expiration and Disposal Form was created to enhance accountability and ensure compliance.