Inspection · 2021-09-03
Date
2021-09-03
Complaint Related
No
Licensing Inspector
Lynette A Storr
(703) 309-9153
(703) 309-9153
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
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 and concluded on 9/3/21. The director was contacted by telephone and a virtual inspection was conducted. There were 35 children present, ranging in ages from infants to 4 years old, with 12 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies, and nutrition. During the virtual inspection, children were observed returning from outside play, washing hands, and preparing for lunch. Infant bottles were reviewed for labeling, and diapering was also observed. A total of 3 children's records including children's medications and authorizations, and 5 staff records were reviewed. Other center documents including emergency drill records were also 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. For any questions regarding this inspection, please contact me at mahrukh.aziz@doe.virginia.gov or 571-835-4718.
Violations
4Standard 22VAC40-185-160-A
Based on records review, the center did not obtain documentation of a negative tuberculosis (TB) screening within 21 days after employment.
Evidence:
1. Staff # 1's first day of employment was 7/22/19.
2. Staff # 1's TB screening was completed on 10/29/19.
Evidence:
1. Staff # 1's first day of employment was 7/22/19.
2. Staff # 1's TB screening was completed on 10/29/19.
Plan of Correction: Original pre-employment TB screening dated 7 /18/19 was located in the file and copy was provided to licensing on 9/16/21. Going forward, all files will be reviewed by the Director and Regional Manager before a new hire starts. Clear expectations of file management have been discussed with the Center management team. Monthly spot checks of file compliance by the Regional Manager will be done to ensure ongoing compliance.
Standard 22VAC40-185-160-C
Based on records review, the center did not obtain documentation of a negative tuberculosis (TB) screening from staff every two years rom the date of the first initial screening.
Evidence: Staff # 2's TB screening was dated 8/15/19 and expired on 8/215/21. An updated TB screening was not obtained.
Evidence: Staff # 2's TB screening was dated 8/15/19 and expired on 8/215/21. An updated TB screening was not obtained.
Plan of Correction: Due to the ongoing COVID pandemic, the staff member was not able to schedule an appointment before the expiration date. Updated TB screening for this staff member was completed on 9/12/21 and provided to licensing on 9/16/21. Going forward the Director and leadership team at the Center will calendar employee's health tests and remind employees 60 days prior to expiry to provide an updated form. The Regional Manager will also do spot checks on employee files during her monthly visits to ensure ongoing compliance.
Standard 22VAC40-191-60-C-2
Based on records review, the center did not obtain results of the Virginia central registry findings for staff within 30 days of employment.
Evidence:
1. Staff # 1's first day of employment was 7/22/19.
2. Staff # 5's first day of employment was 9/11/20.
3. The center has not obtained results of the VA central registry findings for Staff # 1 and Staff # 5 to this date.
Evidence:
1. Staff # 1's first day of employment was 7/22/19.
2. Staff # 5's first day of employment was 9/11/20.
3. The center has not obtained results of the VA central registry findings for Staff # 1 and Staff # 5 to this date.
Plan of Correction: Staff #1: Records indicate that the Center contacted the Virginia Central Registry for this staff member, result of findings was requested, and received on 7/22/19. However, during the time of the visit, the document could not be located. A second request for this document was submitted on 9/15/21. If the results are not received by 10/1/21, the center director will contact crs_operations@dss.virginia.gov or call (804) 726-7544 to follow up. Notes will be kept in the file, of date, name of contact, results of conversation, and signature of director. Director will continue to follow up every two weeks until results are obtained. Additionally, Regional Manager will follow up with director to review compliance of this process.
Staff #2: Records indicate that the Center contacted Virginia Central Registry for this staff member, result of findings was requested on 9/14/20, but was not received. The acting director followed up on 10/8/20 and was told by Ms. Kim Davis that it was begin processed. The Center never received the results. A second request for this document was submitted on 8/26/21. The director reached out on 9/8/21 via email, but did not receive a response. Additionally, the director reached out on 9/17/21 via email and phone call, but has not received a response. Both attempts for follow up are located in the staff member's file. The director will continue to follow up every two weeks until the final results are received. Any additional notes will be kept in the file, of date, name of contact, results of conversation, and signature of director. Director will continue to follow up every two weeks until results are obtained. Additionally, Regional Manager will follow up with director to review compliance of this process.
Staff #2: Records indicate that the Center contacted Virginia Central Registry for this staff member, result of findings was requested on 9/14/20, but was not received. The acting director followed up on 10/8/20 and was told by Ms. Kim Davis that it was begin processed. The Center never received the results. A second request for this document was submitted on 8/26/21. The director reached out on 9/8/21 via email, but did not receive a response. Additionally, the director reached out on 9/17/21 via email and phone call, but has not received a response. Both attempts for follow up are located in the staff member's file. The director will continue to follow up every two weeks until the final results are received. Any additional notes will be kept in the file, of date, name of contact, results of conversation, and signature of director. Director will continue to follow up every two weeks until results are obtained. Additionally, Regional Manager will follow up with director to review compliance of this process.
Standard 63.2(17)-1720.1-B-4
Based on records review, the center did not obtain results of a criminal record check (CRC), sex offender registry searches and out of state central registry checks for staff that have lived outside of Virginia in the last five years.
Evidence:
1. Staff # 1 documents indicated that her first day of employment was 7/22/19, and she has lived in Louisiana and D.C. within the last five years.
2. Staff # 1's out of state central registry results for Louisiana and D.C. were not obtained within 45 days of employment. The central registry result for Louisiana was dated 12/9/19. The central registry result for D.C. was dated 9/27/19.
3. Staff # 1's out of state sex offender search results were not obtained by 12/31/20. The sex offender results for Louisiana and D.C. were both dated 4/22/21.
4. The center did not obtain results of an out of state CRC for Staff # 1 for Louisiana and D.C. by 12/31/20, and they have not been obtained to this date.
5. Staff # 2's first day of employment was 8/9/19, and Staff # 2's record indicated that she resided in Tennessee, Massachusetts and New Jersey in the last five years.
6. Staff # 2's out of state sex offender search results for all three states were not obtained by 12/31/20, and were dated 4/22/21.
7. The center did not obtain an out of state CRC for Staff # 2 for Massachusetts by 12/31/20 and they have not been obtained to this date.
8. Staff # 3's first day of employment was 9/9/19, and her record indicated that she has resided in Maryland in the last five years. Staff # 3's out of state sex offender search result was not obtained by 12/31/20. The sex offender results for Maryland was dated 4/22/21.
9. Staff # 4's first day of employment was 4/22/21, and her record indicated that she resided in D.C. in the last five years.
10. The center has not obtained Staff # 4's results of the D.C. central registry finding to this date. The center also did not obtain results of the CRC for DC prior to Staff # 4's first day of employment.
Evidence:
1. Staff # 1 documents indicated that her first day of employment was 7/22/19, and she has lived in Louisiana and D.C. within the last five years.
2. Staff # 1's out of state central registry results for Louisiana and D.C. were not obtained within 45 days of employment. The central registry result for Louisiana was dated 12/9/19. The central registry result for D.C. was dated 9/27/19.
3. Staff # 1's out of state sex offender search results were not obtained by 12/31/20. The sex offender results for Louisiana and D.C. were both dated 4/22/21.
4. The center did not obtain results of an out of state CRC for Staff # 1 for Louisiana and D.C. by 12/31/20, and they have not been obtained to this date.
5. Staff # 2's first day of employment was 8/9/19, and Staff # 2's record indicated that she resided in Tennessee, Massachusetts and New Jersey in the last five years.
6. Staff # 2's out of state sex offender search results for all three states were not obtained by 12/31/20, and were dated 4/22/21.
7. The center did not obtain an out of state CRC for Staff # 2 for Massachusetts by 12/31/20 and they have not been obtained to this date.
8. Staff # 3's first day of employment was 9/9/19, and her record indicated that she has resided in Maryland in the last five years. Staff # 3's out of state sex offender search result was not obtained by 12/31/20. The sex offender results for Maryland was dated 4/22/21.
9. Staff # 4's first day of employment was 4/22/21, and her record indicated that she resided in D.C. in the last five years.
10. The center has not obtained Staff # 4's results of the D.C. central registry finding to this date. The center also did not obtain results of the CRC for DC prior to Staff # 4's first day of employment.
Plan of Correction: On 9/16/21, Management staff has been retrained on the requirements for staff who have lived outside of Virginia in the past five years. The following corrective action has been taken for each employee:
Staff #1: Louisiana and DC central registry results are on file as of 12/9/19 and 9/27/19. Documentation for any new staff will be obtained within the 45 day requirement. Sex offender search results for Louisiana and DC are on file as of 4/22/21. Documentation for any new staff will be obtained before the first day of employment. Criminal Records Check for Louisiana and DC were requested on 9/20/21. If the results have not been obtained by 10/1/21, the center director will contact the agency to follow up. Notes will be kept in the file, of date, name of contact, results of conversation, and signature of director. Director will continue to follow up every two weeks until results are obtained. Additionally, Regional Manager will follow up with director to review compliance of this process.
Staff #2: Sex offender search results for Tennessee, Massachusetts and New Jersey are on file as of 4/22/21. Documentation for any new staff will be obtained before the first day of employment. Criminal Records Check for Massachusetts was requested on 9/17 /2 l. If the results have not been obtained by 10/1/21, the center director will contact the agency to follow up. Notes will be kept in the file, of date, name of contact, results of conversation, and signature of director. Director will continue to follow up every two weeks until results are obtained. Additionally, Regional Manager will follow up with director to review compliance of this process.
Staff #3: Sex offender search results for Maryland is on file as of 4/22/21. Documentation for any new staff will be obtained before the first day of employment.
Staff #4: Criminal Records Check for DC was requested on 9/11/21. If the results have not been obtained by 10/1/21, the center director will contact the agency to follow up. Notes will be kept in the file, of date, name of contact, results of conversation, and signature of director. Director will continue to follow up every two weeks until results are obtained. Additionally, Regional Manager will follow up with director to review compliance of this process.
Going forward, all files will be reviewed by the Director and Regional Manager before a new hire starts. Clear expectations of file management have been discussed with the Center management team. Monthly spot checks of file compliance by the Regional Manager will be done to ensure ongoing compliance.
Staff #1: Louisiana and DC central registry results are on file as of 12/9/19 and 9/27/19. Documentation for any new staff will be obtained within the 45 day requirement. Sex offender search results for Louisiana and DC are on file as of 4/22/21. Documentation for any new staff will be obtained before the first day of employment. Criminal Records Check for Louisiana and DC were requested on 9/20/21. If the results have not been obtained by 10/1/21, the center director will contact the agency to follow up. Notes will be kept in the file, of date, name of contact, results of conversation, and signature of director. Director will continue to follow up every two weeks until results are obtained. Additionally, Regional Manager will follow up with director to review compliance of this process.
Staff #2: Sex offender search results for Tennessee, Massachusetts and New Jersey are on file as of 4/22/21. Documentation for any new staff will be obtained before the first day of employment. Criminal Records Check for Massachusetts was requested on 9/17 /2 l. If the results have not been obtained by 10/1/21, the center director will contact the agency to follow up. Notes will be kept in the file, of date, name of contact, results of conversation, and signature of director. Director will continue to follow up every two weeks until results are obtained. Additionally, Regional Manager will follow up with director to review compliance of this process.
Staff #3: Sex offender search results for Maryland is on file as of 4/22/21. Documentation for any new staff will be obtained before the first day of employment.
Staff #4: Criminal Records Check for DC was requested on 9/11/21. If the results have not been obtained by 10/1/21, the center director will contact the agency to follow up. Notes will be kept in the file, of date, name of contact, results of conversation, and signature of director. Director will continue to follow up every two weeks until results are obtained. Additionally, Regional Manager will follow up with director to review compliance of this process.
Going forward, all files will be reviewed by the Director and Regional Manager before a new hire starts. Clear expectations of file management have been discussed with the Center management team. Monthly spot checks of file compliance by the Regional Manager will be done to ensure ongoing compliance.