Inspection · 2022-11-09
Date
2022-11-09
Complaint Related
No
Licensing Inspector
Dominick Fields
(540) 359-5244
(540) 359-5244
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
8VAC20-820 THE LICENSE.
8VAC20-770 Background Checks (8VAC20-770)
22.1 Background Checks Code, Carbon Monoxide
Inspector Notes
A renewal inspection was conducted on 11/09/2022 between 11:50am- 2:15pm. There were 23 children present with 8 staff supervising. The inspector reviewed compliance in the areas of administration, staff qualifications and training, physical plant, staffing and supervision, programs, special care provisions and emergencies. A total of 3 child records, 2 staff records, and 4 agent 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
6Standard 22.1-289.035-B-4
Based on record review, a copy of the results of a search of the child abuse and neglect registry or equivalent registry from any state in which the individual has resided in the preceding five years was not obtained for 1 of 2 staff reviewed.
Evidence:
1. Staff #1 (hire date 6/20/2022) has resided outside of the state of Virginia in the preceding 5 years.
2. An out of state child abuse and neglect registry check inquiry was requested on 6/20/2022. No results of the inquiry had been obtained and no follow-up with the agency had been completed at the time of the inspection.
Evidence:
1. Staff #1 (hire date 6/20/2022) has resided outside of the state of Virginia in the preceding 5 years.
2. An out of state child abuse and neglect registry check inquiry was requested on 6/20/2022. No results of the inquiry had been obtained and no follow-up with the agency had been completed at the time of the inspection.
Plan of Correction: The center followed up with the state of New York regarding the request during the inspection.
Standard 8VAC20-770-40-D-1-a
Based on record review, 3 of 4 Agent records did not contain required background checks within 30 days of being designated as an agent.
1. Agent #1 assumed their role as an agent on 12/06/2021. The sworn statement of affirmation in the record for Agent #1 was dated 11/3/2022. The fingerprint-based criminal history record check results in the record for Agent #1 were dated 9/21/2022. The Virginia central registry check results in the record for Agent #1 were dated 11/2/2022.
2. Agent #2 assumed their role as an agent on 12/06/2021. The sworn statement of affirmation in the record for Agent #2 was dated 8/5/2022. The fingerprint-based criminal history record check results in the record for Agent #2 were dated 9/13/2022. The Virginia central registry check results in the record for Agent #2 were dated 10/31/2022.
3. Agent #3 assumed their role as an agent on 12/6/2021. The sworn statement of affirmation in the record for Agent #3 was dated 11/3/2022. The fingerprint-based criminal history record check results in the record for Agent #3 were dated 11/1/2022. The Virginia central registry check results in the record for Agent #3 were dated 11/14/2022.
1. Agent #1 assumed their role as an agent on 12/06/2021. The sworn statement of affirmation in the record for Agent #1 was dated 11/3/2022. The fingerprint-based criminal history record check results in the record for Agent #1 were dated 9/21/2022. The Virginia central registry check results in the record for Agent #1 were dated 11/2/2022.
2. Agent #2 assumed their role as an agent on 12/06/2021. The sworn statement of affirmation in the record for Agent #2 was dated 8/5/2022. The fingerprint-based criminal history record check results in the record for Agent #2 were dated 9/13/2022. The Virginia central registry check results in the record for Agent #2 were dated 10/31/2022.
3. Agent #3 assumed their role as an agent on 12/6/2021. The sworn statement of affirmation in the record for Agent #3 was dated 11/3/2022. The fingerprint-based criminal history record check results in the record for Agent #3 were dated 11/1/2022. The Virginia central registry check results in the record for Agent #3 were dated 11/14/2022.
Plan of Correction: Background checks for all board officers were obtained. A new board officer has been appointed and we have already initiated the process for backgrounds in order to maintain compliance with required time frames.
Standard 8VAC20-780-160-A
Based on record review, documentation of a negative tuberculosis screening was not submitted at the time of employment for 1 of 2 staff reviewed.
Evidence: The documentation of a negative tuberculosis screening for Staff #1 (date of hire 6/20/2022) was dated 7/7/2022.
Evidence: The documentation of a negative tuberculosis screening for Staff #1 (date of hire 6/20/2022) was dated 7/7/2022.
Plan of Correction: A tuberculosis screening was completed and placed in the file. We will pay closer attention to onboarding requirements moving forward.
Standard 8VAC20-780-240-A
Based on record review, 2 of 2 staff records reviewed did not contain documentation of completion of the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.
Evidence: Staff #1 began employment on 6/20/2022. The record for Staff #1 did not contain documentation of the completion of the orientation course.
Staff #2 began employment on 1/20/2022. The record for Staff #2 did not contain documentation of the completion of the orientation course
Evidence: Staff #1 began employment on 6/20/2022. The record for Staff #1 did not contain documentation of the completion of the orientation course.
Staff #2 began employment on 1/20/2022. The record for Staff #2 did not contain documentation of the completion of the orientation course
Plan of Correction: Both staff members are currently working on completing the training.
Standard 8VAC20-780-40-J
Based on record review, injury prevention procedures were not updated at least annually.
Evidence: the center?s injury prevention plan was last updated in 2020.
Evidence: the center?s injury prevention plan was last updated in 2020.
Plan of Correction: The plan has been updated as of 11/11/2022
Standard 8VAC20-780-550-D
Based on record review, evacuation drills were not practiced monthly.
Evidence: An emergency evacuation drill was not completed during the month of May 2022.
Evidence: An emergency evacuation drill was not completed during the month of May 2022.
Plan of Correction: We will practice closer monitoring of our calendar of fire drill implementation.