Inspection · 2023-01-27
Date
2023-01-27
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.
8VAC20-820 HEARINGS PROCEDURES.
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
A monitoring inspection was conducted on 01/27/2023. There were 26 school aged children present with 4 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of 5 child records and 3 staff 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 and discussed with the program director during the exit interview.
Violations
9Standard 8VAC20-780-140-A
Based upon review of records, the facility has not ensured that each child has a physical examination by or under the direction of a physician.
Evidence:
The record provided for child 5, whose first date of attendance was recorded as 9/6/2022, did not have documentation of a physical examination.
Evidence:
The record provided for child 5, whose first date of attendance was recorded as 9/6/2022, did not have documentation of a physical examination.
Plan of Correction: The facility responded with the following:
The youth Development Director will work with the Child Care Administration team to ensure all necessary requirements are updated and will print the updated forms for the onsite child file binder. Staff will audit the binder monthly to ensure everyone attending the program has all required documents.
The youth Development Director will work with the Child Care Administration team to ensure all necessary requirements are updated and will print the updated forms for the onsite child file binder. Staff will audit the binder monthly to ensure everyone attending the program has all required documents.
Standard 8VAC20-780-160-A
Based upon review of documentation, the facility ash not ensured that each staff member submits documentation of a negative tuberculosis screening that was completed within the last 30 calendar days of the date of employment.
Evidence:
1. The date of employment of staff 1 was 4/20/2022. The date of the tuberculosis screening was 6/3/2021.
2. The date of employment of staff 2 was 10/31/2022. The date of the tuberculosis screening was 7/23/2022.
Evidence:
1. The date of employment of staff 1 was 4/20/2022. The date of the tuberculosis screening was 6/3/2021.
2. The date of employment of staff 2 was 10/31/2022. The date of the tuberculosis screening was 7/23/2022.
Plan of Correction: The facility responded with the following:
Staff will obtain an updated TB test and documentation will be updated in their file.
Staff will obtain an updated TB test and documentation will be updated in their file.
Standard 8VAC20-780-245-J-3
Based upon review of medication and staff interview, the facility has not ensured any child for whom emergency medication has been prescribed is always in the care of a staff member who has medication administration training (MAT) certification.
Evidence:
1. From 12:05 PM until 12:15 PM, child 2, child 3 and child 4, all of whom have allergies that may require the administration of epinephrine, were in care without a MAT certified caregiver.
2. Staff 1 acknowledged that staff 1 is the only caregiver with MAT certification and that staff 1 did not arrive until 12:15 PM.
Evidence:
1. From 12:05 PM until 12:15 PM, child 2, child 3 and child 4, all of whom have allergies that may require the administration of epinephrine, were in care without a MAT certified caregiver.
2. Staff 1 acknowledged that staff 1 is the only caregiver with MAT certification and that staff 1 did not arrive until 12:15 PM.
Plan of Correction: The facility responded with the following:
An additional staff member will receive MAT training to cover all hours of the program.
An additional staff member will receive MAT training to cover all hours of the program.
Standard 8VAC20-780-260-B
Based upon review of documentation and staff interview, the facility has not ensured that there is documentation of annual approval of the health department.
Evidence:
1. The facility could not provide documentation of annual approval of the health department.
2. Staff 1 verified that documentation of annual approval of the health department was not available.
Evidence:
1. The facility could not provide documentation of annual approval of the health department.
2. Staff 1 verified that documentation of annual approval of the health department was not available.
Plan of Correction: The facility responded with the following:
The annual health department inspection has been placed in the licensing binder on site.
The annual health department inspection has been placed in the licensing binder on site.
Standard 8VAC20-780-40-E
Based upon observation and staff interview, the facility has not ensured that the center's activities are maintained in compliance with the center's own policies and procedures.
Evidence:
Upon arrival of the children from school, staff were observed asking other children if children who were enrolled in the after school program were in school that day. Staff 1 was heard asking children if children absent from the program were in school that day. When asked by the licensing inspector how the absence of a child arriving from another program was confirmed, staff 1 stated that she asked the other children if the child was in school that day. The center's policy states that the office personnel at the elementary school was to be contacted to confirm children's absences.
Evidence:
Upon arrival of the children from school, staff were observed asking other children if children who were enrolled in the after school program were in school that day. Staff 1 was heard asking children if children absent from the program were in school that day. When asked by the licensing inspector how the absence of a child arriving from another program was confirmed, staff 1 stated that she asked the other children if the child was in school that day. The center's policy states that the office personnel at the elementary school was to be contacted to confirm children's absences.
Plan of Correction: The facility responded with the following:
To confirm a child's absence from the program, staff will get in contact with the appropriate school official in the front office.
To confirm a child's absence from the program, staff will get in contact with the appropriate school official in the front office.
Standard 8VAC20-780-510-P
Based upon observation and staff interview, the facility has not ensured that when medication expires, the parent is notified and the medication is returned to the parent within 14 days.
Evidence:
1. There was epinephrine stored for potential administration to child 2. The epinephrine expired in December 2022 and was not returned to the parent.
2. Staff 1 acknowledged that the epinephrine for child 2 had expired and the parent ws not notified.
Evidence:
1. There was epinephrine stored for potential administration to child 2. The epinephrine expired in December 2022 and was not returned to the parent.
2. Staff 1 acknowledged that the epinephrine for child 2 had expired and the parent ws not notified.
Plan of Correction: The facility responded with the following:
Expired medication will be returned to the parent/guardian and new medication will be obtained. Staff will keep track of all upcoming expirations on the monthly turn in document.
Expired medication will be returned to the parent/guardian and new medication will be obtained. Staff will keep track of all upcoming expirations on the monthly turn in document.
Standard 8VAC20-780-550-P
Based upon review of records and staff interview, the facility has not ensured that they maintain a written record of children's injuries that includes are required documentation.
Evidence:
1. A written injury record dated 12/15/2021 did not include the time the parent was notified of the injury.
2. Staff 1 verified that the injury record of 12/15/2021 did not include the time the parent was notified of the injury.
Evidence:
1. A written injury record dated 12/15/2021 did not include the time the parent was notified of the injury.
2. Staff 1 verified that the injury record of 12/15/2021 did not include the time the parent was notified of the injury.
Plan of Correction: The facility responded with the following:
The Youth Development Director will retrain staff on properly completing the incident report.
The Youth Development Director will retrain staff on properly completing the incident report.
Standard 8VAC20-780-560-F
Based upon observation and staff interview, the facility has not ensured that a menu of foods to be served for snack was posted.
Evidence:
1. There was no snack menu for the current week posted.
2. Staff 1 acknowledged that the menu had not been posted for the current week.
Evidence:
1. There was no snack menu for the current week posted.
2. Staff 1 acknowledged that the menu had not been posted for the current week.
Plan of Correction: The facility responded with the following:
The current snack menu has been posted on the licensing board.
The current snack menu has been posted on the licensing board.
Standard 8VAC20-780-60-A
Based upon review of records, the facility ahs not ensured that children's records include all required information.
Evidence:
The record provided for child 2 did not include two persons other than the parents to be contacted in an emergency when a parent cannot be reached.
Evidence:
The record provided for child 2 did not include two persons other than the parents to be contacted in an emergency when a parent cannot be reached.
Plan of Correction: The facility responded with the following:
The youth Development Director will work with the Child Care Administration team to ensure all necessary requirements are updated and will print the updated forms for the onsite child file binder. Staff will audit the binder monthly to ensure everyone attending the program has all required documents.
The youth Development Director will work with the Child Care Administration team to ensure all necessary requirements are updated and will print the updated forms for the onsite child file binder. Staff will audit the binder monthly to ensure everyone attending the program has all required documents.