Inspection · 2023-01-20
Date
2023-01-20
Complaint Related
No
Licensing Inspector
Brandie Viscayda
(757) 636-3427
(757) 636-3427
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)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
A renewal inspection was conducted on 1/20/23 from 9:45am until 1:15pm. At the time of the inspection, there were 79 children in care with 16 staff present. A sample of 8 children's records and 14 staff/board member records were reviewed. Children were observed participating in learning activities, playing outside on the playground, eating lunch and resting quietly during nap time. Lunch service and handwashing and restroom procedures were also observed. First aid and emergency supplies, the emergency preparedness plan, documentation of emergency practice drills, medication, children's injury reports and required center postings were reviewed. Information gathered during the inspection determined non-compliance with applicable standards or law. Violations were documented on the violation notice issued to the program and discussed with the center director during the exit interview.
Violations
6Standard 22.1-289.035-B-2
Based on record review and interview, the center did not ensure that the results of a national fingerprint search are received for each staff member before employment.
Evidence:
1. Staff 1 has a hire date of 8/1/22. The results of the fingerprint based background check for staff 1 was not received by the center until 8/29/22.
2. Staff 2 has a hire date of 10/17/22. The results of the fingerprint based background check for staff 1 was not received by the center until 12/1/22.
3. Staff 3 has a hire date of 1/10/23. The record for staff 1 does not contain the results of a national fingerprint search.
4. Staff 4 has a hire date of 10/20/22. The results of the fingerprint based background check for staff 1 was not received by the center until 10/21/22.
5. Staff 5 has a hire date of 10/15/22. The results of the fingerprint based background check for staff 1 was not received by the center until 11/7/22.
6. Staff 6 has a hire date of 7/18/22. The results of the fingerprint based background check for staff 1 was not received by the center until 9/1/22.
7. The center director confirmed that the fingerprint based background checks for staff 1, staff 2, staff 3, staff 4, staff 5 and staff 6 were not completed within the required timeframe.
Evidence:
1. Staff 1 has a hire date of 8/1/22. The results of the fingerprint based background check for staff 1 was not received by the center until 8/29/22.
2. Staff 2 has a hire date of 10/17/22. The results of the fingerprint based background check for staff 1 was not received by the center until 12/1/22.
3. Staff 3 has a hire date of 1/10/23. The record for staff 1 does not contain the results of a national fingerprint search.
4. Staff 4 has a hire date of 10/20/22. The results of the fingerprint based background check for staff 1 was not received by the center until 10/21/22.
5. Staff 5 has a hire date of 10/15/22. The results of the fingerprint based background check for staff 1 was not received by the center until 11/7/22.
6. Staff 6 has a hire date of 7/18/22. The results of the fingerprint based background check for staff 1 was not received by the center until 9/1/22.
7. The center director confirmed that the fingerprint based background checks for staff 1, staff 2, staff 3, staff 4, staff 5 and staff 6 were not completed within the required timeframe.
Plan of Correction: The center responded with the following: 1. Staff 1 was in on the job training until 9/7/22. 2. Staff 2 came with background checks from previous job, while awaiting portal duplicate. 3. Staff 3 came with background checks from previous job, while awaiting portal duplicate. 4. Staff 4 report date was 10/24/22. 5. Staff 5 report date was 11/22/23. 6. Staff 6 entire file was lost in transition from one location to another. Background check received 9/1/22 was a duplicate.
7. Director confirmed that a duplicate background check was not received before the report date Staff 2 and Staff 3 came with current background checks from their previous employer.
7. Director confirmed that a duplicate background check was not received before the report date Staff 2 and Staff 3 came with current background checks from their previous employer.
Standard 22.1-289.035-B-4
Based on record review and interview, the center did not ensure that a copy of the results of a criminal history record information check and a search of the child abuse and neglect registry or equivalent registry is obtained from any state in which the individual has resided in the preceding five years.
Evidence:
1. Staff 5 has a hire date of 10/15/22. Staff 5 indicated on her sworn statement or affirmation that she has resided in the state of Florida within the past five years. The results of a central registry search from the state of Florida not available for staff 5.
2. Staff 8 has a hire date of 6/22/22. Staff 8 indicated on her sworn statement or affirmation that she has resided in the state of Ohio within the past five years. The results of a central registry search from the state of Ohio was not available for staff 8.
3. Staff 9 has a hire date of 6/20/22. Staff 9 indicated on her sworn statement or affirmation that she has resided in the state of Ohio within the past five years. The results of a central registry search from the state of Ohio was not available for staff 9.
4. Board member 1 indicated on his sworn statement or affirmation that he has resided in the state of South Carolina within the past 5 years. The results of a criminal history record information check and a search of the child abuse and neglect registry from the state of South Carolina was not available for board member 1.
4. The center director confirmed that the records for staff 5, staff 8, staff 9 and board member 1 are lacking the results of their out-of-state background checks.
Evidence:
1. Staff 5 has a hire date of 10/15/22. Staff 5 indicated on her sworn statement or affirmation that she has resided in the state of Florida within the past five years. The results of a central registry search from the state of Florida not available for staff 5.
2. Staff 8 has a hire date of 6/22/22. Staff 8 indicated on her sworn statement or affirmation that she has resided in the state of Ohio within the past five years. The results of a central registry search from the state of Ohio was not available for staff 8.
3. Staff 9 has a hire date of 6/20/22. Staff 9 indicated on her sworn statement or affirmation that she has resided in the state of Ohio within the past five years. The results of a central registry search from the state of Ohio was not available for staff 9.
4. Board member 1 indicated on his sworn statement or affirmation that he has resided in the state of South Carolina within the past 5 years. The results of a criminal history record information check and a search of the child abuse and neglect registry from the state of South Carolina was not available for board member 1.
4. The center director confirmed that the records for staff 5, staff 8, staff 9 and board member 1 are lacking the results of their out-of-state background checks.
Plan of Correction: The center responded with the following: 1. Florida Central Registry received January 23, 2023. 2. Ohio Central Registry received January 25, 2023. 3. Ohio Central Registry received January 25, 2023. 4. South Carolina Criminal History Record Information Check received January 31, 2023 and Child Abuse and Neglect Registry received February 10, 2023.
Standard 8VAC20-770-60-C-2
Based on record review and interview, the center did not ensure that the results of a central registry finding are received within 30 days of employment.
Evidence:
1. The records for staff 2 (date of hire: 10/17/22) and staff 6 (date of hire: 7/18/22) do not contain the results of a central registry finding.
2. The center director confirmed that the records for staff 2 and staff 6 are lacking documentation of a central registry finding.
Evidence:
1. The records for staff 2 (date of hire: 10/17/22) and staff 6 (date of hire: 7/18/22) do not contain the results of a central registry finding.
2. The center director confirmed that the records for staff 2 and staff 6 are lacking documentation of a central registry finding.
Plan of Correction: The center responded with the following: 1. We are awaiting duplicates for portability for staff 2 while current background checks from previous schools are on file. Duplicate received for staff 6 on 9/1/22. 2. Director confirmed that current, within 2 years, background checks from previous employer were on file for staff 2. Staff 6's entire file was lost in transition from one location to another. Background check received 9/1/22 was a duplicate.
Standard 8VAC20-780-140-A
Based on record review and interview, the center did not ensure that each child shall have a physical examination by or under the direction of a physician before the child's attendance or within 30 days after the first day of attendance.
Evidence:
1. The records for child 1 (date of enrollment: 9/8/22) and child 2 (date of enrollment: 10/17/22) do not contain documentation of a physical examination.
2. The center director confirmed that the records for child 1 and child 2 are lacking documentation of a physical examination.
Evidence:
1. The records for child 1 (date of enrollment: 9/8/22) and child 2 (date of enrollment: 10/17/22) do not contain documentation of a physical examination.
2. The center director confirmed that the records for child 1 and child 2 are lacking documentation of a physical examination.
Plan of Correction: The center responded with the following: Physician error has been corrected for child 1. Physicals obtained for child 1 and child 2.
Standard 8VAC20-780-160-A
Based on record review and interview, the center did not ensure that each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming in contact with children and that the documentation shall have been completed within the last 30 calendar days of the date of employment.
Evidence:
1. The record for staff 1 (date of hire: 8/1/22) contains documentation of a negative tuberculosis screening dated 12/16/22, which is after her first day of employment.
2. The record for staff 2 (date of hire: 10/17/22) contains documentation of a negative tuberculosis screening dated 10/18/22, which is after her first day of employment.
3. The record for staff 3 (date of hire: 1/10/23) contains documentation of a negative tuberculosis screening dated 10/21/22, which is not within the last 30 calendar days of the date of employment.
4. The record for staff 5 (date of hire: 10/15/22) does not contain documentation of a negative tuberculosis screening.
5. The record for staff 6 (date of hire: 7/18/22) contains documentation of a negative tuberculosis screening dated 7/21/22, which is after her first day of employment.
6. The record for staff 7 (date of hire: 8/31/20) does not contain documentation of a negative tuberculosis screening.
7. The record for staff 8 (date of hire: 6/22/22) contains documentation of a negative tuberculosis screening dated 6/26/22, which is after her first day of employment.
8. The record for staff 9 (date of hire: 6/20/22) does not contain documentation of a negative tuberculosis screening.
9. The center director confirmed that the tuberculosis screenings for staff 1, staff 2, staff 3, staff 5, staff 6, staff 7, staff 8 and staff 9 were not completed within the required timeframes.
Evidence:
1. The record for staff 1 (date of hire: 8/1/22) contains documentation of a negative tuberculosis screening dated 12/16/22, which is after her first day of employment.
2. The record for staff 2 (date of hire: 10/17/22) contains documentation of a negative tuberculosis screening dated 10/18/22, which is after her first day of employment.
3. The record for staff 3 (date of hire: 1/10/23) contains documentation of a negative tuberculosis screening dated 10/21/22, which is not within the last 30 calendar days of the date of employment.
4. The record for staff 5 (date of hire: 10/15/22) does not contain documentation of a negative tuberculosis screening.
5. The record for staff 6 (date of hire: 7/18/22) contains documentation of a negative tuberculosis screening dated 7/21/22, which is after her first day of employment.
6. The record for staff 7 (date of hire: 8/31/20) does not contain documentation of a negative tuberculosis screening.
7. The record for staff 8 (date of hire: 6/22/22) contains documentation of a negative tuberculosis screening dated 6/26/22, which is after her first day of employment.
8. The record for staff 9 (date of hire: 6/20/22) does not contain documentation of a negative tuberculosis screening.
9. The center director confirmed that the tuberculosis screenings for staff 1, staff 2, staff 3, staff 5, staff 6, staff 7, staff 8 and staff 9 were not completed within the required timeframes.
Plan of Correction: The center responded with the following: All staff files have been updated to include documentation of a negative tuberculosis screening. This information was lost in the transition in moving from paper to digital files. All staff requested duplicates and they are all on file.
Standard 8VAC20-780-70
Based on record review and interview, the center did not ensure that staff records contain all the required information.
Evidence:
1. The record for staff 1 (date of hire: 8/1/22) does not contain the address of a person to be notified in an emergency or documentation that two or more references as to character and reputation as well as competency were checked before employment.
2. The record for staff 2 (date of hire: 10/17/22) does not contain the address of a person to be notified in an emergency or documentation to demonstrate that she has completed orientation training.
3. The record for staff 3 (date of hire: 1/10/23) does not contain the address of a person to be notified in an emergency.
4. The record for staff 4 (date of hire: 10/20/22) does not contain the name, address and telephone number of a person to be notified in an emergency.
5. The record for staff 5 (date of hire: 10/15/22) does not contain the address of a person to be notified in an emergency.
6. The record for staff 6 (date of hire: 7/18/22) does not contain the address of a person to be notified in an emergency.
7. The record for staff 8 (date of hire: 6/22/22) does not contain the address of a person to be notified in an emergency or the dates of contact for the two reference checks.
8. The record for staff 9 (date of hire: 6/20/22) does not contain the address of a person to be notified in an emergency or documentation to demonstrate that she possesses the education and experience required by the job position of program leader, which is her documented position title.
9. The center director confirmed that the above required information is missing from the staff records.
Evidence:
1. The record for staff 1 (date of hire: 8/1/22) does not contain the address of a person to be notified in an emergency or documentation that two or more references as to character and reputation as well as competency were checked before employment.
2. The record for staff 2 (date of hire: 10/17/22) does not contain the address of a person to be notified in an emergency or documentation to demonstrate that she has completed orientation training.
3. The record for staff 3 (date of hire: 1/10/23) does not contain the address of a person to be notified in an emergency.
4. The record for staff 4 (date of hire: 10/20/22) does not contain the name, address and telephone number of a person to be notified in an emergency.
5. The record for staff 5 (date of hire: 10/15/22) does not contain the address of a person to be notified in an emergency.
6. The record for staff 6 (date of hire: 7/18/22) does not contain the address of a person to be notified in an emergency.
7. The record for staff 8 (date of hire: 6/22/22) does not contain the address of a person to be notified in an emergency or the dates of contact for the two reference checks.
8. The record for staff 9 (date of hire: 6/20/22) does not contain the address of a person to be notified in an emergency or documentation to demonstrate that she possesses the education and experience required by the job position of program leader, which is her documented position title.
9. The center director confirmed that the above required information is missing from the staff records.
Plan of Correction: The center responded with the following: All staff files have been updated to include the address of a person to be notified in case of an emergency, reference checks, and proof of orientation training. This information was lost in the transition in moving from paper to digital files.