Inspection · 2024-01-10
Date
2024-01-10
Complaint Related
No
Licensing Inspector
Rene Old
(757) 404-1784
(757) 404-1784
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.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced renewal inspection was initiated on 01/10/2024 from 12:55 pm - 3:35 pm and completed on 01/19/2024 from 11:20 am - 3:15 pm.
At the time of the tour there were a total of 106 children present with 18 staff supervising on 01/19/2024.
Children were observed during morning program time, outdoor play, lunch and nap. Records were reviewed for 5 children and 11 staff.
Based on the information gathered violations were found in the areas of administration, staff background checks, special care provisions and emergencies and required postings.
These violations are listed on the violation notice issued to the facility and were reviewed with the program director at the conclusion of the inspection.
Violations
7Standard 22.1-289.023-A
Based on observation, the center failed to ensure that a copy of the Notice of Intent was posted in a prominent place at each public entrance of the licensed premises to advise consumers of serious or persistent violations.
Evidence:
1. The Notice of Intent, issued on 03/23/2023, was not posted in a prominent place at the public entrance of the facility on both dates of the renewal inspection which was initiated on 01/10/2024 and completed on 01/19/2024.
a. The Notice of Intent was posted on a bulletin board located on the wall in the back right hand corner of the office area.
Evidence:
1. The Notice of Intent, issued on 03/23/2023, was not posted in a prominent place at the public entrance of the facility on both dates of the renewal inspection which was initiated on 01/10/2024 and completed on 01/19/2024.
a. The Notice of Intent was posted on a bulletin board located on the wall in the back right hand corner of the office area.
Plan of Correction: Laminated Notice of Intent is posted in the main entrance of the building. Document was posted on the bulletin board previously & provided to every family.
Standard 22.1-289.035-B-4
Repeat Violation / Systemic Deficiency
Based on record review and interview, the center failed to obtain 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.
Evidence:
1. The results of an out-of-state central registry check were not on file for staff 1 who has been employed since 09/07/2023 and indicated on her sworn statement of affirmation that she had resided in a state outside of Virginia within the past five years.
2. The results of an out-of-state central registry check were not on file for staff 2 who has been employed since 03/15/2023 and indicated on her sworn statement of affirmation that she had resided in a state outside of Virginia within the past five years.
3. Administrative staff confirmed that the results of an out-of-state central registry check were not on file for these two staff.
Based on record review and interview, the center failed to obtain 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.
Evidence:
1. The results of an out-of-state central registry check were not on file for staff 1 who has been employed since 09/07/2023 and indicated on her sworn statement of affirmation that she had resided in a state outside of Virginia within the past five years.
2. The results of an out-of-state central registry check were not on file for staff 2 who has been employed since 03/15/2023 and indicated on her sworn statement of affirmation that she had resided in a state outside of Virginia within the past five years.
3. Administrative staff confirmed that the results of an out-of-state central registry check were not on file for these two staff.
Plan of Correction: Initiated out-of-state child abuse & neglect registry check for staff 1 & staff 2 on January 24, 2024.
Standard 8VAC20-780-160-A
Repeat Violation/Systemic Deficiency
Based on record review and interview, the center failed to ensure that each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and shall have been completed within the last 30 calendar days of employment.
Evidence:
1. The tuberculosis screening for staff 3 was conducted after her hire date of 01/13/2023. The TB screening on file was completed on 02/06/2023.
2. Administrative staff confirmed that the TB screening for staff 3 was obtained after her hire date.
Based on record review and interview, the center failed to ensure that each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and shall have been completed within the last 30 calendar days of employment.
Evidence:
1. The tuberculosis screening for staff 3 was conducted after her hire date of 01/13/2023. The TB screening on file was completed on 02/06/2023.
2. Administrative staff confirmed that the TB screening for staff 3 was obtained after her hire date.
Plan of Correction: Management conducted a staff file audit the month of February, 2023.
During this audit, it was found that a staff member did not obtain their TB screening before their hire date. Management corrected this error. Moving forward, management will make sure that every employee's TB screening aligns with licensing policies and no staff start without this on file.
During this audit, it was found that a staff member did not obtain their TB screening before their hire date. Management corrected this error. Moving forward, management will make sure that every employee's TB screening aligns with licensing policies and no staff start without this on file.
Standard 8VAC20-780-510-E
Based on record review, the center failed to ensure that medication procedures shall include methods to prevent use of outdated medication.
Evidence:
1. Written medication logs (reviewed on 01/10/2024) indicate that a prescription medication with an expiration date of 10/2023, was administered to child 1 on 11/14/2023 and 11/15/2023 by staff 4.
2. Administrative staff confirmed the accuracy of the medication log that the medication had been administered after the date of expiration.
Evidence:
1. Written medication logs (reviewed on 01/10/2024) indicate that a prescription medication with an expiration date of 10/2023, was administered to child 1 on 11/14/2023 and 11/15/2023 by staff 4.
2. Administrative staff confirmed the accuracy of the medication log that the medication had been administered after the date of expiration.
Plan of Correction: Reviewed medication administration policy & procedures with the management team & staff. Assigned medication administration and authorization protocol to the chief experience officer. Director of the school will review on the 15th of every month.
Standard 8VAC20-780-510-P
Based on medication review, the center failed to ensure that when an authorization for medication expires, the parent shall be notified that the medication needs to be picked up within 14 days or the parent must renew the authorization. Medications that are not picked up by the parent within 14 days will be disposed of by the center by either dissolving the medication down the sink or flushing it down the toilet.
Evidence:
1. An over-the-counter medication with an expired authorization was observed in the center medication box when reviewed on 01/10/2024.
a. The written authorization for an over-the-counter medication for child 2 expired on 12/15/2023.
2. Administrative staff confirmed that an updated authorization had not been obtained from the parent and physician.
Evidence:
1. An over-the-counter medication with an expired authorization was observed in the center medication box when reviewed on 01/10/2024.
a. The written authorization for an over-the-counter medication for child 2 expired on 12/15/2023.
2. Administrative staff confirmed that an updated authorization had not been obtained from the parent and physician.
Plan of Correction: Reviewed medication administration policy & procedures with the management team & staff. Assigned medication administration and authorization protocol to the chief experience officer. Director of school will review on the 15th of every month.
Standard 8VAC20-780-550-D
Based on record review and interview, the center failed to implement monthly practice evacuation drills.
Evidence:
1. The written emergency fire drill log for the facility indicated that a fire drill had not been conducted in October and December of 2023.
2. Administrative staff verified that fire drills had not been conducted in October and December of 2023.
Evidence:
1. The written emergency fire drill log for the facility indicated that a fire drill had not been conducted in October and December of 2023.
2. Administrative staff verified that fire drills had not been conducted in October and December of 2023.
Plan of Correction: Reviewed fire drill policy and procedure with the management team. Assigned emergency procedures to the chief exp. officer. Director will review on the 15th of every month.
Standard 8VAC20-820-120-E-6
Based on observation, the center failed to ensure that a copy of any special order issued by the department was posted in a prominent place at each public entrance of the licensed premises to advise consumers of serious or persistent violations.
Evidence:
1. The special order, issued on 05/08/2023, was not posted in a prominent place at the public entrance of the facility on both dates of the renewal inspection which was initiated on 01/10/2024 and completed on 01/19/2024.
a. The special order was posted on a bulletin board located on the wall in the back right hand corner of the office area.
Evidence:
1. The special order, issued on 05/08/2023, was not posted in a prominent place at the public entrance of the facility on both dates of the renewal inspection which was initiated on 01/10/2024 and completed on 01/19/2024.
a. The special order was posted on a bulletin board located on the wall in the back right hand corner of the office area.
Plan of Correction: Laminated Special Order posted in the main entrance of the building. Document was posted on the bulletin board previously & provided to every family.