Inspection · 2023-04-18
Date
2023-04-18
Complaint Related
No
Licensing Inspector
Sarah Marbert
(703) 479-4678
(703) 479-4678
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
An unannounced monitoring inspection was conducted today.
All rooms were in ration during the inspection and resting quietly.
Emergency evacuation drills, first aid supplies, emergency supplies, attendances records were all incompliance today.
Violations were reviewed with the Director at the exit interview. See Violation Notice for
non-compliances cited today.
If you have questions regarding this inspection you may contact me at (703) 479-4678 or at
Sarah.marbert@doe.virginia.gov.
LI was present today from 1:30 PM - 3:05PM.
Violations
9Standard 22.1-289.035-B-2
Based on a review of records, one staff record does not contain documentation of a competed nationwide fingerprint search prior to employment.
Evidence:
1 of 2 staff records reviewed was missing documentation of the fingerprint search results prior to employment.
There are no results on file. (Staff B - (DOH) 2/13/23)
Evidence:
1 of 2 staff records reviewed was missing documentation of the fingerprint search results prior to employment.
There are no results on file. (Staff B - (DOH) 2/13/23)
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-770-60-B
Based on a review of records, one staff record does not contain documentation of a completed Sorn Disclosure Statement (SDS) prior to employment.
Evidence:
The SDS on file for a staff member was completed for a different LLC and is not transferable to this facility.(Staff B- DOH 2/13/23).
Evidence:
The SDS on file for a staff member was completed for a different LLC and is not transferable to this facility.(Staff B- DOH 2/13/23).
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-770-60-C-2
Based on a review of records, one staff record does not contain documentation of a completed Central Registry Search (CRS) within 30 days of employment.
Evidence:
1 of 2 records reviewed did not contain the results of a CRS search. (Staff B - DOH 2/13/23)
Evidence:
1 of 2 records reviewed did not contain the results of a CRS search. (Staff B - DOH 2/13/23)
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-240-B
Based on a review of records, one staff record does not contain documentation of orientation.
Evidence:
1 of 2 records reviewed did not contain documentation of orientation within 7 days of assuming job responsibilities. Orientation is incomplete. (Staff B (DOH) 2/13/23).
Evidence:
1 of 2 records reviewed did not contain documentation of orientation within 7 days of assuming job responsibilities. Orientation is incomplete. (Staff B (DOH) 2/13/23).
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-245-J-3
Based on a review of records, there is no documentation to show that any staff member is current in Medication Administration training (MAT) certification.
Evidence:
3 staff records were reviewed for staff that have taken the MAT course. The receipt for the course for all 3 staff expired 4/7/23. There are no certificates available for review. (Staff A, C, D)
Evidence:
3 staff records were reviewed for staff that have taken the MAT course. The receipt for the course for all 3 staff expired 4/7/23. There are no certificates available for review. (Staff A, C, D)
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-40-E
Based on a review of medications, the center failed to follow it's own policy regarding informing the parent of an expired medication.
Evidence:
There is on expired Epi-pen at the center. (expired 3/25/23).
The center was not aware that the Epi-pen was expired until the Inspector reviewed the medications. Parents were not notified it was expired. (Child 2)
Evidence:
There is on expired Epi-pen at the center. (expired 3/25/23).
The center was not aware that the Epi-pen was expired until the Inspector reviewed the medications. Parents were not notified it was expired. (Child 2)
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-550-P
Based on a review of records, injury reports do not contain all required components.
Evidence:
5 of 5 injury reports reviewed di not contain documentation on how the parent was notified.
Evidence:
5 of 5 injury reports reviewed di not contain documentation on how the parent was notified.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-60-A
Based on a review of records, one child record was not kept up-to-date.
Evidence:
The written allergy action plan for a child with a diagnosed food allergy, is dated 1/31/22.
There was no annual update to the action plan. (Child 1)
Evidence:
The written allergy action plan for a child with a diagnosed food allergy, is dated 1/31/22.
There was no annual update to the action plan. (Child 1)
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-70
Based on a review of records, one staff record does not contain documentation of all required components.
Evidence:
1 of 2 records reviewed was missing documentation of 2 references prior to employment.
There are no references available for review.
(Staff B- Date of Hire (DOH) 2/13/23.
Evidence:
1 of 2 records reviewed was missing documentation of 2 references prior to employment.
There are no references available for review.
(Staff B- Date of Hire (DOH) 2/13/23.
Plan of Correction: Not available online. Contact Inspector for more information.