Inspection · 2023-03-22
Date
2023-03-22
Complaint Related
No
Licensing Inspector
Lauren Captain
(571) 835-0599
(571) 835-0599
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
8 VAC 20-800 Administration
8 VAC 20-800 Personnel
8 VAC 20-800 Household Members
8 VAC 20-800 Physical Health of Caregivers and Household members
8 VAC 20-800 Caregiver Training
8 VAC 20-800 Physical Equipment and Environment
8 VAC 20-800 Care of Children
8 VAC 20-800 Preventing the Spread of Disease
8 VAC 20-800 Emergencies
8 VAC 20-800 Nutrition
8 VAC2 0-820 THE LICENSE
8 VAC 20-820 THE LICENSING PROCESS
8 VAC 20-770 Background Checks
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child abuse and neglect
Inspector Notes
This renewal inspection was initiated by licensing staff and concluded on 03/22/2023, between the hours of 10 am to 12:30 pm. There were 10 children present (34 points), ranging from infant to preschool-age, with as many as 4 caregivers supervising. The inspector reviewed compliance in the areas of administration; physical plant; staffing and supervision; programming; special care and emergencies; and nutrition. A total of 10 children records, and 4 staff records were reviewed.
Information gathered during the inspection determined that there were (11) non-compliances with the applicable standards, code, and/or law. These violations were documented on the Violation Notice issued to the home.
If you should have any questions, please call or send an email to charlie.perkins@doe.virginia.gov. Thank you.
Charlie Perkins,
Licensing Inspector
(703) 309-3963
Violations
11Standard 8VAC20-770-60-B
Based on review, 1 of 4 staff files indicated that an employee of a licensed Family Day Home (FDH) employed a staff person without a completed sworn statement or affirmation (SDS) on file.
Evidence -
1. On the date of inspection (03/22/23), a SDS was not available for review for Staff #5. The start date for Staff #5 was listed as 03/13/2023.
2. Staff #5 was observed providing care to children on the date of inspection.
Evidence -
1. On the date of inspection (03/22/23), a SDS was not available for review for Staff #5. The start date for Staff #5 was listed as 03/13/2023.
2. Staff #5 was observed providing care to children on the date of inspection.
Plan of Correction: A SDS will be completed and placed on fie for Staff #5.
Standard 8VAC20-770-60-C-2
Based on review and interview, 1 of 4 staff files indicated that the Family Day Home (FDH) does not have a central registry finding (CPS check) within 30 days of employment.
Evidence -
1. On the date of inspection (03/22/2023), a CPS check for Staff #3 was not available for review.
2. The Provider stated (during an interview conducted on the date of inspection) that the CPS check for Staff #3 was originally sent and was returned to the FDH due to an error. The CPS check was then sent once more. Documentation of correspondence was reviewed inquiring the status of the finding, but no response has been received from OBI.
3. The start date of Staff #3 was listed as 09/06/2022. No further follow-up has been conducted on the Provider's behalf.
Evidence -
1. On the date of inspection (03/22/2023), a CPS check for Staff #3 was not available for review.
2. The Provider stated (during an interview conducted on the date of inspection) that the CPS check for Staff #3 was originally sent and was returned to the FDH due to an error. The CPS check was then sent once more. Documentation of correspondence was reviewed inquiring the status of the finding, but no response has been received from OBI.
3. The start date of Staff #3 was listed as 09/06/2022. No further follow-up has been conducted on the Provider's behalf.
Plan of Correction: OBI will be contacted to inquire about the status of the CPS check sent. This will be done within the next 10 days. If needed, a new CPS request will be sent for Staff #3. Once a finding has been received back from OBI, this documentation will be shared and reviewed by the Licensing Inspector.
Standard 8VAC20-800-100-A
Based on review, 1 of 10 children files indicated that the Provider did not obtain documentation of a physical examination by or under the direction of a physician within 30 days after the first day of attendance.
Evidence -
1. On the date of inspection (03/22/2023), documentation of a physical examination for Child #9 was not available for review.
2. The start date for Child #9 was listed as 10/17/2022.
Evidence -
1. On the date of inspection (03/22/2023), documentation of a physical examination for Child #9 was not available for review.
2. The start date for Child #9 was listed as 10/17/2022.
Plan of Correction: Documentation of a physical examination will be obtained.
Standard 8VAC20-800-120-B
Based on review, 2 of 4 staff files indicated that not all of the required information was contained within each record.
Evidence -
1. On the date of inspection (03/22/23) the following information was not available for review for Staff #5: address; verification of age; and the name, address, and telephone number of a person to be notified in an emergency. Start date for Staff #5 was listed as 03/13/23.
2. The emergency contact information was not available for review for: Staff #3. This same standard was cited for Staff #3 during a previous inspection.
Evidence -
1. On the date of inspection (03/22/23) the following information was not available for review for Staff #5: address; verification of age; and the name, address, and telephone number of a person to be notified in an emergency. Start date for Staff #5 was listed as 03/13/23.
2. The emergency contact information was not available for review for: Staff #3. This same standard was cited for Staff #3 during a previous inspection.
Plan of Correction: All missing staff information will be obtained.
Standard 8VAC20-800-180-A
Based on review, 1 of 4 staff files indicated that the Provider did not obtain for each caregiver and adult household member a current Report of Tuberculosis Screening (TB) form, (in accordance with the requirements in 8VAC20-800-170) every two years from the date of the current TB documentation on file.
Evidence -
1. On the date of inspection (03/22/23), the TB documentation on file for Staff #1 was dated 12/21/2018.
2. This same standard for Staff #1 was cited during a previous inspection.
Evidence -
1. On the date of inspection (03/22/23), the TB documentation on file for Staff #1 was dated 12/21/2018.
2. This same standard for Staff #1 was cited during a previous inspection.
Plan of Correction: Updated TB documentation will be obtained for Staff #1.
Standard 8VAC20-800-200-A
Based on review, 1 of 4 staff files indicated that documentation of the Provider conducting an orientation for a new staff member by the end of their first week of assuming their job responsibilities was not available.
Evidence -
1. On the date of inspection (03/22/23), orientation documentation was not available for review for Staff #5.
2. The start date for Staff #5 was listed as 03/13/2023.
Evidence -
1. On the date of inspection (03/22/23), orientation documentation was not available for review for Staff #5.
2. The start date for Staff #5 was listed as 03/13/2023.
Plan of Correction: Documentation of orientation training will be placed on file for Staff #5.
Standard 8VAC20-800-210-A
Based on review, 1 of 4 staff files indicated that a minimum of (16) sixteen clock hours of training annually (in areas relevant to their job responsibilities) was not obtained.
Evidence -
1. On the date of inspection (03/22/23), documentation of certificates of completion for training obtain in 2022 for Staff #2 were not available for review. Therefore, a total of zero of the needed 16 hours was documented.
2. This was confirmed by the Provider on the date of inspection.
Evidence -
1. On the date of inspection (03/22/23), documentation of certificates of completion for training obtain in 2022 for Staff #2 were not available for review. Therefore, a total of zero of the needed 16 hours was documented.
2. This was confirmed by the Provider on the date of inspection.
Plan of Correction: A total of 16 hours of annual training will be completed for Staff #2 for 2023.
Standard 8VAC20-800-570-A
Based on observation, the provider did not ensure that a caregiver does not exceed 16 points by using the required point system (to determine if an additional caregiver is needed).
Evidence -
1. On the date of inspection (03/22/2023) starting at 10 am and until 10:05 am (when the Provider arrived), there were 2 caregivers with 10 children, a total of 34 points.
2. As many as 4 caregivers were on site, once all staff had arrived at the Family Day Home (FDH).
Evidence -
1. On the date of inspection (03/22/2023) starting at 10 am and until 10:05 am (when the Provider arrived), there were 2 caregivers with 10 children, a total of 34 points.
2. As many as 4 caregivers were on site, once all staff had arrived at the Family Day Home (FDH).
Plan of Correction: Due to an unscheduled tardiness of staff, the total went over by 2 points. The required number of staff will be provided to meet the point total.
Standard 8VAC20-800-780-B
Based on review, 4 of 10 children files indicated that annually, the Provider did not review with the parent the emergency contact information (required in 8VAC20-800-60 B 2) to ensure the information is correct, and obtain the parent's signed acknowledgment of this review.
Evidence -
1. On the date of inspection (03/22/2023), the following children were without an annual acknowledgement of their parent's review of the emergency contact information on file: Child #2 (last review dated - 09/24/2021), Child #4 (last review dated - 09/28/2021), Child #5 (last review dated - 04/28/2021), and Child #7 (last review dated - 08/01/2021).
2. This information was obtained off of the signature line at the bottom of each child's record.
Evidence -
1. On the date of inspection (03/22/2023), the following children were without an annual acknowledgement of their parent's review of the emergency contact information on file: Child #2 (last review dated - 09/24/2021), Child #4 (last review dated - 09/28/2021), Child #5 (last review dated - 04/28/2021), and Child #7 (last review dated - 08/01/2021).
2. This information was obtained off of the signature line at the bottom of each child's record.
Plan of Correction: Parents will review and sign off a new acknowledgement for their child's listed emergency information.
Standard 8VAC20-800-90-A
Based on review, 1 of 10 children files indicated that documentation that the child had been adequately immunized (according to the requirements of ? 32.1-46 A of the Code of Virginia and applicable State Board of Health regulations) was not available.
Evidence -
1. On the date of inspection (03/22/2023), an immunization page for Child #9 was not available for review.
2. The start date for Child #9 was listed at 10/17/2022.
Evidence -
1. On the date of inspection (03/22/2023), an immunization page for Child #9 was not available for review.
2. The start date for Child #9 was listed at 10/17/2022.
Plan of Correction: An immunization page will be obtained.
Standard 8VAC20-800-90-C
Based on review, 4 of 10 children files indicated that the Family Day Home (FDH) did not obtain documentation of additional immunizations for children who were not exempt from the immunization requirements (according to subsection B of this section) once every six months for children under the age of two years.
Evidence -
1. On the date of inspection (03/22/2023) the following children were without an updated immunization page: Child #1 (immunization page dated - 04/25/22), Child #2 (immunization page dated - 07/22/22), Child #3 (immunization page dated - 06/22/22), and Child #4 (immunization page dated - 06/08/22).
2. On the date of inspection, all of the above listed children were under 2 years of age.
Evidence -
1. On the date of inspection (03/22/2023) the following children were without an updated immunization page: Child #1 (immunization page dated - 04/25/22), Child #2 (immunization page dated - 07/22/22), Child #3 (immunization page dated - 06/22/22), and Child #4 (immunization page dated - 06/08/22).
2. On the date of inspection, all of the above listed children were under 2 years of age.
Plan of Correction: An updated immunization page will be obtained for all listed children.