Inspection · 2024-11-20
Date
2024-11-20
Complaint Related
No
Licensing Inspector
Jennifer Moore
(540) 430-0384
(540) 430-0384
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
22.1 Religious Exempt; Background Checks Code; Carbon Monoxide
32.1 Report by person other than physician
54.1 Must be MAT Certified.
63.2 Child abuse and neglect
8VAC20-770 Background Checks
During the inspection, the inspector reviewed the areas listed above. Unless otherwise noted as a violation within this inspection report, the provider was in compliance with the standards reviewed. If there were any serious injuries or fatalities related to a violation, the details will be included in the description of the violation.
Inspector Notes
An unannounced, on-site code compliance inspection was initiated on 11/20/2024 and completed on 11/21/2024. The on-site inspection began at 9:20 am and ended at 11:30 am. The inspector reviewed compliance in the areas listed above. There were 23 children present with 4 staff. The inspector reviewed 5 children?s records on site. Nine (9) staff records were reviewed partially on site and electronically on 11/21/2024. This inspection included document review, a tour of the facility, interview and observations.
Information gathered during the inspection determined non-compliance with applicable code sections, and violations are documented on the violation notice issued to the program.
Please complete the plan of correction (POC) and date to be corrected sections for each violation cited on the violation notice. Specify how the violation will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on
11/28/2024. A POC submitted after this date will not appear on the public website.
Violations
10Standard 22.1-289.031-A-4
Prior to providing supervision to children and annually thereafter, each person in a
supervisory position must be certified by a practicing physician or physician assistant
to be free from any disability that would prevent them from caring for children under their
supervision.
Staff #1 who has been employed for over 3 months did not have a current staff health form. Staff #4, who has been employed for over 1 year and 3 months had a staff health form that was not dated. It could not be determined if it was current. The most recent staff health form for staff #6 was overdue by over 3 months. Staff #8 who has been employed for over 3 months did not have a staff health form. Staff #9 who has been employed for 24 days did not have a staff health form.
supervisory position must be certified by a practicing physician or physician assistant
to be free from any disability that would prevent them from caring for children under their
supervision.
Staff #1 who has been employed for over 3 months did not have a current staff health form. Staff #4, who has been employed for over 1 year and 3 months had a staff health form that was not dated. It could not be determined if it was current. The most recent staff health form for staff #6 was overdue by over 3 months. Staff #8 who has been employed for over 3 months did not have a staff health form. Staff #9 who has been employed for 24 days did not have a staff health form.
Plan of Correction: The center has historically required staff health forms to be submitted by December 31st each year, aligning with their annual medical evaluations. However, it was not previously understood that these forms must be renewed before the end of the year to maintain compliance. Upon identifying this issue, all staff moved their medical appointments earlier to ensure timely completion of their health forms, certifying that they are free from any disability that would prevent them from supervising children.
As of November 21, 2024, the following corrective actions have been implemented:Staff #1, #4, #6, #8, and #9 have all submitted updated and current health forms. Administrative procedures have been updated to require that health forms are completed and submitted prior to providing supervision to children and annually by each staff member's health form anniversary date.
As of November 21, 2024, the following corrective actions have been implemented:Staff #1, #4, #6, #8, and #9 have all submitted updated and current health forms. Administrative procedures have been updated to require that health forms are completed and submitted prior to providing supervision to children and annually by each staff member's health form anniversary date.
Standard 22.1-289.031-A-6
The following aspects of the child day center's operations must be described in a written statement provided to the parents or guardians of the children in the center and made available to the general public: physical facilities, enrollment capacity, food services, health requirements for the staff, and public liability insurance.
The administrator stated that the required information was not provided to the parents and made available to the general public.
The administrator stated that the required information was not provided to the parents and made available to the general public.
Plan of Correction: The physical facility infonnation including square footage of the building has been added to the student handbook. The enrollment capacity including how many students the center can fit into the school has been added to the handbook. lnfonnation about the liability insurance has been added to the student handbook. The handbook was updated on the parent portal.
Standard 22.1-289.031-B-3
The center is required to have a daily simple health screening and exclusion of sick children
by a person trained to perform such screenings.
The center did not have staff on site who were trained in daily health observation.
by a person trained to perform such screenings.
The center did not have staff on site who were trained in daily health observation.
Plan of Correction: The center states that they were not previously made aware of the requirement for staff to complete training in daily health observation and exclusion of sick children, as no formal notification of this requirement was provided. Upon learning of this oversight, immediate steps were taken to address the issue. Three staff members who are present on campus with students daily have already completed the required training for dally health observation and exclusion of sick children. Additional staff members will be identified and enrolled in the training to ensure adequate coverage during all operational hours, with training completion targeted by December 1st, 2024.
Standard 22.1-289.031-B-4
The RECDC shall establish and implement procedures for: ensuring the RECDC is in compliance with the immunization provisions of section 32.1-46 of the Code. Before a child may attend the center, the provider must obtain documentation that the child has been adequately immunized according to the requirements of ? 32.1-46 A of the Code of Virginia and applicable State Board of Health regulations.
The center's policy is to obtain a copy of each child's immunization record prior to attendance. The records of child #1 and child #5 did not contain an immunization record. The children have been in attendance for over 3 months.
The center's policy is to obtain a copy of each child's immunization record prior to attendance. The records of child #1 and child #5 did not contain an immunization record. The children have been in attendance for over 3 months.
Plan of Correction: The center has implemented an online records database that allows parents to upload proof of birth and vaccination records directly into the portal. While obtaining these documents has been standard practice, technical issues with the new database resulted in missing or incomplete documentation.
To address this, a complete audit of the student record portal began on November 21, 2024. The administrative team is systematically reviewing all student files to identify any missing or incomplete records. Parents of affected students are being notified of the specific documents required for resubmission. Clear instructions and deadlines for submitting these records will be provided to ensure compliance.Administrative staff will conduct regular reviews of the online portal to confirm that all student records remain up to date and in compliance with state and center requirements.
To address this, a complete audit of the student record portal began on November 21, 2024. The administrative team is systematically reviewing all student files to identify any missing or incomplete records. Parents of affected students are being notified of the specific documents required for resubmission. Clear instructions and deadlines for submitting these records will be provided to ensure compliance.Administrative staff will conduct regular reviews of the online portal to confirm that all student records remain up to date and in compliance with state and center requirements.
Standard 22.1-289.035-B-1
The center is required to obtain a completed sworn statement prior to the employee's first day of employment.
Staff #1 who has been employed for over 3 months did not have a sworn statement. Staff #5 who has been employed for over 3 months did not have a sworn statement. Staff #8 who has been employed for over 3 months did not have a sworn statement. Staff #9 who has been employed for 24 days did not have a sworn statement.
Staff #1 who has been employed for over 3 months did not have a sworn statement. Staff #5 who has been employed for over 3 months did not have a sworn statement. Staff #8 who has been employed for over 3 months did not have a sworn statement. Staff #9 who has been employed for 24 days did not have a sworn statement.
Plan of Correction: As of November 21, 2024, all employees (Staff#1, #5, #8, and #9) have completed their sworn statements, ensuring compliance with the center's policy. Moving forward, no employee will be permitted to begin work without a sworn statement on file. HR staff will verify documentation prior to start dates, conduct monthly record reviews, and maintain a compliance checklist.
Standard 22.1-289.035-B-2
Providers must obtain a completed national criminal background check prior to the employee's first day of employment.
Staff #1, who has been employed for over 3 months, did not have a fingerprint background check. Staff #2, who has been employed for over 1 year and 2 months, did not have a fingerprint background check. Staff #3, who has been employed for over 1 year and 3 months, did not have a fingerprint background check. Staff #4, who has been employed for over 1 year and 3 months, did not have a fingerprint background check. Staff #5, who has been employed for over 3 months, did not have a fingerprint background check. Staff #6, who has been employed for over 1 year and 3 months, did not have a fingerprint background check. Staff #7, who has been employed for over 1 year and 9 months, did not have a fingerprint background check. Staff #8, who has been employed for over 3 months, did not have a fingerprint background check. Staff #9, who has been employed for 24 days, did not have a fingerprint background check.
Staff #1, who has been employed for over 3 months, did not have a fingerprint background check. Staff #2, who has been employed for over 1 year and 2 months, did not have a fingerprint background check. Staff #3, who has been employed for over 1 year and 3 months, did not have a fingerprint background check. Staff #4, who has been employed for over 1 year and 3 months, did not have a fingerprint background check. Staff #5, who has been employed for over 3 months, did not have a fingerprint background check. Staff #6, who has been employed for over 1 year and 3 months, did not have a fingerprint background check. Staff #7, who has been employed for over 1 year and 9 months, did not have a fingerprint background check. Staff #8, who has been employed for over 3 months, did not have a fingerprint background check. Staff #9, who has been employed for 24 days, did not have a fingerprint background check.
Plan of Correction: The center previously conducted background checks for all employees before their date of hire using a federal database but did not undergo VA specific fingerprinting .. As of November 21, 2024, all staff have obtained appointments to have this specific background check done for their staff files .. Moving forward, the center will ensure that all background checks including this specific fingerprinting process will be done prior to an employee's first day of work. Administrative staff will update onboarding procedures to include this requirement, conduct monthly audits of personnel records, and provide staff training to reinforce compliance with state licensing standards.
Standard 22.1-289.035-B-3
The center must request a search of the central registry prior to the employee's first day of employment.
Staff #1 who has been employed for over 3 months did not have a central registry search requested. Staff #5 who has been employed for over 3 months did not have a central registry search requested. Staff #8 who has been employed for over 3 months did not have a central registry search requested. Staff #9 who has been employed for 24 days did not have a central registry search requested.
Staff #1 who has been employed for over 3 months did not have a central registry search requested. Staff #5 who has been employed for over 3 months did not have a central registry search requested. Staff #8 who has been employed for over 3 months did not have a central registry search requested. Staff #9 who has been employed for 24 days did not have a central registry search requested.
Plan of Correction: The center previously conducted background checks for all employees before their date of hire using a federal database but did not request the required state central registry searches, as specified by licensing requirements. As of November 21, 2024, central registry searches have been requested for Staff #1, #5, #8, and #9 to bring their records into compliance. Moving forward, the center will ensure that all central registry searches are completed and documented prior to an employee's first day of work on the designated registry and discontinue utilizing the registry that the church uses for background checks. Administrative staff will update onboarding procedures to include this requirement, conduct monthly audits of personnel records, and provide staff training to reinforce compliance with state licensing standards.
Standard 22.1-289.035-B-4
The center is required to obtain background checks from any state in which the individual has resided in the preceding five years.
Staff # 7, who has been employed for over 1 year and 9 months, did not have documentation of requesting a central registry check, and a sex offender name check from a state in which the individual resided within the preceding 5 years.
Staff # 7, who has been employed for over 1 year and 9 months, did not have documentation of requesting a central registry check, and a sex offender name check from a state in which the individual resided within the preceding 5 years.
Plan of Correction: A search of staff #7 on the sex offender website was conducted, screenshot by method of cell phone camera, and submitted on November 21st, 2024 as requested by the licensing agent to fulfill this requirement. No results of staff #7 or any staff of the center were found on a sex offender site. If any staff who lived outside of the state of Virginia join the team, this process will be completed again.
Standard 22.1-289.049-A
Upon enrollment of a child, the center shall require that the person enrolling the child present the regulated child day program with the proof of the child's identity and age.
The records of child #1, child #2, child #4, and child #5, who have all been in attendance for over 3 months, did not contain documentation of viewing proof of the children's identity and age.
The records of child #1, child #2, child #4, and child #5, who have all been in attendance for over 3 months, did not contain documentation of viewing proof of the children's identity and age.
Plan of Correction: The center has implemented an online records database that allows parents to upload proof of birth and vaccination records directly into the portal. While obtaining these documents has been standard practice, technical issues with the new database resulted in missing or incomplete documentation.
To address this, a complete audit of the student record portal began on November 21, 2024. The administrative team is systematically reviewing all student files to identify any missing or incomplete records. Parents of affected students are being notified of the specific documents required for resubmission. Clear instructions and deadlines for submitting these records will be provided to ensure compliance.Administrative staff will conduct regular reviews of the on line portal to confirm that all student records remain up to date and in compliance with state and center requirements.
To address this, a complete audit of the student record portal began on November 21, 2024. The administrative team is systematically reviewing all student files to identify any missing or incomplete records. Parents of affected students are being notified of the specific documents required for resubmission. Clear instructions and deadlines for submitting these records will be provided to ensure compliance.Administrative staff will conduct regular reviews of the on line portal to confirm that all student records remain up to date and in compliance with state and center requirements.
Standard 8VAC20-770-40-D-2
For staff hired before July 1, 2024, providers must obtain the results of a central registry search for an employee, within 30 days of service. The center is required to obtain a completed sworn statement prior to the employee's first day of employment.
Staff #2, who has been employed for over 1 year and 2 months did not have a central registry and sworn statement. Staff #3, who has been employed for over 1 year and 3 months did not have a central registry and sworn statement. Staff #4, who has been employed for over 1 year and 3 months did not have a central registry and sworn statement. Staff #6, who has been employed for over 1 year and 3 months did not have a central registry and sworn statement. Staff #7, who has been employed for over 1 year and 9 months did not have a central registry and sworn statement.
Staff #2, who has been employed for over 1 year and 2 months did not have a central registry and sworn statement. Staff #3, who has been employed for over 1 year and 3 months did not have a central registry and sworn statement. Staff #4, who has been employed for over 1 year and 3 months did not have a central registry and sworn statement. Staff #6, who has been employed for over 1 year and 3 months did not have a central registry and sworn statement. Staff #7, who has been employed for over 1 year and 9 months did not have a central registry and sworn statement.
Plan of Correction: The center previously conducted background checks for all employees before their date of hire using a federal database but did not request the required state central registry searches, as specified by licensing requirements. As of November 21, 2024, central registry searches have been requested for all staff to bring their records into compliance. Moving forward, the center will ensure that all central registry searches are completed and documented prior to an employee's first day of work on the designated registry and discontinue utilizing the registry that the church uses for background checks. Administrative staff will update onboarding procedures to include this requirement, conduct monthly audits of personnel records, and provide staff training to reinforce compliance with state licensing standards.