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Madison Day School

Inspection · 2025-01-22

Date
2025-01-22
Complaint Related
No
Licensing Inspector
Sarah Zirzow
(703) 479-4675
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
8VAC20-820 THE LICENSING PROCESS
8VAC20-820 HEARINGS PROCEDURES
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect

During the inspection, the inspector reviewed the areas listed above to include standards found out of compliance during the previous inspection. 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 renewal inspection was initiated and completed on January 22, 2025. The on-site inspection began at 9:45 a.m. and ended at 2:00 p.m. The inspector reviewed compliance in the areas listed above. There were 109 children present and 31 staff. The inspector reviewed 10 children?s records and 10 staff records on-site. This inspection included document review, tour of the facility, and observations. Information gathered during the inspection determined non-compliance with applicable standards or law, 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 January 30, 2025. A POC submitted after this date will not appear on the public website.

Violations

9
Standard 22.1-289.035-A
The center is required to have employees undergo a background check every five years.

The most recent criminal background check for staff #4 was overdue by 1 year and 4 months.
Plan of Correction: A system will be put in place to track background checks to ensure a new one is received prior to expiration
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.

The sworn statement for Staff #1, who is currently working, was dated over 3 months after their first day of employment.
Plan of Correction: Sworn statements will be completed prior to an employee's start date.
Standard 22.1-289.035-B-3
The center is required to submit a request for a central registry check prior to the employee's first day of employment.

The central registry for Staff #1, who is currently working, was dated over 3 months after their first day of employment.
Plan of Correction: We will ensure to submit all requests for a central registry checks prior to an employee's first day of employment.
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 #1, employed for more than 10 months, did not have documentation of requesting a central registry check or sex offender check prior to employment from one state they had previously resided.
-Staff #7, employed for more than 3 months, did not have documentation of requesting a central registry check or sex offender check prior to employment from one state they had previously resided.
-Staff #10, employed for more than 3 months, did not have documentation of requesting a central registry check or sex offender check prior to employment for one state they had previously resided and did not have documentation of requesting a central registry check, sex offender check, and a criminal history check from a different state.
Plan of Correction: All current out-of-state background checks will be requested and moving forward any out-of-state background checks will be submitted prior to an employee's first day of employment.
Standard 22.1-289.036-A
An applicant or agent is required to undergo a background check every five years.

The most recent central registry check for Applicant #1 was overdue by eleven months.
Plan of Correction: The central registry check will be requested and moving forward a system will be put in place to track expiration dates to ensure results are received before expiration.
Standard 8VAC20-780-160-C
Repeat Violation
A tuberculosis (TB) screening is required every two years from the last screening.

Staff #2 had a TB screening that was expired for over 7 months before an updated screening was obtained.
Plan of Correction: A new system will be put in place to track expiration dates to ensure new TB screenings are received prior to expiration.
Standard 8VAC20-780-240-I
Documentation of orientation training shall be kept by the center with the required components.

The documentation of orientation training for Staff #7, employed for over 3 months, did not include the training delivery method, the individual providing the training, and the date of training.
Plan of Correction: The orientation information will be documented.
Standard 8VAC20-780-420-E-3
Staff shall request at least annually parent confirmation that the required information in the child's record is up to date. Up-to-date information is required to be requested from the parent for each child's record at least annually.

The information in the record of child #4 and child #8 had not been updated in over 18 months which is overdue by 6 months.
Plan of Correction: The information will be updated and will make sure they are received annually moving forward.
Standard 8VAC20-780-70
Documentation of at least 2 references to character, reputation, and competency are to be checked prior to employment.

Staff #6, who has been actively working at the center for the past 9 months, had one documented reference and was missing a second.
Plan of Correction: A second reference will be documented and will ensure all staff have two on file.
View original record on Virginia Department of Social Services