Inspection · 2024-07-15
Date
2024-07-15
Complaint Related
No
Licensing Inspector
Maria Robles-Lopez
(703) 397-3827
(703) 397-3827
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
8VAC20-800 Administration
8VAC20-800 Personnel
8VAC20-800 Household Members
8VAC20-800 Physical Health of Caregivers and Household members
8VAC20-800 Caregiver Training
8VAC20-800 Physical Equipment and Environment
8VAC20-800 Care of Children
8VAC20-800 Preventing the Spread of Disease
8VAC20-800 Medication Administration
8VAC20-800 Emergencies
8VAC20-800 Nutrition
8VAC20-800 Transportation
8VAC20-800 Nighttime Care
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-770 Background Checks
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
54.1 Provider must be MAT certified to administer prescription medication.
63.2 Child abuse and neglect
Inspector Notes
An unannounced, on-site renewal inspection was initiated on 07/15/2024 and completed on 07/31/2024. The inspector reviewed compliance in the areas listed above. On 07/15/2024, There were 14 children present, three of them being household members and 3 caregivers; the point total was 26. On 07/31/2024, There were 22 children present, three of them being household members and 3 caregivers; the point total was 43.
On 07/15/2024, the inspector reviewed 4 children?s records and 4 staff records on-site. This inspection included document review, review of emergency supplies and tour of the care area.
Information gathered during the inspection determined non-compliance with applicable standards or law and violations were 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 deficient practice will be or has been corrected. Submit your POC within 5 business days from today, which will be the close of business on 08/15/2024. A POC submitted after this date will not appear on the public website.
Violations
15Standard 22.1-289.035-B-1
Based on record review and interview, the provider did not ensure to obtain a completed Sworn Statement prior to first day of employment for caregivers.
Evidence:
1) On the date of inspection, there was no Sworn statement available for review for Caregiver #4 (start date 07/01/2024).
Evidence:
1) On the date of inspection, there was no Sworn statement available for review for Caregiver #4 (start date 07/01/2024).
Plan of Correction: Caregiver #4 completed the Sworn Statement.
Standard 22.1-289.035-B-2
Based on record review and interview, the provider did not ensure to obtain a fingerprint-based criminal history check determination letter prior to first day of employment for caregivers and every five years subsequently.
Evidence:
1) On the date of inspection, there was no criminal history check determination letter available for review for Caregiver #4 (start date 07/01/2024).
2) The criminal history check determination letter in the record for Caregiver #2 was dated 06/10/2019.
Evidence:
1) On the date of inspection, there was no criminal history check determination letter available for review for Caregiver #4 (start date 07/01/2024).
2) The criminal history check determination letter in the record for Caregiver #2 was dated 06/10/2019.
Plan of Correction: The provider must ensure to request appointments to get fingerprints taken. The provider will communicate with the LI when results are received and to follow up with OBI if results are not received in 10 business days.
Standard 22.1-289.035-B-3
Based on record review and interview, the provider did not ensure to obtain that Central Registry search results every five years.
Evidence:
1) The Central Registry search results in the record for Caregiver #3 was dated 02/12/2018.
Evidence:
1) The Central Registry search results in the record for Caregiver #3 was dated 02/12/2018.
Plan of Correction: The CRS requests were submitted on 07/15/2024. The provider must ensure to communicate with the LI when results are received and to follow up with OBI if results are not received in 10 business days.
Standard 22.1-289.036-B-1
Based on record review and interview, the provider did not ensure to obtain a completed Sworn Statement by the end of the 30th day for new household members.
Evidence:
1) The records for Household member #4 and Household Member #5 did not contain a completed Sworn Statement. The provider had stated that they had been living in the home since September 2023.
Evidence:
1) The records for Household member #4 and Household Member #5 did not contain a completed Sworn Statement. The provider had stated that they had been living in the home since September 2023.
Plan of Correction: Corrected. Sworn Statements were completed for Household Member #4 and Household Member #5 during inspection.
Standard 22.1-289.036-B-3
Based on record review and interview, the provider did not ensure to obtain that Central Registry search results by the end of the 30th day for new household members.
Evidence:
1) The records for Household member #4 and Household Member #5 did not contain Central Registry search results. The provider had stated that they had been living in the home since September 2023.
Evidence:
1) The records for Household member #4 and Household Member #5 did not contain Central Registry search results. The provider had stated that they had been living in the home since September 2023.
Plan of Correction: CRS was requested.
Standard 8VAC20-800-120-A
Based on record review and interview, the provider did not maintain a record for each caregiver.
Evidence:
1) On the date of inspection, a record for Caregiver #4 (start date 07/01/2024) was not available for review. The provider stated that she had not prepared a record for Caregiver #4 with all required documentation.
Evidence:
1) On the date of inspection, a record for Caregiver #4 (start date 07/01/2024) was not available for review. The provider stated that she had not prepared a record for Caregiver #4 with all required documentation.
Plan of Correction: File was completed.
Standard 8VAC20-800-170-A
Based on record review, the provider did not obtain from each caregiver at the time of hire and and each adult household member prior to coming into contact with children a current Report of Tuberculosis (Tb) Screening.
Evidence:
1) There was no Tb screening available for review for Caregiver #4 (start date 07/01/2024).
2) The records for Household member #4 and Household Member #5 did not contain a Tb screening. The provider had stated that they had been living in the home since September 2023.
Evidence:
1) There was no Tb screening available for review for Caregiver #4 (start date 07/01/2024).
2) The records for Household member #4 and Household Member #5 did not contain a Tb screening. The provider had stated that they had been living in the home since September 2023.
Plan of Correction: They had their appointment in 07/29/2024.
Standard 8VAC20-800-180-A
Based on record review, the provider did not ensure to obtain from each adult household member the results of a follow-up tuberculosis (Tb) screening at least every two years.
Evidence:
1) The Tb screening form in the record for Household Member #1 was dated 11/30/2021.
Evidence:
1) The Tb screening form in the record for Household Member #1 was dated 11/30/2021.
Plan of Correction: Had the appointment on 07/29/24.
Standard 8VAC20-800-200-A
Based on record review, the provider did not orient the substitute provider and assistant by the end of their first week of assuming job responsibilities.
Evidence:
1) On the date of inspection, there was no documentation available to review to demonstrate that Caregiver #3 (start date 06/01/2023) and Caregiver #4 (start date 07/01/2024) had completed orientation training as required.
Evidence:
1) On the date of inspection, there was no documentation available to review to demonstrate that Caregiver #3 (start date 06/01/2023) and Caregiver #4 (start date 07/01/2024) had completed orientation training as required.
Plan of Correction: Orientation training was completed for all caregivers.
Standard 8VAC20-800-40-A
* REPEAT VIOLATION * SYSTEMIC DEFICIENCY*
Based on observation, the provider exceeded the maximum licensed capacity of the home.
Evidence: The provider is licensed for 12 children. During the visit on 07/31/2024, there were 19 children in care.
Based on observation, the provider exceeded the maximum licensed capacity of the home.
Evidence: The provider is licensed for 12 children. During the visit on 07/31/2024, there were 19 children in care.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-800-50-A
*REPEAT VIOLATION*
Based on documentation review, the family day home did not keep a written record of children in attendance each day.
Evidence:
1) At the time of entrance on 07/15/2024, the attendance for the day had not been documented. The most recent attendance documented was for 06/26/2024.
2) At the time of entrance on 07/31/2024, the attendance for the day had not been documented. The most recent attendance recorded was for 07/30.
3) The attendance sheet was inaccurate. There were 12 children listed on the attendance sheet but 19 children were present. Child #11, 14, 15, 16, 17, 18, 19 were not included in the list.
Based on documentation review, the family day home did not keep a written record of children in attendance each day.
Evidence:
1) At the time of entrance on 07/15/2024, the attendance for the day had not been documented. The most recent attendance documented was for 06/26/2024.
2) At the time of entrance on 07/31/2024, the attendance for the day had not been documented. The most recent attendance recorded was for 07/30.
3) The attendance sheet was inaccurate. There were 12 children listed on the attendance sheet but 19 children were present. Child #11, 14, 15, 16, 17, 18, 19 were not included in the list.
Plan of Correction: Corrected during inspection. The provider filled out the attendance record for the day.
Standard 8VAC20-800-570-A
* REPEAT VIOLATION *
Based on observation, the Provider did not ensure that a caregiver does not exceed points
maximus while supervising children.
Evidence:
1) On 07/31/2024, Caregiver #2 was observed supervising 18 children (3 of them were household members) for a total of 38 points. The Provider had left the FDH and called Caregiver #4 to come downstairs to assist but it took about 5 minutes. Even with two Caregivers present, they were over points maximus.
2) On 07/31/2024, Caregiver #2 and Caregiver #3 took 13 children (36 points) out to play on the outside area. Once outside, Caregiver #2 went back inside for several minutes, leaving Caregiver #4 supervising all children (36 points) outside.
Based on observation, the Provider did not ensure that a caregiver does not exceed points
maximus while supervising children.
Evidence:
1) On 07/31/2024, Caregiver #2 was observed supervising 18 children (3 of them were household members) for a total of 38 points. The Provider had left the FDH and called Caregiver #4 to come downstairs to assist but it took about 5 minutes. Even with two Caregivers present, they were over points maximus.
2) On 07/31/2024, Caregiver #2 and Caregiver #3 took 13 children (36 points) out to play on the outside area. Once outside, Caregiver #2 went back inside for several minutes, leaving Caregiver #4 supervising all children (36 points) outside.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-800-760-A
Based on review of the emergency supplies, the emergency kit did not contain all required components.
Evidence:
1) On the date of inspection, the first aid kit did not contain antiseptic cleaning solution or pads.
Evidence:
1) On the date of inspection, the first aid kit did not contain antiseptic cleaning solution or pads.
Plan of Correction: Bought one.
Standard 8VAC20-800-780-B
Based on record review, the provider did not ensure to annually review with the parent the emergency contact information required in 8VAC20-800-60 B 2 to ensure the information is correct, and to obtain the parent's signed acknowledgment of the review.
Evidence:
1) The most recent record review of the emergency information in the record for Child #1 was dated 01/01/2023 and for Child #4 was dated 2023.
Evidence:
1) The most recent record review of the emergency information in the record for Child #1 was dated 01/01/2023 and for Child #4 was dated 2023.
Plan of Correction: Parents reviewed the information.
Standard 8VAC20-800-920
*REPEAT VIOLATION*
Based on documentation review, the menu for the current one-week period did not meet all requirements.
Evidence:
1) The menu available for review was not dated for the current one-week period. It was dated 02/19-23/2024.
Based on documentation review, the menu for the current one-week period did not meet all requirements.
Evidence:
1) The menu available for review was not dated for the current one-week period. It was dated 02/19-23/2024.
Plan of Correction: Corrected