Inspection · 2023-02-01
Date
2023-02-01
Complaint Related
No
Licensing Inspector
Susan Ellington-Sconiers
(804) 588-2368
(804) 588-2368
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
Inspector Notes
A monitoring inspection was conducted on 05/12/2023 from approximately 2:20 p.m. ? 5:25 p.m. There were 60 children present ranging from 2nd grade through 5th grade and 8 staff supervising. The inspector reviewed compliance in the areas of administration, qualifications and training, physical plant, staffing and supervision, programming, medication, special care and emergencies, and nutrition. Nine child records and four staff records were reviewed.
The information gathered during the inspection determined violations with applicable standards or law. A violation notice was issued. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to me within 5 business days from today, 06/12/2023. Please specify how the deficient practice will be or has been corrected. Your plan of correction should contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).
Violations
13Standard 22.1-289.035-B-2
Based on record review, the provider failed to ensure that all applicants for employment shall submit to fingerprinting and undergo a national criminal background check prior to employment.
Evidence:
The record for S1, employed 08/01/2022 did not have results of a national criminal background check prior to the first day of employment. The results of the national criminal background check for S1 are dated 08/04/2022.
Evidence:
The record for S1, employed 08/01/2022 did not have results of a national criminal background check prior to the first day of employment. The results of the national criminal background check for S1 are dated 08/04/2022.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-770-60-B
Based on record review, the provider failed to ensure an employee must not be employed until the center has the person?s completed sworn statement.
Evidence:
The record for S4, employed 01/03/2023 documented a sworn statement dated 1/25/2023.
Evidence:
The record for S4, employed 01/03/2023 documented a sworn statement dated 1/25/2023.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-770-60-C-2
Based on staff record review, the provider failed to obtain a search of the central registry within 30 days of employment.
Evidence:
The record for S1, employed 08/01/2022 did not contain findings of a central registry search.
The record for S4, employed 01/03/2023 did not have results of a central registry search within 30 days of employment. The results of the central registry search for S4 are dated 02/06/2023.
Evidence:
The record for S1, employed 08/01/2022 did not contain findings of a central registry search.
The record for S4, employed 01/03/2023 did not have results of a central registry search within 30 days of employment. The results of the central registry search for S4 are dated 02/06/2023.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-140-A
Based on review of 9 children?s records, the provider failed to ensure that two of nine children had a physical examination by or under the direction of a physician.
Evidence:
The records for C2, enrolled 03/22/2023 and C7, enrolled 06/12/2022 did not contain physical examinations.
Evidence:
The records for C2, enrolled 03/22/2023 and C7, enrolled 06/12/2022 did not contain physical examinations.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-160-A
Based on review of 4 staff records review, the provider failed to ensure that three of four staff shall submit documentation of a negative tuberculosis (TB) screening. Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children.
Evidence:
The records for S2, employed 06/28/2022 and S3, employed 07/05/2022 did not document a tuberculosis (TB) screening. The records did not contain TB screening results.
The record for S4, employed 01/03/2023 did not document a tuberculosis (TB) screening being submitted at the time of employment and prior to coming in contact with children. The TB screening was completed 02/01/2023.
Evidence:
The records for S2, employed 06/28/2022 and S3, employed 07/05/2022 did not document a tuberculosis (TB) screening. The records did not contain TB screening results.
The record for S4, employed 01/03/2023 did not document a tuberculosis (TB) screening being submitted at the time of employment and prior to coming in contact with children. The TB screening was completed 02/01/2023.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-210-A
Based on staff record review, the provider failed to ensure program leader qualifications
for one staff designated as program leader.
Evidence:
Record for S2 did not contain documentation showing possession of Program Leader qualifications by either: meeting endorsement or bachelor?s degree requirement; educational requirements and programmatic experience; or supervised programmatic experience.
for one staff designated as program leader.
Evidence:
Record for S2 did not contain documentation showing possession of Program Leader qualifications by either: meeting endorsement or bachelor?s degree requirement; educational requirements and programmatic experience; or supervised programmatic experience.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-240-A
Based on record review, the provider did not ensure that three of four staff completed the Virginia Department of Education (VDOE) sponsored orientation course within 90 calendar days of employment.
Evidence:
The record for S2, employed 06/28/2022, S3, employed 07/05/2022, S4 employed 01/03/2023 did not document completion of the 10-hour VDOE sponsored orientation course.
Evidence:
The record for S2, employed 06/28/2022, S3, employed 07/05/2022, S4 employed 01/03/2023 did not document completion of the 10-hour VDOE sponsored orientation course.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-240-B
Based on record review, the provider did not ensure three of four staff records contained documentation showing completion of orientation required by 8VAC20-780-240-C.
The records for C2, employed 06/28/2022, C3, employed 07/05/2022, and S4 employed 01/03/2023 did not contain documentation of required orientation.
The records for C2, employed 06/28/2022, C3, employed 07/05/2022, and S4 employed 01/03/2023 did not contain documentation of required orientation.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-550-E
Based on review of emergency drill documentation, the provider failed to practice at a minimum of twice per year shelter-in-place procedures.
Evidence:
The drill record for 2022 documented one shelter-in-place drill being conducted on 03/03/2022.
Evidence:
The drill record for 2022 documented one shelter-in-place drill being conducted on 03/03/2022.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-550-F
Based on review of emergency drill documentation, the provider failed to practice at least annually lock-down procedures.
Evidence:
The drill record for 2022 did not document practice of the lock-down procedures.
Evidence:
The drill record for 2022 did not document practice of the lock-down procedures.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-550-G
Based on review of emergency evacuation drill documentation, the provider failed to ensure
the documentation includes the required information.
Evidence:
The emergency drill documentation dated March 2022 ? April 2023 did not document:
the method used for notification of the drill and the number of staff participating.
the documentation includes the required information.
Evidence:
The emergency drill documentation dated March 2022 ? April 2023 did not document:
the method used for notification of the drill and the number of staff participating.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-60-A
Based on child record review, the provider failed to ensure that two of nine records contained all the required information.
Evidence:
The record for C2, enrolled 03/22/2023 did not contain two emergency contacts for the child if the children?s parents could not be located.
The records for C4, enrolled 03/30/2023 did not contain a second emergency contact if the child?s parents could not be located.
Evidence:
The record for C2, enrolled 03/22/2023 did not contain two emergency contacts for the child if the children?s parents could not be located.
The records for C4, enrolled 03/30/2023 did not contain a second emergency contact if the child?s parents could not be located.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-70
Based on record review, the provider did not keep records for three of four staff as required.
Evidence:
The record for S2, employed 06/28/2022, did not contain emergency contacts.
The record for S3, employed 07/05/2022 did not document two employment references and emergency contacts.
The record for S4, employed 01/03/2023 did not document and emergency contacts.
Evidence:
The record for S2, employed 06/28/2022, did not contain emergency contacts.
The record for S3, employed 07/05/2022 did not document two employment references and emergency contacts.
The record for S4, employed 01/03/2023 did not document and emergency contacts.
Plan of Correction: Not available online. Contact Inspector for more information.