Inspection · 2021-05-25
Date
2021-05-25
Complaint Related
Yes
Licensing Inspector
Tara K Martin
(804) 588-2371
(804) 588-2371
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
22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-80 THE LICENSE.
22VAC40-191 Background Checks (22VAC40-191)
63.2(17) License & Registration Procedures
Inspector Notes
A complaint inspection was initiated on July 29, 2021 and concluded on August 18, 2021. A complaint was received from the online reporting system on July 8, 2021 related to staffing/supervision/ratios, qualifications of staff, and staff training. There were 18 children present in two classes with seven direct care staff supervising and the director present in addition. The inspector reviewed compliance in the areas of administration, staffing and supervision, staff records/qualifications, and programming. A total of nine staff records were reviewed.
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.
Violations
7Standard 22VAC40-185-160-A
Based on record review, the center failed to ensure that all staff had a current tuberculosis (TB) test or screening as required by the Standards, completed within 21 days after hire or 12 months prior to hire.
Evidence:
1. Staff #2 had documentation of a chest x-ray as an acceptable form of TB screening dated 2/28/19. Staff #2 was hired 5/17/21.
2. Staff #4 did not have documentation of a TB test or screening. Staff #4 was hired 5/17/21.
3. Staff #7 did not have documentation of a TB test or screening. Staff #7 was hired 7/11/21.
Evidence:
1. Staff #2 had documentation of a chest x-ray as an acceptable form of TB screening dated 2/28/19. Staff #2 was hired 5/17/21.
2. Staff #4 did not have documentation of a TB test or screening. Staff #4 was hired 5/17/21.
3. Staff #7 did not have documentation of a TB test or screening. Staff #7 was hired 7/11/21.
Plan of Correction: The director will ensure all staff have a current negative results for a TB screening, test, or chest xray on file.
Standard 22VAC40-185-240-C
Based on record review, the center failed to ensure that staff had 16 hours of training annually.
Evidence:
1. Staff #9 who was hired 11/8/18 did not have the required hours of training completed November 2019 through October 2020. Staff #1 had six and one-half hours of training documented during this period.
2. Staff #5 who was hired 8/5/2020 did not have the required hours of training completed within the year. Staff #5 had nine hours of training documented.
Evidence:
1. Staff #9 who was hired 11/8/18 did not have the required hours of training completed November 2019 through October 2020. Staff #1 had six and one-half hours of training documented during this period.
2. Staff #5 who was hired 8/5/2020 did not have the required hours of training completed within the year. Staff #5 had nine hours of training documented.
Plan of Correction: The director will ensure all staff annually attend at least 16 hours of training
Standard 22VAC40-185-70-A
Based on record review, the center failed to ensure all required information was obtained and documented in the staff records.
Evidence:
1. The records of staff #1,2,4 did not have references documented in their records. Two references are required to be completed and documented as required by the Standards prior to hire.
2. There was no position documented for staff #7 who was present during the inspection and was hired 7/11/21. Staff #7 was also missing documentation of an emergency contact name, address, and phone number.
Evidence:
1. The records of staff #1,2,4 did not have references documented in their records. Two references are required to be completed and documented as required by the Standards prior to hire.
2. There was no position documented for staff #7 who was present during the inspection and was hired 7/11/21. Staff #7 was also missing documentation of an emergency contact name, address, and phone number.
Plan of Correction: The director will ensure references are completed and documented prior to hire.
Standard 22VAC40-191-60-B
191-60-B (complaint related)
Based on record review, the center failed to ensure that a Sworn Statement or Affirmation was complete prior to the staff person?s first day of employment.
Evidence:
1. Staff #1 (hire date 4/10/21; Sworn Statement completed 5/25/2021), staff #2 (hire date 5/17/21; Sworn Statement completed 5/25/2021), staff #3 (hire date 5/17/21; Sworn Statement completed 5/25/2021), staff #4 (hire date 4/17/21; Sworn Statement completed 6/04/2021), staff #6 (hire date 9/07/20; Sworn Statement completed 9/09/2020).
Based on record review, the center failed to ensure that a Sworn Statement or Affirmation was complete prior to the staff person?s first day of employment.
Evidence:
1. Staff #1 (hire date 4/10/21; Sworn Statement completed 5/25/2021), staff #2 (hire date 5/17/21; Sworn Statement completed 5/25/2021), staff #3 (hire date 5/17/21; Sworn Statement completed 5/25/2021), staff #4 (hire date 4/17/21; Sworn Statement completed 6/04/2021), staff #6 (hire date 9/07/20; Sworn Statement completed 9/09/2020).
Plan of Correction: The director will ensure Sworn Statements are completed prior to employment.
Standard 22VAC40-191-60-C-2
Based on record review, the center failed to ensure that a search of the central registry as a part of the background check was completed within 30 days after hire.
Evidence:
1. Staff #6 with a documented hire date of 9/7/20 had a completed DSS search of the central registry dated 12/1/20.
Evidence:
1. Staff #6 with a documented hire date of 9/7/20 had a completed DSS search of the central registry dated 12/1/20.
Plan of Correction: The director will ensure that a search of the central registry is completed within 30 days and document per requirements the sent date/follow-up date if not received within 30 days.
Standard 63.2(17)-1720.1-B-2
Based on record review, the center failed to ensure that a fingerprint criminal record was completed prior to hire.
Evidence:
1.Staff #6 did not have a fingerprint completed prior to hire. Staff #6 documented hire date was 9/7/20 and the fingerprint date of completion letter was dated 9/16/20.
Evidence:
1.Staff #6 did not have a fingerprint completed prior to hire. Staff #6 documented hire date was 9/7/20 and the fingerprint date of completion letter was dated 9/16/20.
Plan of Correction: The director will ensure that fingerprint results are obtained prior to hiring staff.
Standard 63.2(17)-1720.1-B-4
63.2-1720.1 B 4
Based on record review, the center failed to ensure that staff who had lived out of Virginia in the last five years had a criminal record check and sex offender registry check prior to hire.
Evidence:
1. Staff #8 with a documented hire date of 7/11/21 had disclosed on the Sworn Statement dated 6/24/21 that they had lived in another state in the last five years. There was no criminal record check or sex offender registry check completed for staff #8. The director verified that these were not completed.
Based on record review, the center failed to ensure that staff who had lived out of Virginia in the last five years had a criminal record check and sex offender registry check prior to hire.
Evidence:
1. Staff #8 with a documented hire date of 7/11/21 had disclosed on the Sworn Statement dated 6/24/21 that they had lived in another state in the last five years. There was no criminal record check or sex offender registry check completed for staff #8. The director verified that these were not completed.
Plan of Correction: The director will ensure that appropriate out of state background checks are completed as required.