Inspection · 2022-03-15
Date
2022-03-15
Complaint Related
No
Licensing Inspector
LaTasha Smith
(804) 588-2362
(804) 588-2362
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.
8VAC20-770 Background Checks (8VAC20-770)
22.1 Background Checks Code, Carbon Monoxide
Inspector Notes
A renewal inspection was initiated on 03/15/2022 and concluded on 03/30/2022. The facility submitted documentation to the inspector on 03/15/2022 and the inspector conducted an unannounced inspection on-site on 03/16/2022 from approximately 3:45pm to 5:27pm. An announced record review inspection was conducted at the center's administrative office on 03/22/2022. On 03/16/2022, there were 99 children present with seven staff directly supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medications, special care and emergencies and nutrition. A total of five child records and eight staff records were reviewed. Five children's medications and Board Officers' background checks were also 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.
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 the date of receipt. 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 standards, 2) measures to prevent the noncompliance from occurring again, and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s).
Violations
9Standard 22.1-289-036-B-4
Based on a review of documentation, the center did not obtain a copy of the results of a criminal history record information check and a sex offender registry check from any state in which one board officer had resided in the preceding five years within the required time frame.
Evidence: 1) The record for Board Officer #2 indicated the Officer has resided in another state outside of Virginia within the last five years. The results of the out-of-state criminal history record information check were dated 10/07/21. The results of the out-of-state sex offender registry check were dated 10/07/21. The results of the out-of-state background check searches were required to be obtained by December 31, 2020 for existing applicants prior to July 1, 2020. Board Officer #2 was an officer prior to July 1, 2020.
Evidence: 1) The record for Board Officer #2 indicated the Officer has resided in another state outside of Virginia within the last five years. The results of the out-of-state criminal history record information check were dated 10/07/21. The results of the out-of-state sex offender registry check were dated 10/07/21. The results of the out-of-state background check searches were required to be obtained by December 31, 2020 for existing applicants prior to July 1, 2020. Board Officer #2 was an officer prior to July 1, 2020.
Plan of Correction: Per the Center: "Going forward, our office manager will make sure all board officers whom lived out of the state of VA in the past 5 years will have a background check before date of hire."
Standard 8VAC20-770-40-D-6
Based on a review of eight staff records and interview, the center did not ensure that a required central registry finding for one staff member was not dated more than 90 days prior to the date of employment.
Evidence: 1) The record for Staff #6, hired on 11/09/21, had documentation of a central registry finding that was dated 12/17/18. 2) During interview, a member of management reported Staff #6 was rehired and a new central registry search was not requested upon rehire. Staff #6 was separated from employment for more than 12 months.
Evidence: 1) The record for Staff #6, hired on 11/09/21, had documentation of a central registry finding that was dated 12/17/18. 2) During interview, a member of management reported Staff #6 was rehired and a new central registry search was not requested upon rehire. Staff #6 was separated from employment for more than 12 months.
Plan of Correction: Per the Center: "Going forward, our office manager will make sure all central registry are no more than 3 weeks from their hire date."
Standard 8VAC20-780-140-A
Based on a review of five children's records and interview, the center did not ensure one child had a physical examination before the child's attendance or within 30 days after the first day of attendance.
Evidence: 1) The record for Child # 3, enrolled at 10/22/21, did not contain a physical examination. 2) During interview, a member of management reported the physical examination for Child #3 has not been received.
Evidence: 1) The record for Child # 3, enrolled at 10/22/21, did not contain a physical examination. 2) During interview, a member of management reported the physical examination for Child #3 has not been received.
Plan of Correction: Per the Center: "Going forward, prior to each child's start date, will ensure that a child's physical will be included with enrollment forms."
Standard 8VAC20-780-160-C
Based on a review of eight staff records and interview, the center did not ensure 5 staff members resubmitted tuberculosis (TB) test/screening results at least every two years from the date of the first initial screening or testing, or more frequently as if recommended by a licensed physician or the local health department.
Evidence: 1) The TB screening in the record for Staff #1, hired on 08/31/18, expired on 10/30/21. A repeat TB screening was completed on 03/23/22.
2) The TB screening in the record for Staff #2, hired on 10/05/18, expired on 10/30/21. A repeat TB screening was completed on 11/04/21.
3) The TB screening in the record for Staff #4, hired on 05/29/18, expired on 10/30/21. A repeat TB screening was completed on 03/23/22.
4) The TB screening in the record for Staff #5, hired on 09/29/17, expired on 10/30/21. A repeat TB screening was completed on 03/23/22.
5) The TB screening in the record for Staff #8, hired on 09/29/17, expired on 10/30/21. A repeat TB screening was completed on 03/23/22.
6) During interview, a member of management acknowledged the subsequent TB screenings/tests for Staff #2, Staff #4, Staff #5, and Staff #8 were not completed within the required two year time frame.
Evidence: 1) The TB screening in the record for Staff #1, hired on 08/31/18, expired on 10/30/21. A repeat TB screening was completed on 03/23/22.
2) The TB screening in the record for Staff #2, hired on 10/05/18, expired on 10/30/21. A repeat TB screening was completed on 11/04/21.
3) The TB screening in the record for Staff #4, hired on 05/29/18, expired on 10/30/21. A repeat TB screening was completed on 03/23/22.
4) The TB screening in the record for Staff #5, hired on 09/29/17, expired on 10/30/21. A repeat TB screening was completed on 03/23/22.
5) The TB screening in the record for Staff #8, hired on 09/29/17, expired on 10/30/21. A repeat TB screening was completed on 03/23/22.
6) During interview, a member of management acknowledged the subsequent TB screenings/tests for Staff #2, Staff #4, Staff #5, and Staff #8 were not completed within the required two year time frame.
Plan of Correction: Per the Center: "Moving forward, our office manager will make sure all TB screenings for all staff members are up to date."
Standard 8VAC20-780-245-A
Based on a review of eight staff records, the center did not ensure five staff received the required 16 hours of annual training.
Evidence: 1) The record for Staff #1, hired on 8/31/18, did not contain documentation of annual training in the last annual training cycle 9/2020-8/2021.
2) Staff #2, hired on 10/05/18, completed 11 hours of annual training in the last annual training cycle from 11/2020-10/2021.
3) The record for Staff #5, hired on 09/29/17, did not contain documentation of annual training in the last annual training cycle from 10/2020-09/2021.
4) Staff #7, hired on 09/29/17, completed 9 hours of annual training in the last annual training cycle from 10/2020-9/2021.
5) The record for Staff #8, hired on 09/29/17, did not contain documentation of annual training in the last annual training cycle from 10/2020-09/2021.
Evidence: 1) The record for Staff #1, hired on 8/31/18, did not contain documentation of annual training in the last annual training cycle 9/2020-8/2021.
2) Staff #2, hired on 10/05/18, completed 11 hours of annual training in the last annual training cycle from 11/2020-10/2021.
3) The record for Staff #5, hired on 09/29/17, did not contain documentation of annual training in the last annual training cycle from 10/2020-09/2021.
4) Staff #7, hired on 09/29/17, completed 9 hours of annual training in the last annual training cycle from 10/2020-9/2021.
5) The record for Staff #8, hired on 09/29/17, did not contain documentation of annual training in the last annual training cycle from 10/2020-09/2021.
Plan of Correction: Per the Center: "Going forward, will ensure that all staff have the required 16 hours of annual training."
Standard 8VAC20-780-510-F
Based on a review of 10 medications and interviews, the center did not ensure that four medication authorizations were available to staff during the entire time they were effective for two out of five children.
Evidence: 1) A non-prescription medication and one prescribed medication were observed for Child #8, but the medication authorizations for these medications were not present at the center. 2) A non-prescription medication was observed for Child #10, but a medication authorization for this medication was not present at the center. 3) During interview, a member of management reported the authorizations for these medications were not present.
Evidence: 1) A non-prescription medication and one prescribed medication were observed for Child #8, but the medication authorizations for these medications were not present at the center. 2) A non-prescription medication was observed for Child #10, but a medication authorization for this medication was not present at the center. 3) During interview, a member of management reported the authorizations for these medications were not present.
Plan of Correction: Per the Center: "Going forward, ensure that every child have a non-prescription medication form, and or prescribed medication form on file."
Standard 8VAC20-780-60-A
Based on a review of five children's records, the center did not ensure three children's records contained the required information.
Evidence: 1) The two emergency contacts in the record for Child #1, enrolled on 02/04/22, did not contain an address. 2) The record for Child #2, enrolled on 11/19/21, did not contain a second emergency contact. 3) The record for Child #3, enrolled on 10/22/21, did not contain a second emergency contact. Each child record should contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.
Evidence: 1) The two emergency contacts in the record for Child #1, enrolled on 02/04/22, did not contain an address. 2) The record for Child #2, enrolled on 11/19/21, did not contain a second emergency contact. 3) The record for Child #3, enrolled on 10/22/21, did not contain a second emergency contact. Each child record should contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.
Plan of Correction: Per the Center: "Going forward, I will make sure that all child enrollment forms are completed in full prior to their start date."
Standard 8VAC20-780-60-A-8
Based on documentation reviewed and interview, the center did not ensure to have a written care plan for two children with a diagnosed
food allergy, to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction.
Evidence: 1) Documentation reviewed for Child #7 indicated the child has a diagnosed food allergy, but a written care plan was not observed at the center.
2) Documentation reviewed for Child #10 indicated the child has a diagnosed food allergy, but a written care plan was not observed at the center.
3) During interview, a member of management reported the center does not have a written care plan for Child #7 or Child #10.
food allergy, to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction.
Evidence: 1) Documentation reviewed for Child #7 indicated the child has a diagnosed food allergy, but a written care plan was not observed at the center.
2) Documentation reviewed for Child #10 indicated the child has a diagnosed food allergy, but a written care plan was not observed at the center.
3) During interview, a member of management reported the center does not have a written care plan for Child #7 or Child #10.
Plan of Correction: Per the Center: "Going forward, when notified of a child's allergen, I will ensure that an action plan is in place."
Standard 8VAC20-780-80-A
Based on observation and interview, the center did not maintain a written record of daily attendance that documented the departure of each child in care as it occurs.
Evidence: 1) During the inspection on 03/16/22, the written record of daily attendance was observed. The departure of each child in care was not documented as it occurred. 2) During interview, a member of management confirmed the departure of each child was not documented as it occurs.
Evidence: 1) During the inspection on 03/16/22, the written record of daily attendance was observed. The departure of each child in care was not documented as it occurred. 2) During interview, a member of management confirmed the departure of each child was not documented as it occurs.
Plan of Correction: Per the Center: "Going forward, a daily attendance roster has been created to capture an arrival and departure time of each child in the program."