Inspection · 2024-06-10

(Repeat Violation, Systemic) Based on review of seven staff records, it was determined that not all staff had a repeat Central Registry Search every five years as required. Evidence: The record for staff #1 had a Central Registry search results letter dated: 12/19/2017.

(Systemic) Based on review of two applicant records, it was determined that not all applicants had an Office of Background Investigations (OBI) fingerprinting-based criminal history record check, as required. Evidence: the record for applicant #2 did not contain a fingerprint determination letter.

(Systemic) Based on review of two applicant records, it was determined that not all applicants had a sworn statement or an original central registry search report, as required. Evidence: the record for applicant #1 did not contain documentation of a central registry search report and the record for applicant #2 did not contain documentation of a sworn statement or a central registry search report.

(Repeat violation, Systemic) Based on review of seven staff records, it was determined that not all staff had Central Registry Search results within thirty days of employment. Evidence: The record for staff #5 (Date of hire: 5/3/2024) and staff #6 (Date of hire: 5/9/2024) did not have documentation of a Central Registry search request. The record for staff #2 (Date of hire: 8/22/2024) had Central Registry search results dated: 1/31/2024

Based on review of 12 child records, the facility failed to obtain documentation that each child has received immunizations prior to the child's first attendance. Evidence: the record for child #8 (date of first attendance: 5/28/2024) did not have documentation of immunizations.

(Repeat Violation) Based on review of six staff records, the facility did not have documentation of a negative tuberculosis (TB) test/ screening for all staff at the time of employment that was completed within the last 30 calendar days of the date of employment. Evidence: the record for staff #2 (date of hire: 8/22/2023) had a TB test/screening dated: 9/7/2023. The record for staff #6 (date of hire: 5/9/2024) had a TB test/screening dated: 3/22/2024.

Based on review of six staff records, it was determined that not all staff had documentation of a negative tuberculosis (TB) test/screening completed at least every two years from the date of the initial test or screening. Evidence: the record for staff #4 had a negative TB test/screening dated: 5/27/2022.

Based on review of documentation, and an interview with staff, the facility failed to ensure that any child who has been prescribed emergency medication is always in the care of a staff member who meets the Medication Administration Training (MAT) requirements. Evidence: 1) child # 11 went on a field trip with emergency medication but no staff with the child had documentation of current MAT training. Child #14 has prescription Diazepam on site that is required to be administered rectally and no staff on site have the required MAT Rectal Medication Certificate.

Based on review of documentation, the facility failed to obtain documentation of annual approval from the health department. Evidence: the most recent documented health department inspection was dated: 3/10/2023.

Based on review of documentation, and staff interview, the facility failed to maintain a current written list of children's allergies, sensitivities and dietary restrictions in each room or area where children are present. Evidence: the written allergy list did not include child #4, with a diagnosed food allergy, or child #7, with a food sensitivity.

Based on record review, it was determined that not all records contained all required information. Evidence: the records for child #4, child #10 and child #12, with diagnosed food allergies, did not contain a written care plan with instructions from a physician regarding the food to which the child is allergic to and the steps to be taken in the event of a suspected or confirmed allergic reaction.

(Repeat Violation) Based on review of six staff records, it was determined that not all records contained all required information. Evidence: The record for staff #6 did not contain documentation of two reference checks as required.