Inspection · 2024-09-10
Date
2024-09-10
Complaint Related
No
Licensing Inspector
Christina Jones
(540) 340-2672
(540) 340-2672
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.
8VAC20-770 Background Checks (8VAC20-770)
22.1 Background Checks Code, Carbon Monoxide
Inspector Notes
An unannounced, on-site focused inspection was conducted on 9/10/2024 as a part of the provisional licensure period. The on-site inspection began at 12:00 noon and ended at 2:30 pm. The inspector reviewed compliance in the areas listed above. There were 18 staff present. The inspector reviewed 9 children?s records and 9 staff records on-site on 9/10/2024. This inspection included document review and interviews. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations are 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 five (5) business days from today, which will be the close of business on 9/26/2024. A POC submitted after this date will not appear on the public website.
Violations
8Standard 22.1-289.035-B-3
The center must request a search of the central registry prior to the employee's first day of employment.
Staff #6, who has been employed for 1 month, did not have a central registry search requested. Staff #8 was employed for one day before a central registry search request was made.
Staff #6, who has been employed for 1 month, did not have a central registry search requested. Staff #8 was employed for one day before a central registry search request was made.
Plan of Correction: We have revised our on-boarding process for new hires. All paperwork will be completed, appointments scheduled, and central registry sent out prior to new hires start date.
Standard 22.1-289.035-B-4
The center is required to obtain background checks from any state in which the individual has resided in the preceding five years.
Staff #7, employed for one year, did not have documentation of requesting a central registry check or criminal history check from a different state. Staff #8, employed for one month, did not have documentation of requesting a central registry check from a different state.
Staff #7, employed for one year, did not have documentation of requesting a central registry check or criminal history check from a different state. Staff #8, employed for one month, did not have documentation of requesting a central registry check from a different state.
Plan of Correction: New staff file cover sheet has been created along with on-boarding process. Out of state central registry and criminal history check will be requested prior to new hires start date.
Standard 8VAC20-780-160-A
(Repeat Violation) (Systemic) Documentation of a negative tuberculosis (TB) screening must be submitted at the time of employment, before coming into contact with children, and shall have been completed within the last 30 days of the date of employment.
The screening for staff #5 was completed nine months prior to hire; staff #7 had no documentation of screening and had been employed for one year; and staff #9 had no documentation of screening and had been employed for over five years.
The screening for staff #5 was completed nine months prior to hire; staff #7 had no documentation of screening and had been employed for one year; and staff #9 had no documentation of screening and had been employed for over five years.
Plan of Correction: The within 30 days requirement will be implemented and enforced during the on-boarding process.
A monthly staff file review will be conducted, and 30-day notifications will go out to staff with expiring training, background checks, and medical screenings.
A monthly staff file review will be conducted, and 30-day notifications will go out to staff with expiring training, background checks, and medical screenings.
Standard 8VAC20-780-160-C
(Repeat Violation) (Systemic) A tuberculosis (TB) screening is required every two years from the last screening.
The updated screening for staff #3 was due 4 months ago.
The updated screening for staff #3 was due 4 months ago.
Plan of Correction: A monthly staff file review will be conducted, and 30-day notifications will go out to staff with expiring training, background checks, and medical screenings.
Standard 8VAC20-780-240-A
Staff are to complete the VDOE sponsored online orientation course within 90 days of hire.
Staff #5, who is working with children, has not yet completed this course which is overdue by 10 months. Staff #7, who is working with children, has not yet completed this course which is overdue by 9 months.
Staff #5, who is working with children, has not yet completed this course which is overdue by 10 months. Staff #7, who is working with children, has not yet completed this course which is overdue by 9 months.
Plan of Correction: The VA Preservice Training for childcare staff will be completed during the on- boarding process.
Standard 8VAC20-780-240-B
Staff shall complete orientation training prior to working alone with children and no later than 7 days of hire.
Staff #6, who has been working for 1 month, staff #7, who has been working for 1 year, and staff #8, who has been working for 1 month, did not have evidence they have received orientation training.
Staff #6, who has been working for 1 month, staff #7, who has been working for 1 year, and staff #8, who has been working for 1 month, did not have evidence they have received orientation training.
Plan of Correction: We have implemented VDOE orientation training into the on-boarding process.
New hires will receive training within 7 days after their start date.
New hires will receive training within 7 days after their start date.
Standard 8VAC20-780-60-A
(Systemic) Children's records are required to contain the name, address and phone number of two designated people to call in an emergency if a parent cannot be reached.
The records for child #1, attending for 2 years, child #3, attending for 1 day, child #6, attending for 1 month, and child #9, attending for 1 month were missing complete information for two emergency contacts.
The records for child #1, attending for 2 years, child #3, attending for 1 day, child #6, attending for 1 month, and child #9, attending for 1 month were missing complete information for two emergency contacts.
Plan of Correction: Looking at options on how to revise our application to ensure all required information is captured.
Standard 8VAC20-780-70
(Repeat Violation) (Systemic) Documentation of at least 2 references to character, reputation, and competency are to be checked prior to employment.
Staff #4, who has been actively working at the center for the past 4 months, and staff # 8, who has been actively working for 1 month, did not have any completed reference verifications on file; staff #5, who has been actively working at the center for 1 month, only had one completed reference.
Staff #4, who has been actively working at the center for the past 4 months, and staff # 8, who has been actively working for 1 month, did not have any completed reference verifications on file; staff #5, who has been actively working at the center for 1 month, only had one completed reference.
Plan of Correction: Reference checks will be provided prior to start date.