Inspection · 2022-01-31
Date
2022-01-31
Complaint Related
No
Licensing Inspector
Arlene Agustin
(804) 629-7519
(804) 629-7519
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 (22VAC40-191)
Inspector Notes
A monitoring inspection was initiated on 1/31/2022 and concluded on 2/3/2022. There were 23 children present, ranging in ages from 2 to 5 years, with 4 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of 2 children's records and 5 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
9Standard 8VAC20-780-160-A
Based upon review of five staff records and staff interview, the facility has not ensured that each staff member has submitted documentation of a negative tuberculosis screening.
Evidence:
1. The record provided for staff whose hire date staff 5 identified as "around 1/28/2022" did not include the results of a negative tuberculosis screening
2. Staff 6 verified that results of a tuberculosis screening were not on file for staff 5..
Evidence:
1. The record provided for staff whose hire date staff 5 identified as "around 1/28/2022" did not include the results of a negative tuberculosis screening
2. Staff 6 verified that results of a tuberculosis screening were not on file for staff 5..
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-160-A-1
Based upon review of five staff records and staff interview, the facility has not ensured that each staff member has submitted documentation of a negative tuberculosis screening at the time of employment and before coming into contact with children.
Evidence:
1. The record provided for staff 1 included documentation of a positive tuberculosis screening dated 6/4/2021. Staff 1 has been on duty with the children since May 2021 and was on duty with the children during today's inspection.
2. The record provided for staff whose hire date staff 6 identified as "around 1/28/2022" did not include the results of a negative tuberculosis screening. Staff 5 was on duty with the children during today's inspection.
3. Staff 6 verified the above documentation and that staff 1 and 5 have been on duty with the children.
Evidence:
1. The record provided for staff 1 included documentation of a positive tuberculosis screening dated 6/4/2021. Staff 1 has been on duty with the children since May 2021 and was on duty with the children during today's inspection.
2. The record provided for staff whose hire date staff 6 identified as "around 1/28/2022" did not include the results of a negative tuberculosis screening. Staff 5 was on duty with the children during today's inspection.
3. Staff 6 verified the above documentation and that staff 1 and 5 have been on duty with the children.
Plan of Correction: The facility responded with the following:
Staff will be required to bring detailed description of screenings. The staff has never had a positive screening. She has allergic reactions from PPDs which gives false negatives and has to take chest X-Rays which was documented in her record. The staff is negative.
Staff will be required to bring detailed description of screenings. The staff has never had a positive screening. She has allergic reactions from PPDs which gives false negatives and has to take chest X-Rays which was documented in her record. The staff is negative.
Standard 8VAC20-780-160-A-2
Based upon review of five staff records and staff interview, the facility has not ensured that documentation of a tuberculosis screening was completed within the last 30 calendar days of the date of employment.
Evidence:
1. The record provided for staff 2 indicated a hire date of 1/4/2022. The tuberculosis screening on file is dated 10/13/2021.
2. Staff 6 stated that the re-hire date for staff 3 was "round about 1/15/2022". The tuberculosis screening on file is dated 4/15/2021.
3. The record provided for staff 4 indicated a hire date of 1/10/2022. The tuberculosis screening on file is dated 10/4/2021.
4. Staff 6 verified that the timing of tuberculosis screenings above were not within 30 calendar days prior to the staff dates of employment.
Evidence:
1. The record provided for staff 2 indicated a hire date of 1/4/2022. The tuberculosis screening on file is dated 10/13/2021.
2. Staff 6 stated that the re-hire date for staff 3 was "round about 1/15/2022". The tuberculosis screening on file is dated 4/15/2021.
3. The record provided for staff 4 indicated a hire date of 1/10/2022. The tuberculosis screening on file is dated 10/4/2021.
4. Staff 6 verified that the timing of tuberculosis screenings above were not within 30 calendar days prior to the staff dates of employment.
Plan of Correction: The facility responded with the following:
Director will ensure that applicants submit TB screening documentation prior to the hire date.
Director will ensure that applicants submit TB screening documentation prior to the hire date.
Standard 8VAC20-780-240-A
Based upon review of staff records and staff interview, the facility has not ensured that the Virginia Department of Education-sponsored orientation course has been completed within 90 calendar days of employment.
1. Staff 1 was hired in May 2021 and has not completed the required orientation (preservice training) course.
2. Staff 6 verified that staff 1 has not completed the required orientation (preservice training) course.
1. Staff 1 was hired in May 2021 and has not completed the required orientation (preservice training) course.
2. Staff 6 verified that staff 1 has not completed the required orientation (preservice training) course.
Plan of Correction: The facility responded with the following:
Staff will be responsible for completing required courses in the assigned time frame. Due to staffing issues and ensuring ratio, there has been no available time to provide employees with on the job assistance. Staff will be monitored and provided with reminders and deadlines.
Staff will be responsible for completing required courses in the assigned time frame. Due to staffing issues and ensuring ratio, there has been no available time to provide employees with on the job assistance. Staff will be monitored and provided with reminders and deadlines.
Standard 8VAC20-780-270-A
Based upon observation and staff interview, the facility has not ensured that outside areas are maintained to be safe.
Evidence:
1. The fenced outdoor play area was covered with many small pieces (approx: 1' x 1') of blue hard plastic and numerous cigarette butts.
2. Staff 7 acknowledged the presence of the litter and stated that the staff had not cleaned off the playground.
Evidence:
1. The fenced outdoor play area was covered with many small pieces (approx: 1' x 1') of blue hard plastic and numerous cigarette butts.
2. Staff 7 acknowledged the presence of the litter and stated that the staff had not cleaned off the playground.
Plan of Correction: The facility responded with the following:
The resident who resides above the center has been asked on numerous occasions to stop littering on the play area with cigarettes and debris. There has been inclement weather from the snow and below freezing temperatures at which the children do not go outside. Also, due to staffing issues, staff would be out of ratio to go outside to clean the play area. The play area is cleaned every weekend and filled with new mulch. Staff have rotating shifts to go out to the play area to clean during nap time everyday. The play area was due to be cleaned at 1:30pm, once the water dried up from the inclement weather.
The resident who resides above the center has been asked on numerous occasions to stop littering on the play area with cigarettes and debris. There has been inclement weather from the snow and below freezing temperatures at which the children do not go outside. Also, due to staffing issues, staff would be out of ratio to go outside to clean the play area. The play area is cleaned every weekend and filled with new mulch. Staff have rotating shifts to go out to the play area to clean during nap time everyday. The play area was due to be cleaned at 1:30pm, once the water dried up from the inclement weather.
Standard 8VAC20-780-280-B
Based upon observation and staff interview, the facility has not ensured that hazardous substances are kept in a locked place using a safe locking method that prevents access by children.
Evidence:
1. The door to the janitorial closet in classroom D was not locked. There were several gallons of bleach, Ajax, hand sanitizer and rto sanitzer, all with warning labels stored on the floor of the closet.
2. Staff 7 acknowledged that the closet door was not locked.
3. The children's bathrooms are equipped with Dermasil hand soap. The soap is labeled "caution, avoid getting into eyes".
Evidence:
1. The door to the janitorial closet in classroom D was not locked. There were several gallons of bleach, Ajax, hand sanitizer and rto sanitzer, all with warning labels stored on the floor of the closet.
2. Staff 7 acknowledged that the closet door was not locked.
3. The children's bathrooms are equipped with Dermasil hand soap. The soap is labeled "caution, avoid getting into eyes".
Plan of Correction: The facility responded with the following:
Staff will be re-trained on policies and procedures for ensuring all doors are locked that contain hazardous materials. Staff who violate policies and procedures of not ensuring doors are secured will be terminated.
Dermasil: there was no label on the back of the Dermasil located in the bathroom. Staff will ensure only "Soft Soap" containers are located in the restrooms.
Staff will be re-trained on policies and procedures for ensuring all doors are locked that contain hazardous materials. Staff who violate policies and procedures of not ensuring doors are secured will be terminated.
Dermasil: there was no label on the back of the Dermasil located in the bathroom. Staff will ensure only "Soft Soap" containers are located in the restrooms.
Standard 8VAC20-780-500-B
Based upon observation and staff interview, the facility has not ensured that the diaper changing area is equipped with a leakproof or plastic-lined storage system that is either foot-operated or used in such a way that neither the staff member's hand nor the soiled diaper touches an exterior surface of the storage system during disposal.
Evidence:
1. The diaper disposal can by the changing table in the back bathroom was not equipped with a lid.
2. Staff 7 acknowledged that there was no lid on the diaper disposal can.
Evidence:
1. The diaper disposal can by the changing table in the back bathroom was not equipped with a lid.
2. Staff 7 acknowledged that there was no lid on the diaper disposal can.
Plan of Correction: The facility responded with the following:
Staff are required to deep clean the trash can after each pull as a COVID measure. The lid was located. A staff member left the lid soaking in the sanitizer. Staff will be reminded to ensure the lid is placed back on the trash can everyday after each trash pull.
Staff are required to deep clean the trash can after each pull as a COVID measure. The lid was located. A staff member left the lid soaking in the sanitizer. Staff will be reminded to ensure the lid is placed back on the trash can everyday after each trash pull.
Standard 8VAC20-780-60-A
Based upon review of children's records and staff interview, the facility has not ensured that each child's record includes the name, street address and telephone number of two persons to be contacted in an emergency when a parent cannot be reached.
Evidence:
1. The record provided for child 2 did not include the complete street address for one of the two emergency contact persons.
2. Staff 6 verified that the street address for one emergency contact was not in the record for child 2.
Evidence:
1. The record provided for child 2 did not include the complete street address for one of the two emergency contact persons.
2. Staff 6 verified that the street address for one emergency contact was not in the record for child 2.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-70
Based upon review of five staff records and staff interview, the facility has not ensured that each staff record contains all required information/documentation.
Evidence:
1. The record provided for staff 3 did not include documentation of a re-hire date.
2. The record provided for staff 5 did not include the hire date.
3. None of the five staff records provided included the address of the emergency contact person.
4. Staff 6 verified the above missing documentation.
Evidence:
1. The record provided for staff 3 did not include documentation of a re-hire date.
2. The record provided for staff 5 did not include the hire date.
3. None of the five staff records provided included the address of the emergency contact person.
4. Staff 6 verified the above missing documentation.
Plan of Correction: The facility responded with the following:
Director will ensure staff provided emergency contact address information and document the information in the staff record. Staff hire dates will be documented with fidelity.
Director will ensure staff provided emergency contact address information and document the information in the staff record. Staff hire dates will be documented with fidelity.