Inspection · 2022-05-09
Date
2022-05-09
Complaint Related
No
Licensing Inspector
Michele Patchett
(757) 439-6816
(757) 439-6816
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.
Yes
Areas Reviewed
22VAC40-665 INTRODUCTION
22VAC40-665 ADMINISTRATION
22VAC40-665 STAFF QUALIFICATIONS & TRAINING
22VAC40-665 PHYSICAL PLANT
22VAC40-665 STAFFING & SUPERVISION
22VAC40-665 PROGAMS
22VAC40-665 SPECIAL CARE PROVISIONS & EMERGENCIES
22VAC40-665 SPECIAL SERVICES
Inspector Notes
A subsidy health and safety (SHSI) inspection was initiated and concluded on 5/9/2022. There were 49 children present with 8 staff supervising. A licensing inspection was also conducted on this date. Both inspections combined cover subsidy health and safety regulations. Only subsidy requirements that are not covered in licensing standards were reviewed during this supplemental inspection.
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
4Standard 22VAC40-665-520-B
Based on a review of records and interview, the vendor did not ensure that each enrolled child's record contains all of the required information.
Evidence:
Five children's records were reviewed.
The record for child #1 did not have an address for either of the two required emergency contacts to be contacted in an emergency if the parents can not be reached.
The record for child #2 did not contain an address for one of the two required emergency contacts to be contacted in an emergency if the parents can not be reached.
The program director stated that she did not have documentation of this information available at the time of inspection.
Evidence:
Five children's records were reviewed.
The record for child #1 did not have an address for either of the two required emergency contacts to be contacted in an emergency if the parents can not be reached.
The record for child #2 did not contain an address for one of the two required emergency contacts to be contacted in an emergency if the parents can not be reached.
The program director stated that she did not have documentation of this information available at the time of inspection.
Plan of Correction: The program director stated that she will obtain an address for both emergency contacts for child #1 and for the second emergency contact for child #2 within 10 days of the inspection on 5/9/2022.
Enrollment forms will be reviewed at the time of enrollment for all required information before the child attends the program.
Enrollment forms will be reviewed at the time of enrollment for all required information before the child attends the program.
Standard 22VAC40-665-540-B
Based on a review of records and interview, the vendor did not ensure that each staff person obtains a subsequent Tuberculosis (TB) screening within 2 years of the last documented TB screening results.
Evidence:
Five staff records were reviewed.
The record for staff #3 contained results of a TB screening which was dated 10/23/2017. Documentation of a subsequent TB screening was not available.
The program Director stated that more recent TB screening results were not available at the time of inspection.
Evidence:
Five staff records were reviewed.
The record for staff #3 contained results of a TB screening which was dated 10/23/2017. Documentation of a subsequent TB screening was not available.
The program Director stated that more recent TB screening results were not available at the time of inspection.
Plan of Correction: The program director stated that a more recent screening had been conducted but that she was unable to locate documentation of the results of the screening. Staff #3 will be asked to obtain documentation of the screening results or will be asked to obtain a new screening if she is unable to obtain the results of the last screening within 30 days of the inspection which was conducted on 5/9/2022.
Standard 22VAC40-665-580-D
Based on a review of records and interview, the vendor was unable to demonstrate that each staff member received, prior to the staff member working alone with children and within seven days of the date of employment, an orientation training of facility specific topics to include playground safety procedures, responsibilities for reporting suspected child abuse or neglect, confidentiality, Supervision of children, procedures for action in the case of lost or missing children, ill or injured children, medical and general emergencies, medication administration, the written emergency preparedness plan, prevention of shaken baby syndrome, prevention of sudden infant death syndrome, preventing exposure to foods to which the child is allergic, preventing cross contamination, and recognizing and responding to any allergic reactions and transportation policies.
Evidence:
Five staff records were reviewed.
The records for staff #1 (hired 2/21/2022), #2 (hired 2/10/2022) #3 (hired 9/7/2017), #4 (hired 3/15/2022) and #5 (hired 2/10/2020) did not contain documentation of a program specific orientation documentation prior to the staff member working alone with children and within seven days of the date of employment
The Program Director was unable to provide, during the inspection, documentation that a program specific orientation was conducted which included all of the required topics.
Evidence:
Five staff records were reviewed.
The records for staff #1 (hired 2/21/2022), #2 (hired 2/10/2022) #3 (hired 9/7/2017), #4 (hired 3/15/2022) and #5 (hired 2/10/2020) did not contain documentation of a program specific orientation documentation prior to the staff member working alone with children and within seven days of the date of employment
The Program Director was unable to provide, during the inspection, documentation that a program specific orientation was conducted which included all of the required topics.
Plan of Correction: The program director stated that many of these topics were covered during various trainings of new staff but did that she did not not have documentation that each topic was covered at the time of hire.
The Program director will review these topics with all staff and document the orientation training in each staff record within 30 days of the inspection which was conducted 5/9/2022.
New staff will be oriented to these policies and procedures at the time of hire and documentation will be placed in the staff record showing that the required topics were reviewed before the staff member works alone with children and within seven days of the date of employment .
The Program director will review these topics with all staff and document the orientation training in each staff record within 30 days of the inspection which was conducted 5/9/2022.
New staff will be oriented to these policies and procedures at the time of hire and documentation will be placed in the staff record showing that the required topics were reviewed before the staff member works alone with children and within seven days of the date of employment .
Standard 22VAC40-665-580-H
Based on a review of records and interview, the vendor was unable to demonstrate that each staff person who works directly with children, in addition to preservice and orientation training required in subsections A through D of this section, obtains, at least 16 hours of training and staff development activities annually, to include the department's health and safety update course. The training shall be related to child safety, child development, the function of the center, and any required department sponsored training.
Evidence:
Five staff records were reviewed.
Four of the five staff whose records were reviewed work directly with the children.
Only staff #3 had been working at the center for a year or longer.
The record for staff #3 contained only 6 of the 16 required annual training required within the past 12 month period.
Evidence:
Five staff records were reviewed.
Four of the five staff whose records were reviewed work directly with the children.
Only staff #3 had been working at the center for a year or longer.
The record for staff #3 contained only 6 of the 16 required annual training required within the past 12 month period.
Plan of Correction: The program director will remind staff of the requirement for 16 hours of training annually and will devise a system for collecting and documenting staff training hours.