Inspection · 2022-12-15
Date
2022-12-15
Complaint Related
No
Licensing Inspector
Emily Walsh
(757) 404-2575
(757) 404-2575
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.
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
A monitoring inspection was conducted on 12/15/2022. There were 13 children present 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 3 child records and 2 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 were reviewed with the provider during the exit interview.
Violations
7Standard 8VAC20-770-70-A
Based upon review of staff records and staff interview, the facility has not ensured that staff records include all required documentation.
Evidence:
1. The record provided for staff 2, hired on 9/6/2022, did not include documentation that at least two references as to character, reputation and competency of the applicant were checked prior to hire.
2. The tuberculosis screening in the record for staff 2 was not dated.
3. Staff 1 confirmed that the record for staff 2 did not have at least two documented reference checks and that the tuberculosis screening was not dated.
Evidence:
1. The record provided for staff 2, hired on 9/6/2022, did not include documentation that at least two references as to character, reputation and competency of the applicant were checked prior to hire.
2. The tuberculosis screening in the record for staff 2 was not dated.
3. Staff 1 confirmed that the record for staff 2 did not have at least two documented reference checks and that the tuberculosis screening was not dated.
Plan of Correction: The program director discussed plans of correction during the exit interview:
In the future, at least two references as to character, reputation and competency will be obtained prior to hiring any staff.
Documents, such as tuberculosis screenings, will be carefully reviewed to ensure that all required information has been included.
In the future, at least two references as to character, reputation and competency will be obtained prior to hiring any staff.
Documents, such as tuberculosis screenings, will be carefully reviewed to ensure that all required information has been included.
Standard 8VAC20-780-240-I
Based upon review of staff records and staff interview, the facility has not ensured that the documentation of orientation training of new staff includes all required topics and information required.
Evidence:
1. The record provided for staff 2, hired on 9/6/2022, did not include documentation that the required topics and information was reviewed with the staff.
2. Staff 1 acknowledged that the orientation training documentation for staff 2 did not include documentation of all required topics and information.
Evidence:
1. The record provided for staff 2, hired on 9/6/2022, did not include documentation that the required topics and information was reviewed with the staff.
2. Staff 1 acknowledged that the orientation training documentation for staff 2 did not include documentation of all required topics and information.
Plan of Correction: The program director discussed plans of correction during the exit interview:
An orientation training will be held with all staff to ensure that all required information and topics have been reviewed. Documentation of the orientation training will include all required information. The model form will be used to ensure adequate documentation.
An orientation training will be held with all staff to ensure that all required information and topics have been reviewed. Documentation of the orientation training will include all required information. The model form will be used to ensure adequate documentation.
Standard 8VAC20-780-260-A
Based upon review of records and staff interview, the facility has not ensured that there has been an annual fire marshal inspection of the facility.
Evidence:
1. The most recent fire marshal inspection of the facility is dated 9/22/2021.
2. Staff 1 verified that the fire inspector had not been to the facility since September 2021.
Evidence:
1. The most recent fire marshal inspection of the facility is dated 9/22/2021.
2. Staff 1 verified that the fire inspector had not been to the facility since September 2021.
Plan of Correction: The program director discussed plans of correction during the exit interview:
The fire department will be contacted to conduct an inspection. Contact with the fire department will be clearly documented.
The fire department will be contacted to conduct an inspection. Contact with the fire department will be clearly documented.
Standard 8VAC20-780-260-B
Based upon review of records and staff interview, the facility has not ensured that there has been an annual health department inspection of the facility.
Evidence:
1. The most recent health department inspection of the facility is dated 9/29/2021.
2. Staff 1 verified that the health department inspector had not been to the facility since September 2021.
Evidence:
1. The most recent health department inspection of the facility is dated 9/29/2021.
2. Staff 1 verified that the health department inspector had not been to the facility since September 2021.
Plan of Correction: The program director discussed plans of correction during the exit interview:
The health department will be contacted to conduct an inspection. Contact with the health department will be clearly documented.
The health department will be contacted to conduct an inspection. Contact with the health department will be clearly documented.
Standard 8VAC20-780-340-A
Based upon staff interview, the facility has not ensured that when supervising children, staff ensure their care and protection.
Evidence:
Upon arrival of the inspector, staff 4stated that there were a total of 13 children in care. There were actually 12 children in care.
Evidence:
Upon arrival of the inspector, staff 4stated that there were a total of 13 children in care. There were actually 12 children in care.
Plan of Correction: The program director responded with the following:
Staff 4 was nervous due to the inspection and responded without thinking. All staff will be reminded that it is of primary importance that they know how many children are in their care at all times.
Staff 4 was nervous due to the inspection and responded without thinking. All staff will be reminded that it is of primary importance that they know how many children are in their care at all times.
Standard 8VAC20-780-550-G
Based upon staff interview, the facility has not ensured that documentation is maintained that includes all required information pertaining to shelter-in-place and lock-down drills.
Evidence:
Staff 1 stated that they had practiced shelter-in-place drills and lock-down drills throughout the year, but there was no documentation kept of these drills.
Evidence:
Staff 1 stated that they had practiced shelter-in-place drills and lock-down drills throughout the year, but there was no documentation kept of these drills.
Plan of Correction: The program director discussed plans of correction during the exit interview:
At least two shelter-in-place drills and one lock-down drill will be conducted and documented annually. Records will be kept to ensure documentation of compliance.
At least two shelter-in-place drills and one lock-down drill will be conducted and documented annually. Records will be kept to ensure documentation of compliance.
Standard 8VAC20-780-60-A
Based upon review of children's records and staff interview, the facility has not ensured that children's records include the first date of enrollment and the names, addresses and telephone numbers of two persons to be contacted in an emergency when a parent cannot be reached.
Evidence:
1. The record provided for child 3 did not have indicated the first date of attendance. The same record also did not include a telephone number for one of te two listed emergency contact persons.
2. Staff 1 acknowledged the missing information in the record of child 3.
Evidence:
1. The record provided for child 3 did not have indicated the first date of attendance. The same record also did not include a telephone number for one of te two listed emergency contact persons.
2. Staff 1 acknowledged the missing information in the record of child 3.
Plan of Correction: The program director discussed plans of correction during the exit interview:
All children's records will be reviewed to ensure that all required information has been provided in the records.
All children's records will be reviewed to ensure that all required information has been provided in the records.