Inspection · 2023-08-29
Date
2023-08-29
Complaint Related
No
Licensing Inspector
Michelle Argenbright
(540) 848-4123
(540) 848-4123
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 initiated on 08/29/2023 and concluded on 08/29/2023 from 11:00 PM to 2:00 PM. There were 45 children present, ranging in ages from infant to five, with 15 staff. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies. A total of five children?s records and the five staff?s records were reviewed for updates.
Information gathered during the inspection determined noncompliance with applicable standards or law and violations were documented on the violation notice issued to the facility.
Violations
5Standard 8VAC20-770-60-C-2
Based on record review and interview, the center failed to obtain a central registry finding within 30 days of employment for one out of five staff records reviewed.
Evidence:
1. The record for staff 4 documents the start date as 7/5/23. The record did not contain central registry findings.
2. The director verified the center did not have central registry findings for staff 4.
Evidence:
1. The record for staff 4 documents the start date as 7/5/23. The record did not contain central registry findings.
2. The director verified the center did not have central registry findings for staff 4.
Plan of Correction: 1. Director trained Assistant Director on managing staff files; AD will participate in reviewing files/employment spreadsheet upon hiring with Director and support monitoring follow ups;
2. Director will not allow staff to return to work if documentation is incomplete per their responsibility for background checks and all other staff file requirements.
2. Director will not allow staff to return to work if documentation is incomplete per their responsibility for background checks and all other staff file requirements.
Standard 8VAC20-780-140-A
Based on record review and interview, the center failed to obtain documentation of a physical examination within 30 days after the first day of attendance for one out of five children records reviewed.
Evidence:
1. The record for child 1 documents the first day of attendance as 6/19/23. There was no physical examination documentation in the record.
2. The director verified the center did not have documentation of a physical examination for child 1.
Evidence:
1. The record for child 1 documents the first day of attendance as 6/19/23. There was no physical examination documentation in the record.
2. The director verified the center did not have documentation of a physical examination for child 1.
Plan of Correction: 1. Assistant Director to monitor an enrollment spreadsheet for routine follow up on file requirements;
2. Director to routinely review spreadsheet and check in with AD/families with concerns;
3. Director will not allow child to be in attendance if documentation is incomplete per family responsibility for file requirements.
2. Director to routinely review spreadsheet and check in with AD/families with concerns;
3. Director will not allow child to be in attendance if documentation is incomplete per family responsibility for file requirements.
Standard 8VAC20-780-340-D
Based on record review and interview, the center failed to ensure in each grouping of children at least one staff member who meets the qualifications of a program leader or program director is regularly present.
Evidence:
The center was unable to provide documentation that one of the three staff in the infant room met the program lead or program director qualifications in the infant room.
Evidence:
The center was unable to provide documentation that one of the three staff in the infant room met the program lead or program director qualifications in the infant room.
Plan of Correction: 1. Director gained clarification during inspection on how training hours are to be effectively acquired for staff to qualify for program leader;
2. Previously unqualified staff are currently provided training opportunities in the mornings while additional staff are available for classroom coverage, as well as in-person opportunities when available, to meet the requirements accordingly.
2. Previously unqualified staff are currently provided training opportunities in the mornings while additional staff are available for classroom coverage, as well as in-person opportunities when available, to meet the requirements accordingly.
Standard 8VAC20-780-570-E
Based on observation, the center failed to date and label prepared infant formula with the child's name.
Evidence:
In the Waddlers classroom a bottle of prepared infant formula was in the refrigerator that was not dated or labeled with the child's name.
Evidence:
In the Waddlers classroom a bottle of prepared infant formula was in the refrigerator that was not dated or labeled with the child's name.
Plan of Correction: 1. Classroom leads are to check bottles and food for name and date labels upon arrival of child and remind family of labeling policy as needed;
2. Staff are to label when incomplete by family;
3. Assistant director began routine of double checking labels for infant rooms upon arrival at 7:30 AM every day.
2. Staff are to label when incomplete by family;
3. Assistant director began routine of double checking labels for infant rooms upon arrival at 7:30 AM every day.
Standard 8VAC20-780-70
Based on record review and interview, the center failed to keep all the required information for staff records.
Evidence:
1. The record for staff 4 did not have documentation of orientation.
2. Staff records did not have documentation to demonstrate each staff member possessed the education, certification, and experience required by the job position.
3. Staff records did not have documentation of first aid and CPR certification as required by the responsibilities held by the staff member.
Evidence:
1. The record for staff 4 did not have documentation of orientation.
2. Staff records did not have documentation to demonstrate each staff member possessed the education, certification, and experience required by the job position.
3. Staff records did not have documentation of first aid and CPR certification as required by the responsibilities held by the staff member.
Plan of Correction: 1. Director trained Assistant Director on managing staff filed; AD will participate in reviewing files/employment spreadsheet upon hiring with Director and support monitoring follow-ups;
2. Director will not allow staff to return to work if documentation is incomplete per their responsibility for background checks and all other staff file requirements;
3. At 9/16/23 class, First Aid/CPR instructor agreed to provide course documentation directly to Director for file purposes (instead of only to staff class participants).
2. Director will not allow staff to return to work if documentation is incomplete per their responsibility for background checks and all other staff file requirements;
3. At 9/16/23 class, First Aid/CPR instructor agreed to provide course documentation directly to Director for file purposes (instead of only to staff class participants).