Inspection · 2022-06-01
Date
2022-06-01
Complaint Related
No
Licensing Inspector
Stephanie Reed
(540) 272-6558
(540) 272-6558
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 (8VAC20-770)
22.1 Background Checks Code, Carbon Monoxide
Inspector Notes
A monitoring inspection was conducted on June 1, 2022 from 10:15 A.M.-3:45 P.M. There were 180 children present, ranging in ages from five months to five years of age, with 32 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 10 child records and 13 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.
If you have any questions or concerns please contact the Licensing Inspector at 540-430-9257.
Violations
11Standard 22.1-289.035-B-4
Based on review of staff records, the center failed to ensure that all required out-of-state criminal history background checks were completed prior to date of hire.
Evidence:
1. Staff #10 indicated on a sworn disclosure statement dated 05/23/2022 that they had resided in one other state outside of Virginia within the last five years. There was not a completed out-of-state criminal history background check on file for Staff #10 prior to the date of hire. Date of hire for Staff #10 was 05/23/2022. Staff #10 was observed working in a classroom with a group of children on 06/01/2022.
2. Staff #13 indicated on a sworn disclosure statement dated 05/24/2022 that they had resided in one other state outside of Virginia within the last five years. There was not a completed out-of-state criminal history background check on file for Staff #13 prior to the date of hire. Date of hire for Staff #13 was 05/24/2022. Staff #13 was observed working in a classroom with a group of children on 06/01/2022.
3. Administration verified the date of hire for Staff #10 and Staff #13, and that the out-of-state background checks had not been completed.
Evidence:
1. Staff #10 indicated on a sworn disclosure statement dated 05/23/2022 that they had resided in one other state outside of Virginia within the last five years. There was not a completed out-of-state criminal history background check on file for Staff #10 prior to the date of hire. Date of hire for Staff #10 was 05/23/2022. Staff #10 was observed working in a classroom with a group of children on 06/01/2022.
2. Staff #13 indicated on a sworn disclosure statement dated 05/24/2022 that they had resided in one other state outside of Virginia within the last five years. There was not a completed out-of-state criminal history background check on file for Staff #13 prior to the date of hire. Date of hire for Staff #13 was 05/24/2022. Staff #13 was observed working in a classroom with a group of children on 06/01/2022.
3. Administration verified the date of hire for Staff #10 and Staff #13, and that the out-of-state background checks had not been completed.
Plan of Correction: Administration will ensure that all out-of-state and out-of-state criminal history background checks for non-NFF states are received prior to new hire?s start date.
Within 10 business days administration will send to the Licensing Inspector evidence that the out of state background checks have been completed or requested.
Within 10 business days administration will send to the Licensing Inspector evidence that the out of state background checks have been completed or requested.
Standard 8VAC20-780-160-C
Based on review of staff files, the center failed to ensure that an updated tuberculosis screening was completed every two years.
Evidence:
1. Staff #7?s last documented tuberculosis test/screening was dated 01/29/2020. A new one was required by 01/29/2022.
2. Staff #8?s last documented tuberculosis test/screening was dated 10/13/20219. A new one was required by 10/13/2021.
3. Staff #9?s last documented tuberculosis test/screening was dated 12/9/2019. A new one was required by 12/09/21.
4. Staff verified that updated tuberculosis test/screening had not be completed by the three staff members.
Evidence:
1. Staff #7?s last documented tuberculosis test/screening was dated 01/29/2020. A new one was required by 01/29/2022.
2. Staff #8?s last documented tuberculosis test/screening was dated 10/13/20219. A new one was required by 10/13/2021.
3. Staff #9?s last documented tuberculosis test/screening was dated 12/9/2019. A new one was required by 12/09/21.
4. Staff verified that updated tuberculosis test/screening had not be completed by the three staff members.
Plan of Correction: Administration will ensure tuberculosis test/screening are updated every two years. Administration will utilize an updated tracking system to ensure expiration dates are not missed.
Standard 8VAC20-780-280-B
Based on observation, the center failed to ensure that all hazardous materials were kept in a locked location.
Evidence:
In Classroom #5 there was a container of Glad Air Freshener in the cabinet next to the children?s handwashing sink. The cabinet was not locked and accessible to children. The manufacturer?s label stated to ?keep out of reach of children and pets?.
Evidence:
In Classroom #5 there was a container of Glad Air Freshener in the cabinet next to the children?s handwashing sink. The cabinet was not locked and accessible to children. The manufacturer?s label stated to ?keep out of reach of children and pets?.
Plan of Correction: Administration has retrained staff on the centers policy regarding personal belongings to ensure that all hazardous materials are kept in a locked location.
Standard 8VAC20-780-380-A
Based on observation, the center failed to ensure that a daily classroom schedule was posted in two classrooms.
Evidence:
1. In Classroom #1 and Classroom #4 there was not a daily classroom schedule posted.
2. Staff verified that the classroom schedules were not posted.
Evidence:
1. In Classroom #1 and Classroom #4 there was not a daily classroom schedule posted.
2. Staff verified that the classroom schedules were not posted.
Plan of Correction: Administration has re-posted and provided center staff additional and laminated copies of their daily schedules.
Standard 8VAC20-780-40-E
Based on observation, and interviews, the licensee did not ensure that the center?s services and facilities are maintained within the terms of the current license issued by the department.
Evidence:
1. The census of children in care on June 1, 2022 was 180 children. The licensed capacity on the current license is 163 children.
2. Administration verified the census count, and the capacity number that is on the current license.
Evidence:
1. The census of children in care on June 1, 2022 was 180 children. The licensed capacity on the current license is 163 children.
2. Administration verified the census count, and the capacity number that is on the current license.
Plan of Correction: The center is monitoring total occupancy to ensure that the numbers are within the permit guidelines. Administration recognized on the original plans that two classrooms were not considered in the occupancy calculations. New plans have been submitted to Frederick County and administration is working directly with building and development to increase current occupancy permit
Standard 8VAC20-780-430-I
Based on observation, the center failed to ensure that all personal articles were labeled with the child?s name.
Evidence:
1. In Classroom #2 there was one water cup not labeled with the child?s name.
2. In Classroom #6 there were three water bottles that were not labeled with the child?s name.
3. Staff verified that the cups were labeled with the classroom, but not the child that is was assigned to for the day.
Evidence:
1. In Classroom #2 there was one water cup not labeled with the child?s name.
2. In Classroom #6 there were three water bottles that were not labeled with the child?s name.
3. Staff verified that the cups were labeled with the classroom, but not the child that is was assigned to for the day.
Plan of Correction: Administration has retrained staff on the centers policy regarding personal belongings to ensure that all items are properly labeled with the child?s name.
Standard 8VAC20-780-500-A
Based on observation, the center failed to ensure that children?s hands were washed at all the required times.
Evidence:
1. In Classroom #1 the children did not wash their hands before eating lunch. The children washed their hands and then went back to the group activity on the rug. Child were observed touching other children, the floor, and materials. Children did not re-wash their hands before sitting down at the table to eat lunch.
2. In Classroom #1 a child did not wash their hands after diapering. The child was removed from the changing table and went directly to the table to eat lunch.
Evidence:
1. In Classroom #1 the children did not wash their hands before eating lunch. The children washed their hands and then went back to the group activity on the rug. Child were observed touching other children, the floor, and materials. Children did not re-wash their hands before sitting down at the table to eat lunch.
2. In Classroom #1 a child did not wash their hands after diapering. The child was removed from the changing table and went directly to the table to eat lunch.
Plan of Correction: Administration has retrained center staff on proper handwashing and diaper changing procedures. Administration will utilize an updated health and safety checks to help ensure handwashing and diaper changing procedures are followed daily. Administration has also provided staff updated handwashing and diaper changing procedures.
Standard 8VAC20-780-500-B
8VAC20-780-500-B
Based on observation, the center failed to ensure that proper diapering procedures were followed.
Evidence:
1. In Classroom #2 the diaper changing table was being used as a catch all and had toys, and binders setting on top of the changing table.
2. In Classroom #7 there was laundry and toys on top of the changing table.
3. In Classroom #1 the diapering surface was not cleaned or sanitized in between children being changed.
4. In Classroom #4, staff did not allow the sanitizing agent to air dry for at least two minutes before it was wiped off the mat.
Based on observation, the center failed to ensure that proper diapering procedures were followed.
Evidence:
1. In Classroom #2 the diaper changing table was being used as a catch all and had toys, and binders setting on top of the changing table.
2. In Classroom #7 there was laundry and toys on top of the changing table.
3. In Classroom #1 the diapering surface was not cleaned or sanitized in between children being changed.
4. In Classroom #4, staff did not allow the sanitizing agent to air dry for at least two minutes before it was wiped off the mat.
Plan of Correction: Administration has retrained center staff on proper diaper changing and cleaning and sanitizing procedures. Administration will utilize an updated health and safety check to help ensure diaper changing and cleaning and sanitizing procedures are followed daily. Administration has also provided staff updated diaper changing and cleaning and sanitizing procedures and what is appropriate to be on the diaper changing area.
Standard 8VAC20-780-510-B
Based on review of medications, the center failed to ensure that that non-prescription medication was given according the medication policies.
Evidence:
1. The medication policy states, ?A physician must also authorize the dispensing of any medication contrary to the package directions.?
2. Child 4M, (age 17 months), had a non-prescription medication that stated on the manufacturer?s directions under the age of 2 to consult a doctor. There was no authorization form on file signed by a physician.
3. Child 4M was administered 5ml of the medication on May 27, 2022.
Evidence:
1. The medication policy states, ?A physician must also authorize the dispensing of any medication contrary to the package directions.?
2. Child 4M, (age 17 months), had a non-prescription medication that stated on the manufacturer?s directions under the age of 2 to consult a doctor. There was no authorization form on file signed by a physician.
3. Child 4M was administered 5ml of the medication on May 27, 2022.
Plan of Correction: Administration has retrained all MAT trained staff on the center?s medication policy to ensure that medication is given accordingly. Parents have also been updated on the medication policy to ensure that 10-day forms are completed with physicians? consent for non-prescription medication that states under the age of 2 to consult a doctor.
Standard 8VAC20-780-520-A
Based on review of non-prescription medication and over the counter the counter skin products, the center failed to ensure that products were not kept beyond the expiration date.
Evidence:
1. In Classroom #1 there was a container of Aquaphor Ointment that expired in May 2021, and a container of Butt Paste that expired in May 2022.
2. In Classroom #3 there was a bottle of Green Butt Creme that expired in April 2022.
3. In Classroom #4 there was a jar of Destin that had expired in March 2022.
4. In Classroom #5 there was bottle of sunscreen in the cabinet that had expired in April 2022.
5. Child 2M had bottle of non-prescription medication that expired in September 2021.
Evidence:
1. In Classroom #1 there was a container of Aquaphor Ointment that expired in May 2021, and a container of Butt Paste that expired in May 2022.
2. In Classroom #3 there was a bottle of Green Butt Creme that expired in April 2022.
3. In Classroom #4 there was a jar of Destin that had expired in March 2022.
4. In Classroom #5 there was bottle of sunscreen in the cabinet that had expired in April 2022.
5. Child 2M had bottle of non-prescription medication that expired in September 2021.
Plan of Correction: Administration has retrained center staff on the centers policy regarding non-prescription and over the counter skin products to ensure that products are not kept beyond their expiration date.
Standard 8VAC20-780-70
Based on review of staff files, the center failed to ensure reference checks were completed prior to employment.
Evidence:
1.Staff #12?s date of employment was 05/06/2022. There were no references on file for Staff #12.
2. Staff verified that there were no references on file for Staff #12.
Evidence:
1.Staff #12?s date of employment was 05/06/2022. There were no references on file for Staff #12.
2. Staff verified that there were no references on file for Staff #12.
Plan of Correction: Administration was unable to locate the completed reference checks. Administration will ensure that all reference checks are completed and added to new hire?s file, prior to their start date.