Inspection · 2023-01-13
Date
2023-01-13
Complaint Related
No
Licensing Inspector
Lauren Captain
(571) 835-0599
(571) 835-0599
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
8 VAC 20-800 Administration
8 VAC 20-800 Personnel
8 VAC 20-800 Household Members
8 VAC 20-800 Physical Health of Caregivers and Household members
8 VAC 20-800 Caregiver Training
8 VAC 20-800 Physical Equipment and Environment
8 VAC 20-800 Care of Children
8 VAC 20-800 Preventing the Spread of Disease
8 VAC 20-800 Medication Administration
8 VAC 20-800 Emergencies
8 VAC 20-800 Nutrition
8 VAC2 0-820 THE LICENSE
8 VAC 20-770 Background Checks
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
54.1 Provider must be MAT certified to administer prescription medication.
63.2 Child abuse and neglect
Inspector Notes
This monitoring inspection was initiated by licensing staff and concluded on 01/13/2023, between the hours of 9:30 am to 12:30 pm. There were 7 children in care with 1 resident child present (20 points), ranging from infant to preschool-age, with 2 caregivers supervising starting at 9:35 am. 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 children records, 2 household records, and 2 staff records were reviewed.
Information gathered during the inspection determined that there were (13) non-compliances with the applicable standards, code, and/or law. These violations were documented on the Violation Notice issued to the home.
If you should have any questions, please call or send an email to charlie.perkins@doe.virginia.gov. Thank you.
Charlie Perkins,
Licensing Inspector
(703) 309-3963
Violations
13Standard 8VAC20-770-40-D-4-a
Based on review and interview, 1 of 2 household records did not include a search of the central registry (CPS check) within 30 days of a person 18 years of age or older beginning to reside in the home, and a sworn statement or affirmation (SDS) when a person 18 years or older begins residing in the home.
Evidence -
1. On the date of inspection (01/13/2023), a CPS check and a SDS were not available for review for Household Member #1.
2. Based on interview of the Provider, Household Member #1 moved into the home on 10/13/2022.
Evidence -
1. On the date of inspection (01/13/2023), a CPS check and a SDS were not available for review for Household Member #1.
2. Based on interview of the Provider, Household Member #1 moved into the home on 10/13/2022.
Plan of Correction: Household Member has been away since December. Upon their return, a CPS request shall be sent and a SDS completed.
Standard 8VAC20-800-100-A
Based on review, 4 of 10 children files indicated that the Provider did not obtain documentation of a physical examination (by or under the direction of a physician) prior to a child's attendance or within 30 days after the first day of attendance.
Evidence -
1. On the date of inspection (01/13/2023), documentation of a physical examination was not available for review for the following children: Child #1, Child #2, Child #3, and Child #4.
2. Their start dates were listed as - 02/28/2022 for Child #1 and Child #2; 11/07/2022 for Child #3, and 01/13/2022 for Child #4.
Evidence -
1. On the date of inspection (01/13/2023), documentation of a physical examination was not available for review for the following children: Child #1, Child #2, Child #3, and Child #4.
2. Their start dates were listed as - 02/28/2022 for Child #1 and Child #2; 11/07/2022 for Child #3, and 01/13/2022 for Child #4.
Plan of Correction: All missing physicals will be obtained.
Standard 8VAC20-800-120-B
Based on review, 1 of 2 staff files reviewed indicated that not all of the required documentation was on file for both staff.
Evidence -
1. On the date of inspection, 0 of 2 references were on file for Staff #2.
2. The start date for Staff #2 was listed as 03/01/2022.
Evidence -
1. On the date of inspection, 0 of 2 references were on file for Staff #2.
2. The start date for Staff #2 was listed as 03/01/2022.
Plan of Correction: At least 2 references will be placed on file for Staff #2.
Standard 8VAC20-800-170-A
Based on review and interview, 1 of 2 household records indicated that the Provider did not obtain for each adult household member a current Report of Tuberculosis Screening (TB).
Evidence -
1. On the date of inspection (01/13/2023), initial TB documentation for Household Member #1 was not available for review.
2. Based on interview, Household Member #1 moved in to the home on 10/13/2022.
Evidence -
1. On the date of inspection (01/13/2023), initial TB documentation for Household Member #1 was not available for review.
2. Based on interview, Household Member #1 moved in to the home on 10/13/2022.
Plan of Correction: TB documentation will be obtained and placed on file for Household Member #1 upon their return. They have been away since December.
Standard 8VAC20-800-210-A
Based on review, 1 of 2 staff files indicated that a minimum of 16 clock hours of annual training was not obtained.
Evidence -
1. On the date of inspection (01/13/2023) documentation of 16 hours of annual training was not available for review for Staff #1.
2. This finding was confirmed by the Provider on the date of inspection.
Evidence -
1. On the date of inspection (01/13/2023) documentation of 16 hours of annual training was not available for review for Staff #1.
2. This finding was confirmed by the Provider on the date of inspection.
Plan of Correction: A total of 16 hours of annual training will be obtained by all staff.
Standard 8VAC20-800-570-A
Based on observation and interview, the Provider did not ensure that a caregiver did not exceed 16 points within their Family Day Home (FDH).
Evidence -
1. On the date of inspection (01/13/2023), at approximately 9:30 am, upon arrival at the FDH, there were a total of 8 children (7 children in care with 1 resident child) with 1 caregiver.
2. Staff #2 was alone with these children; totaling 20 points until the Provider arrived 5 minutes later.
3. Once the Provider arrived, the Licensing Inspector was let into the home. A count of the number of children and the number of points were tallied at that time.
4. The Provider stated that she needed to take a family member to the doctor.
Evidence -
1. On the date of inspection (01/13/2023), at approximately 9:30 am, upon arrival at the FDH, there were a total of 8 children (7 children in care with 1 resident child) with 1 caregiver.
2. Staff #2 was alone with these children; totaling 20 points until the Provider arrived 5 minutes later.
3. Once the Provider arrived, the Licensing Inspector was let into the home. A count of the number of children and the number of points were tallied at that time.
4. The Provider stated that she needed to take a family member to the doctor.
Plan of Correction: The Family Day Home will comply with the points system of having no more than 16 points for each caregiver.
Standard 8VAC20-800-60-B
Based on review, 8 of 10 children records did not contain all of the required information.
Evidence -
1. On the date of inspection (01/13/2023), the information for each child's medical insurance was not available for: Child #5, Child #6, Child #7, Child #8, and Child #10. While the policy name was listed, the following children did not have the policy number listed: Child #3, Child #4, and Child #9.
2. Parent information was not available for: Child #7.
3. Parent's work information was not available for: Child #7, Child #8, Child #9, and Child #10.
4. The emergency contact information (2 contacts) for each child was not available for: Child #7. While the names, addresses, were listed for each of the two emergency contacts, the following children had 1 of 2 phone numbers listed: Child #8, Child #9, and Child #10.
5. The signed written authorization for emergency medical treatment for each child was not available for review for the following children: Child #7, Child #8, Child #9, and Child #10.
Evidence -
1. On the date of inspection (01/13/2023), the information for each child's medical insurance was not available for: Child #5, Child #6, Child #7, Child #8, and Child #10. While the policy name was listed, the following children did not have the policy number listed: Child #3, Child #4, and Child #9.
2. Parent information was not available for: Child #7.
3. Parent's work information was not available for: Child #7, Child #8, Child #9, and Child #10.
4. The emergency contact information (2 contacts) for each child was not available for: Child #7. While the names, addresses, were listed for each of the two emergency contacts, the following children had 1 of 2 phone numbers listed: Child #8, Child #9, and Child #10.
5. The signed written authorization for emergency medical treatment for each child was not available for review for the following children: Child #7, Child #8, Child #9, and Child #10.
Plan of Correction: All missing information will be obtained.
Standard 8VAC20-800-780-B
Based on review, 4 of 10 children files indicated that the Provider did not review annually with the parent the emergency contact information (as required in 8VAC20-800-60 B 2) to ensure the information is correct and did not obtain the parent's signed acknowledgment of the review.
Evidence -
1. On the date of inspection (01/13/2023), the following children did not have verification of the signed review of each child's emergency contact information: Child #1 (start date - 02/28/2022), Child #2 (start date - 02/28/2022), Child #5 (start date - 01/09/2023), and Child #6 (start date - 01/09/2023).
2. On the above forms of the Child's Record, this section remained blank for these listed children.
Evidence -
1. On the date of inspection (01/13/2023), the following children did not have verification of the signed review of each child's emergency contact information: Child #1 (start date - 02/28/2022), Child #2 (start date - 02/28/2022), Child #5 (start date - 01/09/2023), and Child #6 (start date - 01/09/2023).
2. On the above forms of the Child's Record, this section remained blank for these listed children.
Plan of Correction: The Child's Record for each child will be signed and dated by their parent. This review will be conducted on an annual basis.
Standard 8VAC20-800-80-B
Based on review, written documentation that the proof of identification for each child was verified was not available.
Evidence -
1. On the date of inspection (01/13/2023), written documentation that the proof of identification was verified was not available for the following children: Child #8, Child #9, and Child #10.
2. This finding was confirmed by the Provider on the date of inspection.
Evidence -
1. On the date of inspection (01/13/2023), written documentation that the proof of identification was verified was not available for the following children: Child #8, Child #9, and Child #10.
2. This finding was confirmed by the Provider on the date of inspection.
Plan of Correction: All missing documentation will be obtained. Proof of each child's identity will be verified with written documentation.
Standard 8VAC20-800-800-B
Based on review, the Provider did not review the emergency preparedness and response plan (EP&RP) on an annual basis.
Evidence -
1. The last review documented in writing by the Provider was dated 08/28/2020.
2. This date was observed on the last page of the EP&RP posted on site at the FDH.
Evidence -
1. The last review documented in writing by the Provider was dated 08/28/2020.
2. This date was observed on the last page of the EP&RP posted on site at the FDH.
Plan of Correction: The EP&RP will be updated, signed, and dated.
Standard 8VAC20-800-90-A
Based on review, 1 of 10 children files indicated that the provider did not obtain documentation that each child has been adequately immunized according to the requirements of ? 32.1-46 A of the Code of Virginia and applicable State Board of Health regulations, before a child may attend the Family Day Home (FDH).
Evidence -
1. On the date of inspection (01/13/2023), the following child did not have their immunization record available for review: Child #4.
2. The start date for Child #4 was listed as 01/13/2022.
Evidence -
1. On the date of inspection (01/13/2023), the following child did not have their immunization record available for review: Child #4.
2. The start date for Child #4 was listed as 01/13/2022.
Plan of Correction: All missing immunizations will be obtained and/or updated as required.
Standard 8VAC20-800-90-C
Based on review, 1 of 10 children files indicated that the Family Day Home did not obtain documentation of additional immunizations for children (who were not exempt from the immunization requirements according to subsection B of this section) once every six months for children under the age of two years.
Evidence -
1. On the date of inspection (01/13/2023), an immunization page for Child #5 was dated - 01/31/2022.
2. Based on the information on file, Child #5 was under the age of 2 years on the date of inspection.
Evidence -
1. On the date of inspection (01/13/2023), an immunization page for Child #5 was dated - 01/31/2022.
2. Based on the information on file, Child #5 was under the age of 2 years on the date of inspection.
Plan of Correction: This immunization will be updated.
Standard 8VAC20-820-120-E-1
Based on observation and interview, the most recently issued license was not posted at the Family Day Home (FDH).
Evidence -
1. While on site, it was determined that the current license for the FDH was not posted.
2. The most recent inspection reports were posted.
Evidence -
1. While on site, it was determined that the current license for the FDH was not posted.
2. The most recent inspection reports were posted.
Plan of Correction: The current license will be printed and then posted.