Inspection · 2023-07-07
Date
2023-07-07
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 20-820 THE LICENSING PROCESS
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 renewal inspection was initiated by licensing staff and concluded on 07/07/2023, between the hours of 9:30 am to 12:30 pm. There were 7 children present (18 points), ranging from infant to preschool-age, with 2 caregivers 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 11 children records, 2 staff records, and 2 household records were reviewed.
Information gathered during the inspection determined that there were (11) 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
11Standard 22.1-289.035-B-2
Based on review, 1 of 2 staff files indicated that the licensed family day home (FDH) did not have a correct fingerprinting check (FPC) on file.
Evidence -
1. On the date of inspection (07/07/2023), a FPC for Staff #2 did not identify with the current address of the FDH.
2. This FPC was dated - 06/05/2023
Evidence -
1. On the date of inspection (07/07/2023), a FPC for Staff #2 did not identify with the current address of the FDH.
2. This FPC was dated - 06/05/2023
Plan of Correction: The Provider will look into doing portability for Staff #2. Once obtained, the finding will be placed on file.
Standard 22.1-289.036-B-2
Based on review, 2 of 2 household records indicated that the licensed family day home (FDH) did not have a correct fingerprinting check (FPC) on file.
Evidence -
1. On the date of inspection (07/07/2023), a FPCs for both Household Member #1, and Household Member #2 did not identify with the current address of the FDH.
2. This FPC for HM #1 was dated - 12/14/2022, and the FPC for HM #2 was dated - 05/23/2023.
Evidence -
1. On the date of inspection (07/07/2023), a FPCs for both Household Member #1, and Household Member #2 did not identify with the current address of the FDH.
2. This FPC for HM #1 was dated - 12/14/2022, and the FPC for HM #2 was dated - 05/23/2023.
Plan of Correction: New fingerprint checks will be conducted for HM #1 and HM#2. The findings will be placed on file once they are obtained.
Standard 8VAC20-770-40-D-4-a
Based on review, 1 of 2 staff files, and 2 of 2 household records indicated that all of the required background checks were not available for review.
Evidence -
1. On the date of inspection 07/07/2023) a sworn statement or affirmation (SDS) was not available for review for Household Member #1, and Household Member #2. Both have moved into the home since the last inspection.
2. A search of the central registry (CPS) for Household Member #1 was not available for review.
Evidence -
1. On the date of inspection 07/07/2023) a sworn statement or affirmation (SDS) was not available for review for Household Member #1, and Household Member #2. Both have moved into the home since the last inspection.
2. A search of the central registry (CPS) for Household Member #1 was not available for review.
Plan of Correction: New SDS will be completed and placed on file for both new household members. A request of the central registry will be sent out within 10 days for HM #1. Once this finding is obtained it will be shared with the Licensing Inspector (LI).
Standard 8VAC20-770-60-B
Based on review and interview, 1 of 2 staff files indicated that an employee of a family day home (FDH) was employed prior to the FDH having the person's completed sworn statement or affirmation (SDS).
Evidence -
1. On the date of inspection (07/07/2023), the SDS of Staff #2 was signed and dated - 06/03/2023.
2. The Provider stated (during an interview conducted on the date of inspection) and documented that the start date for Staff #2 was 03/04/2023.
Evidence -
1. On the date of inspection (07/07/2023), the SDS of Staff #2 was signed and dated - 06/03/2023.
2. The Provider stated (during an interview conducted on the date of inspection) and documented that the start date for Staff #2 was 03/04/2023.
Plan of Correction: Going forward, the SDS will be completed prior to any new assistant coming in contact with the children.
Standard 8VAC20-800-100-A
Based on review, 3 of 11 children files indicated that the Provider did not obtain documentation of a physical examination (by or under the direction of a physician) within 30 days after the first day of attendance.
Evidence -
1. On the date of inspection (07/07/2023), the following children did not have documentation of a physical examination on file: Child #1, Child #2, and Child #11.
2. Their start dates were: Child #1 - 02/28/2022; Child #2 - 02/28/2022; and Child #11 - 04/17/2023.
Evidence -
1. On the date of inspection (07/07/2023), the following children did not have documentation of a physical examination on file: Child #1, Child #2, and Child #11.
2. Their start dates were: Child #1 - 02/28/2022; Child #2 - 02/28/2022; and Child #11 - 04/17/2023.
Plan of Correction: Documentation of a physical examination will be obtained and placed on file for all applicable children.
Standard 8VAC20-800-120-B
Based on review, 1 of 2 staff files indicated that not all of the required documentation was on file.
Evidence -
1. On the date of inspection (07/07/2023), 1 of 2 references were on file for Staff #2.
2. The start date for Staff #2 was listed as 03/04/2023.
Evidence -
1. On the date of inspection (07/07/2023), 1 of 2 references were on file for Staff #2.
2. The start date for Staff #2 was listed as 03/04/2023.
Plan of Correction: An additional reference will be obtained and placed on file.
Standard 8VAC20-800-210-A
Based on review and interview, 1 of 2 staff files indicated that a minimum of sixteen (16) clock hours of training annually in areas relevant to their job responsibilities was not obtained.
Evidence -
1. On the date of inspection (07/07/2023), a total of 8 hours of annual training was documented for Staff #1.
2. Staff #1 stated (during an interview conducted on the date of inspection) that she did not realize that the overall total of annual training hours needed was 16.
Evidence -
1. On the date of inspection (07/07/2023), a total of 8 hours of annual training was documented for Staff #1.
2. Staff #1 stated (during an interview conducted on the date of inspection) that she did not realize that the overall total of annual training hours needed was 16.
Plan of Correction: A total of 16 annual training hours will be completed for all applicable staff. Certificates of these training will be placed on file for verification.
Standard 8VAC20-800-60-B
Based on review, 3 of 11 children files indicated that not all of the required information was contained within each child's record.
Evidence -
1. On the date of inspection (07/07/2023), 1 of 2 emergency contact phone numbers was listed for Child #7, Child #8, and Child #9.
2. The insurance policy number was not available for the named medical insurance policy for Child #7, Child #8, and Child #9.
Evidence -
1. On the date of inspection (07/07/2023), 1 of 2 emergency contact phone numbers was listed for Child #7, Child #8, and Child #9.
2. The insurance policy number was not available for the named medical insurance policy for Child #7, Child #8, and Child #9.
Plan of Correction: All missing information will be obtained and placed on file for the listed children.
Standard 8VAC20-800-830-A
Based on review, the emergency evacuation procedures were not practiced monthly with all caregivers and children in care during all shifts that children were in care.
Evidence -
1. Based on the posted drill log, the last documented fire drill was conducted in March 2023.
2. The Provider confirmed this observation on the date of inspection.
Evidence -
1. Based on the posted drill log, the last documented fire drill was conducted in March 2023.
2. The Provider confirmed this observation on the date of inspection.
Plan of Correction: Fire drills will be conducted on a monthly basis and documented on the posted log.
Standard 8VAC20-800-830-B
Based on review, shelter-in-place procedures were not practiced a minimum of twice per year.
Evidence -
1. Based on the posted drill log, no shelter-in-place drills were practiced within the past year.
2. The Provider confirmed this observation on the date of inspection.
Evidence -
1. Based on the posted drill log, no shelter-in-place drills were practiced within the past year.
2. The Provider confirmed this observation on the date of inspection.
Plan of Correction: Shelter-in-place drills will be conducted every six months and documented on the posted drill log.
Standard 8VAC20-800-90-C
Based on review, 1 of 11 children files indicated that the family day home (FDH) did not obtain documentation of additional immunizations for a child (who was 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 (07/07/2023), an immunization page for Child #5 was dated - 01/05/2023.
2. Based on information on file, Child #5 was under the age of two years on the date of inspection.
Evidence -
1. On the date of inspection (07/07/2023), an immunization page for Child #5 was dated - 01/05/2023.
2. Based on information on file, Child #5 was under the age of two years on the date of inspection.
Plan of Correction: An updated immunization page will be obtained for Child #5 and placed on file.