Inspection · 2023-11-17
Date
2023-11-17
Complaint Related
No
Licensing Inspector
Brandie Viscayda
(757) 636-3427
(757) 636-3427
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)
20 Access to minor's records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
A renewal inspection was conducted on 11/17/23 from 10:20am until 2:50pm. At the time of the inspection, there were 65 children in care with 13 staff present. A sample of 7 children's records and 8 staff records were reviewed. Children were observed participating in learning activities, playing on the playground and eating snack. Handwashing and restroom procedures and parent pick-up procedures were also observed. First aid and emergency supplies, the emergency preparedness plan, documentation of emergency practice drills, medication and required center postings were reviewed. Information gathered during the inspection determined non-compliance with applicable standards or law. Violations were documented on the violation notice issued to the program and discussed with the Head of School during the exit interview.
Violations
9Standard 22.1-289.035-B-2
Based on record review and interview, the center did not ensure that the results of the fingerprint based criminal history records check is obtained before an employee's first day of employment.
Evidence:
1. Staff 1 has a documented hire date of 1/12/23. The results of the fingerprint based background check for staff 1 was not received until 1/13/23.
2. Staff 2 has a documented hire date of 9/20/23. The results of the fingerprint based background check for staff 2 was not received until 10/6/23.
3. Staff 3 has a documented hire date of 6/15/22. The results of the fingerprint based background check for staff 3 was not received until 6/16/23.
4. The Head of School confirmed that staff 1, staff 2 and staff 3 began employment prior to the results of the fingerprint background checks being received.
Evidence:
1. Staff 1 has a documented hire date of 1/12/23. The results of the fingerprint based background check for staff 1 was not received until 1/13/23.
2. Staff 2 has a documented hire date of 9/20/23. The results of the fingerprint based background check for staff 2 was not received until 10/6/23.
3. Staff 3 has a documented hire date of 6/15/22. The results of the fingerprint based background check for staff 3 was not received until 6/16/23.
4. The Head of School confirmed that staff 1, staff 2 and staff 3 began employment prior to the results of the fingerprint background checks being received.
Plan of Correction: The center responded with the following: We will not let another staff member start without getting the fingerprints back.
Standard 8VAC20-780-160-A
Based on record review and interview, the center did not ensure that each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children.
Evidence:
1. Staff 1 has a documented date of hire of 1/12/23. Documentation of a tuberculosis screening for staff 1 was not obtained by the center until 1/15/23.
2. Staff 2 has a documented date of hire of 9/20/23. Documentation of a tuberculosis screening for staff 2 was not obtained by the center until 9/22/23.
3. Staff 3 has a documented date of hire of 6/15/22. Documentation of a tuberculosis screening for staff 3 was not obtained by the center until 6/17/22.
4. Staff 5 has a documented date of hire of 8/21/23. Documentation of a tuberculosis screening for staff 5 was not obtained by the center until 9/5/23.
5. The Head of School confirmed that the TB screenings for staff 1, staff 2, staff 3 and staff 5 were not obtained until after they began employment.
Evidence:
1. Staff 1 has a documented date of hire of 1/12/23. Documentation of a tuberculosis screening for staff 1 was not obtained by the center until 1/15/23.
2. Staff 2 has a documented date of hire of 9/20/23. Documentation of a tuberculosis screening for staff 2 was not obtained by the center until 9/22/23.
3. Staff 3 has a documented date of hire of 6/15/22. Documentation of a tuberculosis screening for staff 3 was not obtained by the center until 6/17/22.
4. Staff 5 has a documented date of hire of 8/21/23. Documentation of a tuberculosis screening for staff 5 was not obtained by the center until 9/5/23.
5. The Head of School confirmed that the TB screenings for staff 1, staff 2, staff 3 and staff 5 were not obtained until after they began employment.
Plan of Correction: The center responded with the following: We will not let another staff member start without a TB finalized and negative result.
Standard 8VAC20-780-240-A
Based on record review and interview, the center did not ensure that each staff member shall complete the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.
Evidence:
1. Staff 1 (date of hire: 1/12/23) and staff 3 (date of hire: 6/15/22) have not completed the Virginia Department of Education-sponsored orientation course.
2. The Head of School confirmed that staff 1 and staff 3 have not completed the Virginia Department of Education-sponsored orientation course.
Evidence:
1. Staff 1 (date of hire: 1/12/23) and staff 3 (date of hire: 6/15/22) have not completed the Virginia Department of Education-sponsored orientation course.
2. The Head of School confirmed that staff 1 and staff 3 have not completed the Virginia Department of Education-sponsored orientation course.
Plan of Correction: The center responded with the following: Staff 1 and staff 3 have been notified.
Standard 8VAC20-780-245-L
Based on record review and interview, the center did not ensure that there shall always be at least one staff member on duty who has obtained within the last three years instruction in performing the daily health observation of children.
Evidence:
There is no one currently working at the center who has obtained instruction in performing the daily health observation of children.
Evidence:
There is no one currently working at the center who has obtained instruction in performing the daily health observation of children.
Plan of Correction: The center responded with the following: All office admin staff will do this next week. It's three of us.
Standard 8VAC20-780-260-B
Repeat Violation
Based on a review of the most recent health inspection and interview, the center did not ensure that annual approval from the health department shall be provided.
Evidence:
1. The most recent health inspection for the center is dated 9/1/22. An updated health inspection was due in September 2023.
2. The Head of School confirmed that the health inspection is expired.
Based on a review of the most recent health inspection and interview, the center did not ensure that annual approval from the health department shall be provided.
Evidence:
1. The most recent health inspection for the center is dated 9/1/22. An updated health inspection was due in September 2023.
2. The Head of School confirmed that the health inspection is expired.
Plan of Correction: The center responded with the following: Spoke to Health Department. They will come next week between 10-2 by Friday.
Standard 8VAC20-780-510-E
Based on medication and record review, as well as interview, the center did not ensure that procedures for administering medication shall include written authorization from the child's physician and parent for long-term prescription drug use and methods to prevent use of outdated medication.
Evidence:
1. Child 1 has an emergency medication being stored at the center. There is no current written physician authorization to administer this medication to child 1.
2. The emergency medication for child 1 has an expiration date of April 2023.
2. Staff 3 (office manager) confirmed that child 1 has an emergency medication being stored at the center and that there is no written physician authorization for the center to administer the medication to the child and that the emergency medication is expired.
Evidence:
1. Child 1 has an emergency medication being stored at the center. There is no current written physician authorization to administer this medication to child 1.
2. The emergency medication for child 1 has an expiration date of April 2023.
2. Staff 3 (office manager) confirmed that child 1 has an emergency medication being stored at the center and that there is no written physician authorization for the center to administer the medication to the child and that the emergency medication is expired.
Plan of Correction: The center responded with the following: Child 1 - parents notified by email and in person and brought in yesterday.
Standard 8VAC20-780-550-D
Based on interview and a review of the emergency practice drill log, the center did not ensure that a monthly practice evacuation drill is implemented.
Evidence:
1. There is no documentation of a practice evacuation drill for the months of July 2023 or August 2023 for the center.
2. The Head of School confirmed that practice evacuation drills for the months of July and August 2023 were not conducted.
Evidence:
1. There is no documentation of a practice evacuation drill for the months of July 2023 or August 2023 for the center.
2. The Head of School confirmed that practice evacuation drills for the months of July and August 2023 were not conducted.
Plan of Correction: The center responded with the following: We will conduct fire drills during the summer, 12 months of the year.
Standard 8VAC20-780-550-G
Based on a review of the emergency drill log and interview, the center did not ensure that documentation of emergency practice drills contain all the required elements.
Evidence:
1. The emergency drill log for the center does not include the person conducting the drill, method used for notification of the drill or any special conditions simulated.
2. The center director confirmed that the center's emergency drill log does not contain the above required elements.
Evidence:
1. The emergency drill log for the center does not include the person conducting the drill, method used for notification of the drill or any special conditions simulated.
2. The center director confirmed that the center's emergency drill log does not contain the above required elements.
Plan of Correction: The center responded with the following: We will change our form to include what is needed.
Standard 8VAC20-780-70
Based on record review and interview, the center did not ensure that staff records contain all the required information.
Evidence:
1. The record for staff 3 (date of hire: 6/15/22) does not contain documentation that two or more references as to character and reputation as well as competency were checked before employment.
2. The record for staff 4 (date of hire: 8/21/23) contains documentation that only one reference as to character and reputation as well as competency were checked before employment, where two are required.
3. The Head of School confirmed that the required number of references for staff 3 and staff 4 were not completed.
Evidence:
1. The record for staff 3 (date of hire: 6/15/22) does not contain documentation that two or more references as to character and reputation as well as competency were checked before employment.
2. The record for staff 4 (date of hire: 8/21/23) contains documentation that only one reference as to character and reputation as well as competency were checked before employment, where two are required.
3. The Head of School confirmed that the required number of references for staff 3 and staff 4 were not completed.
Plan of Correction: The center responded with the following: Staff 3 has been notified. Staff 4 has two references now.