Inspection · 2022-09-20
Date
2022-09-20
Complaint Related
No
Licensing Inspector
Susan Ellington-Sconiers
(804) 588-2368
(804) 588-2368
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.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor's records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
The licensing inspector conducted an unannounced renewal inspection on Tuesday, September 20, 2022 from 9:45am to approximately 3:00pm. There were a total of 94 children in care in the direct care of 22 staff members. During the inspection, the children and staff were observed participating in a variety of activities. Staff were observed having positive interactions with the children. All areas of the facility including classrooms, playground, kitchen, hallways, and bathrooms were inspected. The center is equipped with toys and supplies and items were available to the children. The required postings were reviewed and found to be in compliance. Medication is administered when required and medication and medication authorizations were reviewed. During the inspection, eight children's records and eight staff records were reviewed. Additional information was later submitted to the inspector and was reviewed virtually.
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.
Violations
10Standard 22.1-289.035-B-2
Based on a review of eight staff records and interview, the center did not ensure three staff obtained a national criminal background check prior to employment.
Evidence: 1) The record for Staff #4, employed 08/01/22, did not contain the results of a national criminal background check by the current employer. The record for Staff #4 contained a national criminal background check dated 06/18/18, this background check was conducted by a different center. National criminal background checks cannot be transferred from center to center unless both centers are sponsored by the same business entity. New results should have been obtained prior to employment.
2) The record for Staff #7, employed 03/28/22, did not contain the results of a national criminal background check. 3) The record for Staff #8, employed 03/28/22, did not contain the results of a national criminal background check. 4) During interview, Staff #9 reported the background checks were requested, but the results have not been received.
Evidence: 1) The record for Staff #4, employed 08/01/22, did not contain the results of a national criminal background check by the current employer. The record for Staff #4 contained a national criminal background check dated 06/18/18, this background check was conducted by a different center. National criminal background checks cannot be transferred from center to center unless both centers are sponsored by the same business entity. New results should have been obtained prior to employment.
2) The record for Staff #7, employed 03/28/22, did not contain the results of a national criminal background check. 3) The record for Staff #8, employed 03/28/22, did not contain the results of a national criminal background check. 4) During interview, Staff #9 reported the background checks were requested, but the results have not been received.
Plan of Correction: Appointments will be scheduled. The center will follow up upon receipt.
Standard 8VAC20-770-60-B
Based on a review of eight staff records and interview, the center did not obtain a completed sworn statement or affirmation for three staff members prior to employment.
Evidence: 1) The record for Staff #4, employed 08/01/22, contained a completed sworn statement dated 09/10/19. 2) The record for Staff #5, employed 03/28/22, contained a completed sworn statement dated 07/23/19. 3) During interview, Staff #9 reported Staff #4 and Staff #5 did not complete a new sworn statement prior to employment with the current employer.
4) The sworn statement in the record for Staff #8, employed 03/28/22, was not complete. The sworn statement was missing the date it was completed.
Evidence: 1) The record for Staff #4, employed 08/01/22, contained a completed sworn statement dated 09/10/19. 2) The record for Staff #5, employed 03/28/22, contained a completed sworn statement dated 07/23/19. 3) During interview, Staff #9 reported Staff #4 and Staff #5 did not complete a new sworn statement prior to employment with the current employer.
4) The sworn statement in the record for Staff #8, employed 03/28/22, was not complete. The sworn statement was missing the date it was completed.
Plan of Correction: Staff will complete an updated sworn statement. Moving forward, a sworn statement will be required at the time of employment.
Standard 8VAC20-770-60-C-2
Based on a review of eight staff records and interview, the center did not ensure that five staff members had a central registry finding within 30 days of employment.
Evidence: 1) The following staff records did not have the results of a central registry finding ? Staff #3 (employed 08/26/22); Staff #4 (employed 08/01/22); Staff #6 (employed 04/26/22); Staff #7 (employed 03/28/22); and Staff #8 (employed 03/28/22). 2) During interview, Staff #9 reported the central registry searches were sent, but have not been received to date.
Evidence: 1) The following staff records did not have the results of a central registry finding ? Staff #3 (employed 08/26/22); Staff #4 (employed 08/01/22); Staff #6 (employed 04/26/22); Staff #7 (employed 03/28/22); and Staff #8 (employed 03/28/22). 2) During interview, Staff #9 reported the central registry searches were sent, but have not been received to date.
Plan of Correction: The center will request new searches and will follow up upon receipt.
Standard 8VAC20-780-130-A
Based on a review of eight children?s records and interview, the center did not obtain documentation that one child had received the immunizations required by the State Board of Health before the child attended the center.
Evidence: 1) The immunizations in the record for Child #3, date of attendance 05/31/22, were dated 06/27/22. 2) During interview, a member of management confirmed the immunizations for Child #3 were not obtained before the child attended the center.
Evidence: 1) The immunizations in the record for Child #3, date of attendance 05/31/22, were dated 06/27/22. 2) During interview, a member of management confirmed the immunizations for Child #3 were not obtained before the child attended the center.
Plan of Correction: Moving forward, all immunizations will be obtained prior to a child's first day of attendance.
Standard 8VAC20-780-130-E
Based on a review of eight children's records and interview, the center did not obtain documentation of additional immunizations once every six months for children under the age of two years.
Evidence: 1) The immunizations in the record for Child #4 (11 months old), date of attendance 03/28/22, were dated 01/28/22. 2) During interview, a member of management reported there were no additional immunizations in the record for Child #4.
Evidence: 1) The immunizations in the record for Child #4 (11 months old), date of attendance 03/28/22, were dated 01/28/22. 2) During interview, a member of management reported there were no additional immunizations in the record for Child #4.
Plan of Correction: The updated immunizations will be requested and added to the child's record.
Standard 8VAC20-780-160-A
Based on a review of eight staff records, the center did not ensure eight staff submitted documentation of a negative tuberculosis (TB) screening within the required timeframe.
Evidence: 1) The following staff members did not submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children ? The TB screening in the record for Staff #1, employed 09/12/22, was dated 09/15/22; the TB screening in the record for Staff #3, employed 08/26/22, was dated 09/06/22; the TB screening in the record for Staff #4, employed 08/01/22, was dated 09/06/22; and the TB screening in the record for Staff #6, employed 04/26/22, was dated 07/06/22.
2) The TB screenings in the record for the following staff members were not completed within the last 30 calendar days of the date of employment ? The TB screening in the record for Staff #2, employed 07/25/22, was dated 02/23/22; the TB screening in the record for Staff #5, employed 03/28/22, was dated 02/14/22; the TB screening in the record for Staff #7, employed 03/28/22, was dated 02/14/22; and the TB screening in the record for Staff #8, employed 03/28/22, was dated 02/16/22.
Evidence: 1) The following staff members did not submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children ? The TB screening in the record for Staff #1, employed 09/12/22, was dated 09/15/22; the TB screening in the record for Staff #3, employed 08/26/22, was dated 09/06/22; the TB screening in the record for Staff #4, employed 08/01/22, was dated 09/06/22; and the TB screening in the record for Staff #6, employed 04/26/22, was dated 07/06/22.
2) The TB screenings in the record for the following staff members were not completed within the last 30 calendar days of the date of employment ? The TB screening in the record for Staff #2, employed 07/25/22, was dated 02/23/22; the TB screening in the record for Staff #5, employed 03/28/22, was dated 02/14/22; the TB screening in the record for Staff #7, employed 03/28/22, was dated 02/14/22; and the TB screening in the record for Staff #8, employed 03/28/22, was dated 02/16/22.
Plan of Correction: TB documentation will be obtained prior to employment and won't be more than 30 days prior to employment.
Standard 8VAC20-780-200-A
Based on interview and observation, the center did not have a qualified program director or a qualified back-up program director who meets one of the director qualifications who shall regularly be on site at least 50% of the center?s hours of operation.
Evidence: 1) Staff #9 was identified as the Program Director that is on site at least 50% of the center?s hours of operation and was present during the renewal inspection. 2) During interview, Staff #9 reported she did not have the complete education background required to meet director qualifications. Staff #9 reported there are no other staff members that meet director qualifications.
Evidence: 1) Staff #9 was identified as the Program Director that is on site at least 50% of the center?s hours of operation and was present during the renewal inspection. 2) During interview, Staff #9 reported she did not have the complete education background required to meet director qualifications. Staff #9 reported there are no other staff members that meet director qualifications.
Plan of Correction: Corrected 10/07/2022. The final requirements were met and there is now a qualified program director on site.
Standard 8VAC20-780-240-A
Based on a review of eight staff records and interview, the center did not ensure one staff completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.
Evidence: 1) The record for Staff #8, employed 03/28/22, did not contain a certificate for the Virginia Department of Education-sponsored orientation course. 2) During interview, Staff #9 confirmed Staff #8 has not completed the required orientation course.
Evidence: 1) The record for Staff #8, employed 03/28/22, did not contain a certificate for the Virginia Department of Education-sponsored orientation course. 2) During interview, Staff #9 confirmed Staff #8 has not completed the required orientation course.
Plan of Correction: The staff will complete the required training. Moving forward, it will be completed within 90 days of employment.
Standard 8VAC20-780-510-F
Based on a review of five medications, the center did not ensure the medication authorizations for four medications were available to staff during the entire time they were effective.
Evidence: 1) On 09/20/22, two medications were observed on site for Child #5, but the authorizations to administer the medications were not on available on site.
2) On 09/21/2022, two medications were observed on site for Child #10, but the authorizations to administer the medications were not on available on site.
Evidence: 1) On 09/20/22, two medications were observed on site for Child #5, but the authorizations to administer the medications were not on available on site.
2) On 09/21/2022, two medications were observed on site for Child #10, but the authorizations to administer the medications were not on available on site.
Plan of Correction: The center will request the authorizations for each medication.
Standard 8VAC20-780-70
Based on a review of eight staff records, the center did not ensure seven staff records contained the required information.
Evidence: 1) The following staff records did not contain documentation that two or more references as to character and reputation as were checked before employment or volunteering ? Staff #1, employed 09/12/22; Staff #3, employed 08/26/22; and Staff #7, employed 03/28/22.
2) The following staff records, whose references were taken over the phone, did not contain the date of contact, results, and signature of person making the call ? Staff #2, employed 07/25/22; Staff #5, employed 03/28/22; and Staff #6, employed 04/26/22.
3) The record for Staff #8, employed 03/28/22, did not contain documentation of orientation training no later than seven days of the date of assuming job responsibilities.
Evidence: 1) The following staff records did not contain documentation that two or more references as to character and reputation as were checked before employment or volunteering ? Staff #1, employed 09/12/22; Staff #3, employed 08/26/22; and Staff #7, employed 03/28/22.
2) The following staff records, whose references were taken over the phone, did not contain the date of contact, results, and signature of person making the call ? Staff #2, employed 07/25/22; Staff #5, employed 03/28/22; and Staff #6, employed 04/26/22.
3) The record for Staff #8, employed 03/28/22, did not contain documentation of orientation training no later than seven days of the date of assuming job responsibilities.
Plan of Correction: Moving forward, when a reference is obtained, the center will document the required information. Staff will complete the orientation and it will be kept in the staff record.