Inspection · 2022-10-24
Date
2022-10-24
Complaint Related
No
Licensing Inspector
Jennifer Moore
(540) 430-0384
(540) 430-0384
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.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minors records
22.1 Background Checks Code, Carbon Monoxide
22.1 Early Childhood Care and Education
Inspector Notes
An unannounced monitoring inspection was initiated and concluded on 10/24/2022. The inspector was on site from approximately 9:55 am-2:25 pm. There were 104 children present, ranging in ages from 4 months to five (5) years, with 19 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies, nutrition and background checks. A total of 10 child records and 20 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.
Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to me within 5 business days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word corrected is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measures. Please do not use staff names; list staff by positions only.
Violations
11Standard 22.1-289.035-B-2
Based on a review of 20 staff records and interview, the center did not ensure to obtain the results of a fingerprint background check prior to the first date of employment for five (5)
staff as required.
Evidence:
1. The record of staff #10 (date of employment 8/29/2022) contained a fingerprint background check dated 9/9/2022. The record of staff #14 (date of employment 8/29/2022) contained a fingerprint background check dated 9/9/2022. The record of staff # 16 (date of employment 8/29/2022) contained a fingerprint background check dated 8/30/2022. The record of staff # 18 (date of employment 8/29/2022) contained a fingerprint background check dated 8/31/2022. The record of staff #19 (date of employment 8/29/2022) contained a fingerprint background check dated 8/30/2022.
2. Administration acknowledged that they had not received the fingerprint background checks prior to the first date of employment as required.
staff as required.
Evidence:
1. The record of staff #10 (date of employment 8/29/2022) contained a fingerprint background check dated 9/9/2022. The record of staff #14 (date of employment 8/29/2022) contained a fingerprint background check dated 9/9/2022. The record of staff # 16 (date of employment 8/29/2022) contained a fingerprint background check dated 8/30/2022. The record of staff # 18 (date of employment 8/29/2022) contained a fingerprint background check dated 8/31/2022. The record of staff #19 (date of employment 8/29/2022) contained a fingerprint background check dated 8/30/2022.
2. Administration acknowledged that they had not received the fingerprint background checks prior to the first date of employment as required.
Plan of Correction: We recognize that things were missed during the transfer process. Going forward, we are implementing a staff information log that will be reviewed by our directors on a monthly basis. When reviewing the staff information log, our directors will have access to current and expiring dates from each staff member, and will be able to proactively obtain updated certificates and trainings. We recognize that things were missed during the transfer process. Going forwards, we will ensure applications and enrollment packets are dated prior to the enrollment date.
Standard 22.1-289.035-B-4
Based on a review of 20 staff records and interview, the center did not ensure that three (3) staff had the required out of state background checks.
Evidence:
1. The record of staff #3 (date of employment: 8/29/2022) contained a sworn statement that indicated that the staff had resided outside of the state within the preceding five (5) years. The record did not contain an out of state child abuse and neglect search request by the end of the 30th day of employment. The record of staff # 7 (date of employment: 8/29/2022) contained a sworn statement that indicated that the staff had resided outside of the state within the preceding five (5) years. The sworn statement listed two (2) NFF states. The record did not contain the out of state criminal name check(s) required for non NFF states prior to the first date of employment. The record of staff #7 did not contain an out of state child abuse and neglect search request by the end of the 30th day of employment for both states. The record of staff #14 (date of employment: 8/29/2022) contained a sworn statement that indicated that the staff had resided outside of the state within the preceding five (5) years. The record did not contain an out of state child abuse and neglect search request by the end of the 30th day of employment.
2. Administration acknowledged that the out of state background checks were not completed.
Evidence:
1. The record of staff #3 (date of employment: 8/29/2022) contained a sworn statement that indicated that the staff had resided outside of the state within the preceding five (5) years. The record did not contain an out of state child abuse and neglect search request by the end of the 30th day of employment. The record of staff # 7 (date of employment: 8/29/2022) contained a sworn statement that indicated that the staff had resided outside of the state within the preceding five (5) years. The sworn statement listed two (2) NFF states. The record did not contain the out of state criminal name check(s) required for non NFF states prior to the first date of employment. The record of staff #7 did not contain an out of state child abuse and neglect search request by the end of the 30th day of employment for both states. The record of staff #14 (date of employment: 8/29/2022) contained a sworn statement that indicated that the staff had resided outside of the state within the preceding five (5) years. The record did not contain an out of state child abuse and neglect search request by the end of the 30th day of employment.
2. Administration acknowledged that the out of state background checks were not completed.
Plan of Correction: We recognize that things were missed during the transfer process. Going forward, we are implementing a staff information log that will be reviewed by our directors on a monthly basis. When reviewing the staff information log, our directors will have access to current and expiring dates from each staff member, and will be able to proactively obtain updated certificates and trainings. We recognize that things were missed during the transfer process. Going forwards, we will ensure applications and enrollment packets are dated prior to the enrollment date.
Standard 8VAC20-770-60-B
Based on a review of 20 staff records and interview, the center did not ensure that 1 staff had a completed sworn statement prior to the first date of employment as required.
Evidence:
1. The record of staff #12 (date of employment: 10/17/2022) did not contain a sworn statement.
2. Administration acknowledged that the sworn statement was not completed.
Evidence:
1. The record of staff #12 (date of employment: 10/17/2022) did not contain a sworn statement.
2. Administration acknowledged that the sworn statement was not completed.
Plan of Correction: We recognize that things were missed during the transfer process. Going forward, we are implementing a staff information log that will be reviewed by our directors on a monthly basis. When reviewing the staff information log, our directors will have access to current and expiring dates from each staff member, and will be able to proactively obtain updated certificates and trainings. We recognize that things were missed during the transfer process. Going forwards, we will ensure applications and enrollment packets are dated prior to the enrollment date.
Standard 8VAC20-770-60-C-2
Based on a review of 20 staff records and interview, the center did not ensure to obtain a central registry finding for one (1) staff within 30 days of employment as required.
Evidence:
1. The record of staff #7 (date of employment: 8/29/2022) did not contain a central registry finding.
2. Administration acknowledged that the findings were not obtained within the required
time frame.
Evidence:
1. The record of staff #7 (date of employment: 8/29/2022) did not contain a central registry finding.
2. Administration acknowledged that the findings were not obtained within the required
time frame.
Plan of Correction: We recognize that things were missed during the transfer process. Going forward, we are implementing a staff information log that will be reviewed by our directors on a monthly basis. When reviewing the staff information log, our directors will have access to current and expiring dates from each staff member, and will be able to proactively obtain updated certificates and trainings. We recognize that things were missed during the transfer process. Going forwards, we will ensure applications and enrollment packets are dated prior to the enrollment date.
Standard 8VAC20-780-130-A
Based on a review of 10 children?s records and interview, the center did not ensure to
obtain documentation that three (3) children had received the immunizations required by the State Board of Health before the first date of attendance as required.
Evidence:
1. The record of child #1 (date of attendance: 08/29/2022) contained an immunization record dated 9/19/2022. The record of child #3 (date of attendance: 8/29/2022) contained an immunization record dated 9/26/2022. The record of child #8 (date of attendance: 8/29/2022) did not contain an immunization record.
2. Administration acknowledged that the documentation had not been obtained prior to the first date of attendance.
obtain documentation that three (3) children had received the immunizations required by the State Board of Health before the first date of attendance as required.
Evidence:
1. The record of child #1 (date of attendance: 08/29/2022) contained an immunization record dated 9/19/2022. The record of child #3 (date of attendance: 8/29/2022) contained an immunization record dated 9/26/2022. The record of child #8 (date of attendance: 8/29/2022) did not contain an immunization record.
2. Administration acknowledged that the documentation had not been obtained prior to the first date of attendance.
Plan of Correction: We recognize that things were missed during the transfer process. Going forward, we are implementing a staff information log that will be reviewed by our directors on a monthly basis. When reviewing the staff information log, our directors will have access to current and expiring dates from each staff member, and will be able to proactively obtain updated certificates and trainings. We recognize that things were missed during the transfer process. Going forwards, we will ensure applications and enrollment packets are dated prior to the enrollment date.
Standard 8VAC20-780-140-A
Based on a review of 10 children?s records and interview, the center did not ensure that two (2) children had a physical examination by or under the direction of a physician: 1. before the child's attendance; or 2. within 30 days after the first day of attendance as required.
Evidence:
1. The record of child #8 (date of attendance: 8/29/2022) did not contain a physical record. The record of child #10 (date of attendance: 8/29/2022) did not contain a physical record.
2. Administration acknowledged that the physical reports were not obtained.
Evidence:
1. The record of child #8 (date of attendance: 8/29/2022) did not contain a physical record. The record of child #10 (date of attendance: 8/29/2022) did not contain a physical record.
2. Administration acknowledged that the physical reports were not obtained.
Plan of Correction: We recognize that things were missed during the transfer process. Going forward, we are implementing a staff information log that will be reviewed by our directors on a monthly basis. When reviewing the staff information log, our directors will have access to current and expiring dates from each staff member, and will be able to proactively obtain updated certificates and trainings. We recognize that things were missed during the transfer process. Going forwards, we will ensure applications and enrollment packets are dated prior to the enrollment date.
Standard 8VAC20-780-160-A
Based on a review of 20 staff records and interview, the center did not ensure that 11 staff submitted documentation of a negative tuberculosis (TB) screening at the of employment and prior to coming into contact with children. The documentation shall have been completed within the last 30 calendar days of the date of employment.
Evidence:
1. The record of staff #1 (date of employment: 8/29/2022) contained a TB screening dated 8/31/2022. The record of staff #3 (date of employment: 8/29/2022) contained a TB screening dated 9/9/2022. The record of staff #4 (date of employment: 8/29/2022) contained a TB screening dated 9/1/2022. The record of staff #8 (date of employment: 8/29/2022) contained a TB screening dated 7/22/2022. The record of staff #9 (date of employment: 8/29/2022) contained a TB screening dated 9/14/2022. The record of staff #11 (date of employment: 8/29/2022) contained a TB screening dated 9/16/2022. The record of staff #12 (date of employment: 10/19/2022) did not contain a TB screening. The record of staff #13 (date of employment: 10/29/2022) contained a TB screening dated 7/21/2022. The record of staff #14 (date of employment: 8/29/2022) contained a TB screening dated 9/13/2022. The record of staff #15 (date of employment: 8/29/2022) contained a TB screening dated 9/13/2022. The record of staff #17 (date of employment: 8/29/2022) contained a TB screening dated 8/30/2022.
2. Administration acknowledged that the TB screenings were not submitted within the required time frame.
Evidence:
1. The record of staff #1 (date of employment: 8/29/2022) contained a TB screening dated 8/31/2022. The record of staff #3 (date of employment: 8/29/2022) contained a TB screening dated 9/9/2022. The record of staff #4 (date of employment: 8/29/2022) contained a TB screening dated 9/1/2022. The record of staff #8 (date of employment: 8/29/2022) contained a TB screening dated 7/22/2022. The record of staff #9 (date of employment: 8/29/2022) contained a TB screening dated 9/14/2022. The record of staff #11 (date of employment: 8/29/2022) contained a TB screening dated 9/16/2022. The record of staff #12 (date of employment: 10/19/2022) did not contain a TB screening. The record of staff #13 (date of employment: 10/29/2022) contained a TB screening dated 7/21/2022. The record of staff #14 (date of employment: 8/29/2022) contained a TB screening dated 9/13/2022. The record of staff #15 (date of employment: 8/29/2022) contained a TB screening dated 9/13/2022. The record of staff #17 (date of employment: 8/29/2022) contained a TB screening dated 8/30/2022.
2. Administration acknowledged that the TB screenings were not submitted within the required time frame.
Plan of Correction: We recognize that things were missed during the transfer process. Going forward, we are implementing a staff information log that will be reviewed by our directors on a monthly basis. When reviewing the staff information log, our directors will have access to current and expiring dates from each staff member, and will be able to proactively obtain updated certificates and trainings. We recognize that things were missed during the transfer process. Going forwards, we will ensure applications and enrollment packets are dated prior to the enrollment date.
Standard 8VAC20-780-530-A-1
Based on interview, the center did not ensure that at least one staff in each classroom or area where children are present had current certification in cardiopulmonary resuscitation (CPR) as appropriate to the age of the children.
Evidence:
1. On 10/24/2022, a classroom of nine (9) toddlers were observed with two (2) staff. In interview, both staff stated that they did not have current certification in cardiopulmonary resuscitation (CPR) as appropriate to the age of the children in care.
2. Administration acknowledged that there was not a CPR certified staff in the classroom.
Evidence:
1. On 10/24/2022, a classroom of nine (9) toddlers were observed with two (2) staff. In interview, both staff stated that they did not have current certification in cardiopulmonary resuscitation (CPR) as appropriate to the age of the children in care.
2. Administration acknowledged that there was not a CPR certified staff in the classroom.
Plan of Correction: 100% of our staff will hold a current certification in cardiopulmonary
resuscitation (CPR) no later than November 9 th , 2022 through the Red Cross.
resuscitation (CPR) no later than November 9 th , 2022 through the Red Cross.
Standard 8VAC20-780-530-A-2
Based on interview, the center did not ensure that at least one staff in each classroom or area where children are present had current certification in certification in first aid.
Evidence:
1. On 10/24/2022, a classroom of nine (9) toddlers were observed with two (2) staff. In interview, both staff stated that they did not have current certification in first aid.
2. Administration acknowledged that there was not a first aid certified staff in the classroom.
Evidence:
1. On 10/24/2022, a classroom of nine (9) toddlers were observed with two (2) staff. In interview, both staff stated that they did not have current certification in first aid.
2. Administration acknowledged that there was not a first aid certified staff in the classroom.
Plan of Correction: 100% of our staff will hold a current certification in first aid no later than
November 9 th , 2022 through the Red Cross.
November 9 th , 2022 through the Red Cross.
Standard 8VAC20-780-60-A
Based on a review of 10 children?s records and interview, the center did not ensure to maintain a separate record for four (4) children that contained the required information.
Evidence:
1. The record of child #1 (date of attendance: 8/29/2022) contained written agreements dated 9/15/2022. The record of child #3 (date of attendance: 8/29/2022) contained written agreements dated 9/25/2022. The record of child #8 (date of attendance: 8/29/2022) contained written agreements dated 10/17/2022. The record of child #9 (date of attendance: 8/29/2022) contained written agreements dated 10/14/2022. Written agreement between the parent and the center are required to be in the child?s record by the first day of the child's attendance. The agreement shall be signed by the parent.
2. The record of child #8 (date of attendance: 8/29/2022) was missing emergency contact addresses. The record of child #10 (date of attendance: 8/29/2022) was missing two emergency contacts. Children?s records are required to contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached
3. Administration acknowledged that the records were not complete.
Evidence:
1. The record of child #1 (date of attendance: 8/29/2022) contained written agreements dated 9/15/2022. The record of child #3 (date of attendance: 8/29/2022) contained written agreements dated 9/25/2022. The record of child #8 (date of attendance: 8/29/2022) contained written agreements dated 10/17/2022. The record of child #9 (date of attendance: 8/29/2022) contained written agreements dated 10/14/2022. Written agreement between the parent and the center are required to be in the child?s record by the first day of the child's attendance. The agreement shall be signed by the parent.
2. The record of child #8 (date of attendance: 8/29/2022) was missing emergency contact addresses. The record of child #10 (date of attendance: 8/29/2022) was missing two emergency contacts. Children?s records are required to contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached
3. Administration acknowledged that the records were not complete.
Plan of Correction: We recognize that things were missed during the transfer process. Going forward, we are implementing a staff information log that will be reviewed by our directors on a monthly basis. When reviewing the staff information log, our directors will have access to current and expiring dates from each staff member, and will be able to proactively obtain updated certificates and trainings. We recognize that things were missed during the transfer process. Going forwards, we will ensure applications and enrollment packets are dated prior to the enrollment date.
Standard 8VAC20-780-70
Based on a review of 20 staff records and interview, the center did not ensure that 19 records contained the required information.
Evidence:
1. The records of 19 out of the 20 staff did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment
2. The record of #7 (date of employment: 8/29/2022) identified the staff as a lead teacher. The record did not contain documentation to demonstrate that the individual possessed the education required by the job position
3. The record of staff 11 (date of employment: 8/29/2022) did not contain documentation of the required orientation training and the name, address, and telephone number of a person to be notified in an emergency. The record did not contain information about any health problems that may interfere with fulfilling the job responsibilities.
4. Administration acknowledged that the records were not complete.
Evidence:
1. The records of 19 out of the 20 staff did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment
2. The record of #7 (date of employment: 8/29/2022) identified the staff as a lead teacher. The record did not contain documentation to demonstrate that the individual possessed the education required by the job position
3. The record of staff 11 (date of employment: 8/29/2022) did not contain documentation of the required orientation training and the name, address, and telephone number of a person to be notified in an emergency. The record did not contain information about any health problems that may interfere with fulfilling the job responsibilities.
4. Administration acknowledged that the records were not complete.
Plan of Correction: We recognize that things were missed during the transfer process. Going forward, we are implementing a staff information log that will be reviewed by our directors on a monthly basis. When reviewing the staff information log, our directors will have access to current and expiring dates from each staff member, and will be able to proactively obtain updated certificates and trainings. We recognize that things were missed during the transfer process. Going forwards, we will ensure applications and enrollment packets are dated prior to the enrollment date.