Inspection · 2024-01-05
Date
2024-01-05
Complaint Related
Yes
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 Staffing and Supervision.
8VAC20-780 Programs.
Inspector Notes
An unannounced inspection was initiated on 01/05/2024 in response to a complaint that was received by the licensing department on 01/04/2024 regarding allegations in the areas of supervision, behavioral guidance, forbidden actions, and operational responsibilities. The investigation was initiated on 01/05/2024 and completed on 01/18/2024. On 01/05/2024, the inspector was on site from approximately 8:38 am to 9:31 am. Interviews with staff were completed, observations were made in the center, and documentation was reviewed. Additional interviews were conducted remotely on 01/08/2024 and 01/09/2024.
The preponderance of the evidence gathered during the investigation supports the allegations; therefore, the complaint is determined to be valid. See the violation notice for more details. If you have any questions about this inspection, please contact the licensing inspector at (540) 430-0384.
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
5Standard 8VAC20-780-340-A
Based on a review of documentation and interview, the center did not ensure that when staff are supervising children, they always ensure their care and protection.
Evidence:
1. On 01/04/2024 the department received a complaint that child #1 (age 21 months) was taped to a nap mat by staff #1 (date of employment: 10/05/2023). In interview, two witnessing staff members stated that staff #1 announced that she was going to tape child #1 to his cot. The staff stated that staff #1 had previously expressed frustration with child #1?s behavior and she was overheard saying she was ?fed up.? Staff reported that when tape was placed over child #1?s legs, he cried. It was reported that the tape was kept on child #1?s body for approximately 2 minutes.
2. Administration acknowledged that child #1 was not cared for properly during the reported incident.
Evidence:
1. On 01/04/2024 the department received a complaint that child #1 (age 21 months) was taped to a nap mat by staff #1 (date of employment: 10/05/2023). In interview, two witnessing staff members stated that staff #1 announced that she was going to tape child #1 to his cot. The staff stated that staff #1 had previously expressed frustration with child #1?s behavior and she was overheard saying she was ?fed up.? Staff reported that when tape was placed over child #1?s legs, he cried. It was reported that the tape was kept on child #1?s body for approximately 2 minutes.
2. Administration acknowledged that child #1 was not cared for properly during the reported incident.
Plan of Correction: Leadership team will review staff onboarding procedures by 1/26/24 to ensure that safety is the highest priority. Leadership will also encourage staff to use the code phrase " my lunch is burned" to indicate that they need a break from the classroom to ensure the care and protection of all children. The phrase will be introduced at the staff meeting on 1/30/24.
Standard 8VAC20-780-40-E
Based on review of documentation and interview, the center did not ensure that the center?s activities and services were maintained in compliance with the center's own policies and procedures that are required by the standards.
Evidence:
1. On 12/21/2023, staff #1 placed tape over child #1?s legs to get him to stay on his nap mat. Child #1 laid on his cot with tape placed over his legs for approximately two minutes before staff #3 arrived and instructed her to remove it. Staff reported that staff #1 appeared frustrated with child #1 when she applied the tape and stated she was ?fed up? with his behavior.
2. The center?s handbook contains a discipline policy that states, ?physical restraint will not be used except as necessary to ensure a child?s safety or that of others, and then only for as long as is necessary for control of the situation? At no time will a child be subjected to physical corporal punishment, humiliated, frightened, or verbally abused by the staff.?
3. Administration acknowledged that staff #1 did not follow the center?s discipline policy when she attempted to restrain the child with tape.
Evidence:
1. On 12/21/2023, staff #1 placed tape over child #1?s legs to get him to stay on his nap mat. Child #1 laid on his cot with tape placed over his legs for approximately two minutes before staff #3 arrived and instructed her to remove it. Staff reported that staff #1 appeared frustrated with child #1 when she applied the tape and stated she was ?fed up? with his behavior.
2. The center?s handbook contains a discipline policy that states, ?physical restraint will not be used except as necessary to ensure a child?s safety or that of others, and then only for as long as is necessary for control of the situation? At no time will a child be subjected to physical corporal punishment, humiliated, frightened, or verbally abused by the staff.?
3. Administration acknowledged that staff #1 did not follow the center?s discipline policy when she attempted to restrain the child with tape.
Plan of Correction: Leadership have reviewed policies and procedures via staff handbook by 1/23/2024 and will hold a staff meeting on 1/30/2024 to review discipline policy and what it means to be a care giver/ mandated reporter with all staff members. Our new policy states that all new staff are required to complete abuse prevention training prior to counting as ratio in a classroom. We have also added that: "infractions of rules of conduct that may result in the disciplinary action, up to and including termination of employment include, restraining or dragging a child and not using two hands to lift or guide a child." Any staff member who is absent that day will given a written agenda of the meeting and will sign that they've read and reviewed topics. Staff members will be required to re-take abuse prevention training by 2/15/2024.
Standard 8VAC20-780-400-B
Based on a review of documentation and interview, the center did not ensure that
behavioral guidance was constructive in nature, age and stage appropriate, and intended to redirect children to appropriate behavior.
Evidence:
1. In interview, staff reported that staff #1 was frustrated with child #1 because he was running around the room and wouldn?t listen. Staff #1 was observed placing tape over child #1?s legs to keep him on his nap mat. Child #1 was observed crying.
2. Administration acknowledged that the actions taken by staff #1 were not constructive or age and stage appropriate. They reported that staff #1 was terminated on 12/21/23 for her actions.
behavioral guidance was constructive in nature, age and stage appropriate, and intended to redirect children to appropriate behavior.
Evidence:
1. In interview, staff reported that staff #1 was frustrated with child #1 because he was running around the room and wouldn?t listen. Staff #1 was observed placing tape over child #1?s legs to keep him on his nap mat. Child #1 was observed crying.
2. Administration acknowledged that the actions taken by staff #1 were not constructive or age and stage appropriate. They reported that staff #1 was terminated on 12/21/23 for her actions.
Plan of Correction: Leadership team is to hold staff meeting on 1/30/2024 to review discipline policy as well as what it means to be care givers. Leadership team will observe classrooms unannounced on a weekly basis to ensure policies are being followed. We have created a new role in our administrative team, bringing up a seasoned teacher to observe, mentor and uphold QA and licensing policies in the classroom. She began her classroom observation as of 1/15/2024, and will be observing classrooms on a daily basis.
Standard 8VAC20-780-410-1
Based on a review of documentation and interview, the center did not ensure that the action of restricting movement through binding or tying was forbidden as required.
Evidence:
1. On 12/21/2023 at approximately 12:30 pm, staff #1 (date of employment: 10/5/2023) used painter?s tape to keep child #1 (date of enrollment: 8/21/2023) on his nap mat.
2. In interview, staff #2 and staff #4 reported that they overheard staff #1 state that she was going to tape child #1 to his mat. Staff #2 stated that she heard and saw staff #1 rip the tape used and left the room to alert management. Staff #3 stated that she saw staff #1 place a piece of the tape over child #1?s legs for approximately 2 minutes. She said the tape was not tight but child #1 cried and did not attempt to remove the tape. Staff #3 reported that she was notified of the situation by staff #2 and went to the room to check on the situation. When staff #3 arrived she stated staff #1 was sitting by child #1 who was crying. She reported that she told staff #1 to ?stop? and staff #1 replied that she would remove the tape.
3. In interview staff #1 acknowledged that she placed painter?s tape on child #1.
Evidence:
1. On 12/21/2023 at approximately 12:30 pm, staff #1 (date of employment: 10/5/2023) used painter?s tape to keep child #1 (date of enrollment: 8/21/2023) on his nap mat.
2. In interview, staff #2 and staff #4 reported that they overheard staff #1 state that she was going to tape child #1 to his mat. Staff #2 stated that she heard and saw staff #1 rip the tape used and left the room to alert management. Staff #3 stated that she saw staff #1 place a piece of the tape over child #1?s legs for approximately 2 minutes. She said the tape was not tight but child #1 cried and did not attempt to remove the tape. Staff #3 reported that she was notified of the situation by staff #2 and went to the room to check on the situation. When staff #3 arrived she stated staff #1 was sitting by child #1 who was crying. She reported that she told staff #1 to ?stop? and staff #1 replied that she would remove the tape.
3. In interview staff #1 acknowledged that she placed painter?s tape on child #1.
Plan of Correction: To ensure that our staff is clear that the action of restricting movement through binding or tying is forbidden, leadership will review discipline policy so that it is explicitly stated as such then will have all staff review policy in the presents of the leadership team.
Standard 8VAC20-780-80-B
Based on observation, review of documentation and interview, the center did not ensure that a suspected incident of child abuse was reported in accordance with ? 63.2-1509 of the Code of Virginia.
Evidence:
1. On 12/21/2023, staff #1 placed tape over child #1?s legs to keep him on his nap mat. Multiple staff to include three classroom staff and two management staff were aware of the situation the day it occurred. A report was not made within 24 hours as required for mandated reporters.
2. In interview, three staff stated that they believed the incident to be abusive. Administration also acknowledged that the incident was abusive and they failed to report.
Evidence:
1. On 12/21/2023, staff #1 placed tape over child #1?s legs to keep him on his nap mat. Multiple staff to include three classroom staff and two management staff were aware of the situation the day it occurred. A report was not made within 24 hours as required for mandated reporters.
2. In interview, three staff stated that they believed the incident to be abusive. Administration also acknowledged that the incident was abusive and they failed to report.
Plan of Correction: All staff will be required to re-take abuse prevention by 2/15/2024 and administration team will re-take abuse prevention as well as skilled screening training by 2/15/2024.
Each staff member will receive an updated staff handbook and will sign off that they've reviewed all updated policies.
Each staff member will receive an updated staff handbook and will sign off that they've reviewed all updated policies.