Inspection · 2023-06-13
Date
2023-06-13
Complaint Related
No
Licensing Inspector
Rebecca Forestier
(540) 309-2835
(540) 309-2835
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
20 ACCESS TO MINOR?S RECORDS
22.1 BACKGROUND CHECKS, CODE, CARBON MONOXIDE
63.2 CHILD ABUSE AND NEGLECT
Inspector Notes
An unannounced renewal inspection was conducted on 06/13/2023 and concluded with an electronic record review on 06/15/2023. There were 44 children, ages 2 months-8 years, and 12 staff members present during the inspection. The inspector reviewed compliance in the areas of administration, staff qualifications and trainings, staffing and supervision, physical plant, programs, emergencies and nutrition. The children were observed during free choice activities, having lunch, and during rest time; infants were observed in play and sleeping and eating on demand. A total of 5 children?s records, 5 staff records, 3 applicant records, and 5 medications were reviewed. The inspector arrived for the inspection at 9:30 am and departed at 12:40 pm.
Information gathered during the inspection determined non-compliance with applicable standards or laws and violations were documented on the violation notice issued to the provider.
Violations
13Standard 22.1-289.036-A
Based on record review, the center failed to ensure that all applicants shall undergo a background check in accordance with the Code of Virginia prior to employment and every five years thereafter.
Evidence:
1. The record for Applicant 1 contained a criminal record fingerprint eligibility letter dated 03/06/2018; the date on the most recent eligibility letter was 06/13/2023.
2. The record for Applicant 3 contained a criminal record fingerprint eligibility letter dated 03/06/2018; the date on the most recent eligibility letter was 06/13/2023.
Evidence:
1. The record for Applicant 1 contained a criminal record fingerprint eligibility letter dated 03/06/2018; the date on the most recent eligibility letter was 06/13/2023.
2. The record for Applicant 3 contained a criminal record fingerprint eligibility letter dated 03/06/2018; the date on the most recent eligibility letter was 06/13/2023.
Plan of Correction: There will be a systemic change of how paperwork is completed and checked. Monthly checklist/folder to assure that files are completed before expiration date.
Standard 8VAC20-770-60-C-2
Based on record review and discussion with the staff, the center failed to obtain the finding from a search of the central registry within 30 days of employment.
Evidence:
1. The documented hire date in the record for Staff 2 was 03/31/2023. There were no findings from a search of the central registry available for review during the inspection.
2. The documented hire date in the record for Staff 4 was 08/20/2022. The findings from a search of the central registry were dated 11/06/2022.
Evidence:
1. The documented hire date in the record for Staff 2 was 03/31/2023. There were no findings from a search of the central registry available for review during the inspection.
2. The documented hire date in the record for Staff 4 was 08/20/2022. The findings from a search of the central registry were dated 11/06/2022.
Plan of Correction: Will now only use the portal and will send before hiring.
Standard 8VAC20-780-140-A
Based on record review, the center failed to ensure that each child shall have a physical examination by or under the direction of a physician before the child?s attendance or within 30 days after the first day of attendance.
Evidence: The record for Child 4 did not contain a physical examination; the documented first date of attendance for Child 4 was 11/01/2021.
Evidence: The record for Child 4 did not contain a physical examination; the documented first date of attendance for Child 4 was 11/01/2021.
Plan of Correction: Will request a copy from the parent.
Standard 8VAC20-780-160-A
Based on record review, the center failed to 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; documentation shall have been completed within the last 30 calendar days of the date of employment.
Evidence: The record for Staff 2 contained a documented hire date of 03/31/2023. The tuberculosis screening was dated 07/04/2022. The tuberculosis screening had not been completed within 30 calendar days from employment.
Evidence: The record for Staff 2 contained a documented hire date of 03/31/2023. The tuberculosis screening was dated 07/04/2022. The tuberculosis screening had not been completed within 30 calendar days from employment.
Plan of Correction: When staff are hired there will be a hiring appointment scheduled to ensure that all information is obtained in the required timeframe.
Standard 8VAC20-780-240-B
Based on record review, the center failed to ensure that staff shall complete orientation training prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities.
Evidence: The record for Staff 3 contained a documented hire date of 02/27/2023. There was no documentation to demonstrate that Staff 3 has completed orientation training in the record. Staff 3 was observed working during the inspection.
Evidence: The record for Staff 3 contained a documented hire date of 02/27/2023. There was no documentation to demonstrate that Staff 3 has completed orientation training in the record. Staff 3 was observed working during the inspection.
Plan of Correction: Will get the orientation done with the staff.
Standard 8VAC20-780-350-B-2
Based on observation and interviews, the center failed to ensure that the required staff to child ratio, 1 staff for every 5 children for children 16 months up to 24 months, is met whenever children are in care.
Evidence: There were 7 children, ages 16 months-24 months, and 1 staff observed in the 16-24 month old class during rest time. Staff 6 stated that they were the only staff member with the 7 children following lunch until the children went down for nap. The required ratio for this age group is 1 staff for every 5 children.
Evidence: There were 7 children, ages 16 months-24 months, and 1 staff observed in the 16-24 month old class during rest time. Staff 6 stated that they were the only staff member with the 7 children following lunch until the children went down for nap. The required ratio for this age group is 1 staff for every 5 children.
Plan of Correction: Will ensure all ratios are met.
Standard 8VAC20-780-370-1
Based on observation and interviews, the center failed to ensure that when an infant is placed in their crib, they shall be placed on their backs.
Evidence:
1. There were signs posted on the wall behind the cribs that read ?you can lay me on my back or my stomach?. Staff verified that they do place children in their cribs on their stomachs.
2. A child was observed sleeping on their stomach in their crib. Staff verified that they had placed the child on their stomach.
Evidence:
1. There were signs posted on the wall behind the cribs that read ?you can lay me on my back or my stomach?. Staff verified that they do place children in their cribs on their stomachs.
2. A child was observed sleeping on their stomach in their crib. Staff verified that they had placed the child on their stomach.
Plan of Correction: All babies will be placed on their backs to sleep. A reminder for staff and parents will be placed on the door of the class and on the wall behind the cribs.
Standard 8VAC20-780-510-B
Based on observations and interviews, the center failed to ensure that nonprescription medication shall be administered only with written authorization from the parent.
Evidence:
1. There was written documentation that Medication 1 had been administered on 03/02/2023. There was not a written authorization from the parent available for review. Staff 7 stated that they had thrown the authorization forms in the trash once they expired.
2. There was written documentation that Medication 3 had been administered multiple times between 04/06/2023 and 05/09/2023. There was not a written authorization from the parent available for review. Staff 7 stated that they had thrown the authorization forms in the trash once they expired.
Evidence:
1. There was written documentation that Medication 1 had been administered on 03/02/2023. There was not a written authorization from the parent available for review. Staff 7 stated that they had thrown the authorization forms in the trash once they expired.
2. There was written documentation that Medication 3 had been administered multiple times between 04/06/2023 and 05/09/2023. There was not a written authorization from the parent available for review. Staff 7 stated that they had thrown the authorization forms in the trash once they expired.
Plan of Correction: Will change the medication administration practices.
Standard 8VAC20-780-560-M
Based on observations, the center failed to ensure that no child shall be allowed to drink or eat while walking around.
Evidence: Child 6 was observed drinking from a sippy cup while walking around in the infant room.
Evidence: Child 6 was observed drinking from a sippy cup while walking around in the infant room.
Plan of Correction: Will remind the staff.
Standard 8VAC20-780-570-C
Based on interviews, the center failed to ensure that the record of each child on formula shall contain the brand of formula and the child?s feeding schedule.
Evidence: Staff 5 verified that there were a total of 7 children on formula in the Infant Class. There was not a record for each child on formula that included the brand of formula and the child?s feeding schedule for any of the 7 children on formula available for review during the inspection.
Evidence: Staff 5 verified that there were a total of 7 children on formula in the Infant Class. There was not a record for each child on formula that included the brand of formula and the child?s feeding schedule for any of the 7 children on formula available for review during the inspection.
Plan of Correction: Will get the information documented and posted inside of the cabinet in the infant class.
Standard 8VAC20-780-60-A
REPEAT VIOLATION
Based on record review, the center failed to ensure that the separate record for each enrolled child contains all of the elements as required by the standards.
Evidence:
1. The record for Child 1 did not contain the following information: the work phone number and place of employment of each parent (there was not a work phone number provided for both parents); phone number of the child?s physician; name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached (the address for the second designated person was incomplete); allergies and intolerance to medication or any other substances, and actions to take in an emergency situation; and first date of attendance.
2. The record for Child 2 did not contain the following information: first date of attendance.
3. The record for Child 3 did not contain the following information: first date of attendance.
4. The record for Child 4 did not contain the following information: documentation of child updates and confirmation of up-to-date information in the child?s record (the most recent update took place on 11/01/2021).
5. The record for Child 5 did not contain the following information: documentation of child updates and confirmation of up-to-date information in the child?s record (the most recent update took place on 09/20/2021).
Based on record review, the center failed to ensure that the separate record for each enrolled child contains all of the elements as required by the standards.
Evidence:
1. The record for Child 1 did not contain the following information: the work phone number and place of employment of each parent (there was not a work phone number provided for both parents); phone number of the child?s physician; name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached (the address for the second designated person was incomplete); allergies and intolerance to medication or any other substances, and actions to take in an emergency situation; and first date of attendance.
2. The record for Child 2 did not contain the following information: first date of attendance.
3. The record for Child 3 did not contain the following information: first date of attendance.
4. The record for Child 4 did not contain the following information: documentation of child updates and confirmation of up-to-date information in the child?s record (the most recent update took place on 11/01/2021).
5. The record for Child 5 did not contain the following information: documentation of child updates and confirmation of up-to-date information in the child?s record (the most recent update took place on 09/20/2021).
Plan of Correction: Will review all of the children's records and update them.
Standard 8VAC20-780-70
Based on record review and discussion with staff, the center failed to ensure that staff records contain all of the elements as required by the standards.
Evidence:
1. The record for Staff 1 did not contain the following information: date of employment.
2. The record for Staff 2 did not contain the following information: job title; name, address, and telephone number of a person to be notified in an emergency; and documentation to demonstrate that the individual possesses the educational, certification, and experience required by the job position.
3. The record for Staff 3 did not contain the following information: job title; documentation to demonstrate that the individual possesses the educational, certification, and experience required by the job position; and documentation that two or more references as to character and reputation as well as competency were checked before employment (there was only one reference in the record and the reference did not contain the signature of the person making the call as required).
4. The record for Staff 4 did not contain the following information: documentation to demonstrate that the individual possesses the educational, certification, and experience required by the job position; and documentation that two or more references as to character and reputation as well as competency were checked before employment (there was only one reference in the record and the reference did not contain the signature of the person making the call as required).
5. The record for Staff 5 did not contain the following information: documentation to demonstrate that the individual possesses the educational, certification, and experience required by the job position.
Evidence:
1. The record for Staff 1 did not contain the following information: date of employment.
2. The record for Staff 2 did not contain the following information: job title; name, address, and telephone number of a person to be notified in an emergency; and documentation to demonstrate that the individual possesses the educational, certification, and experience required by the job position.
3. The record for Staff 3 did not contain the following information: job title; documentation to demonstrate that the individual possesses the educational, certification, and experience required by the job position; and documentation that two or more references as to character and reputation as well as competency were checked before employment (there was only one reference in the record and the reference did not contain the signature of the person making the call as required).
4. The record for Staff 4 did not contain the following information: documentation to demonstrate that the individual possesses the educational, certification, and experience required by the job position; and documentation that two or more references as to character and reputation as well as competency were checked before employment (there was only one reference in the record and the reference did not contain the signature of the person making the call as required).
5. The record for Staff 5 did not contain the following information: documentation to demonstrate that the individual possesses the educational, certification, and experience required by the job position.
Plan of Correction: Will review all staff records and update them.
Standard 8VAC20-780-80-A
Based on document review and discussion with staff, the center failed to ensure that for each group of children, the center shall maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs.
Evidence:
1. There were 10 children observed in care in the Infant Class; there were only 7 children marked present on the attendance record. The daily attendance did not document the arrival of each child as it occurs.
2. There were 5 children observed in care in the Toddler Class; there were 6 children marked in attendance. The daily attendance did not document the departure of each child as it occurs.
3. There were 5 children observed in care in the 2 year old class; there were 6 children marked in attendance. The daily attendance did not document the departure of each child as it occurs.
4. There were 11 children observed in care in the 2 ?-3 year old class; there were only 8 children marked present on the attendance record. The daily attendance did not document the arrival of each child as it occurs.
Evidence:
1. There were 10 children observed in care in the Infant Class; there were only 7 children marked present on the attendance record. The daily attendance did not document the arrival of each child as it occurs.
2. There were 5 children observed in care in the Toddler Class; there were 6 children marked in attendance. The daily attendance did not document the departure of each child as it occurs.
3. There were 5 children observed in care in the 2 year old class; there were 6 children marked in attendance. The daily attendance did not document the departure of each child as it occurs.
4. There were 11 children observed in care in the 2 ?-3 year old class; there were only 8 children marked present on the attendance record. The daily attendance did not document the arrival of each child as it occurs.
Plan of Correction: All staff will be required to follow the written procedures for taking attendance that are provided in the staff handbook.