Inspection · 2023-05-08
Date
2023-05-08
Complaint Related
No
Licensing Inspector
Katie Gifford
(276) 698-9981
(276) 698-9981
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.
8VAC20-820 HEARINGS PROCEDURES. 8VAC20-770 Background Checks
Inspector Notes
An unannounced non-mandated 60 day inspection was completed on 05/08/2023 from 9:55am until 1:40pm. There were 16 children in care with 8 staff supervising. The licensee/owner was present as well as two another staff. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of 5 child records and 6 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.
The inspector discussed with the licensee the need for safety procedures and close supervision of children when on the playground due to the location of the playground being adjacent to the parking lot and two streets.
As per 8VAC20-820-80, when the conditional period is over, the facility must substantially meet the standards or be denied a license.
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 five (5) business days from today. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction should contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person or person(s) responsible for implementation.
Thank you for you cooperation.
Violations
15Standard 22.1-289.035-B-2
Based on record review and interview, the center failed to have fingerprint results prior to first day of employment.
Evidence:
1. There were no fingerprint results for staff #2 (DOH 1/3/23), staff #3 (DOH 3/27/23), staff #4 (DOH 3/27/23), staff #5 (DOH 1/3/23), staff #6 (DOH 3/27/23) and staff #7 (DOH 5/3/23). 2. Staff #8 verified there were no fingerprint resultson file.
Evidence:
1. There were no fingerprint results for staff #2 (DOH 1/3/23), staff #3 (DOH 3/27/23), staff #4 (DOH 3/27/23), staff #5 (DOH 1/3/23), staff #6 (DOH 3/27/23) and staff #7 (DOH 5/3/23). 2. Staff #8 verified there were no fingerprint resultson file.
Plan of Correction: Staff have been signed up with field print for fingerprinting to be completed.
Standard 8VAC20-770-60-B
Based on record review and interview, the center failed to have employees complete a sworn disclosure statement before the hire date.
Evidence:
1. There were no sworn disclosure statements completed for staff #2 (DOH 1/3/23), staff #3 (DOH 3/27/23), staff #4 (DOH 3/27/23), staff #5 (DOH 1/3/23), staff #6 (DOH 3/27/23) and staff #7 (DOH 5/3/23). 2. Staff #8 verified there were no sworn disclsoures on file.
Evidence:
1. There were no sworn disclosure statements completed for staff #2 (DOH 1/3/23), staff #3 (DOH 3/27/23), staff #4 (DOH 3/27/23), staff #5 (DOH 1/3/23), staff #6 (DOH 3/27/23) and staff #7 (DOH 5/3/23). 2. Staff #8 verified there were no sworn disclsoures on file.
Plan of Correction: Corrected during inspection.
Standard 8VAC20-770-60-C-2
Based on record review and interview, the center failed to have central registry findings within 30 days of employment.
Evidence:
1. There were no central registry findings for staff #2 (DOH 1/3/23), staff #3 (DOH 3/27/23), staff #4 (DOH 3/27/23), staff #5 (DOH 1/3/23), staff #6 (DOH 3/27/23) and staff #7 (DOH 5/3/23). 2. Staff #8 verified there were no central registry's on file.
Evidence:
1. There were no central registry findings for staff #2 (DOH 1/3/23), staff #3 (DOH 3/27/23), staff #4 (DOH 3/27/23), staff #5 (DOH 1/3/23), staff #6 (DOH 3/27/23) and staff #7 (DOH 5/3/23). 2. Staff #8 verified there were no central registry's on file.
Plan of Correction: Central registry on current staff will be processed; new hires will be done within 7 days of hire and in employee file within 30 days.
Standard 8VAC20-780-140-A
Based on record review and interview, the center failed to have a physical examination for each child within 30 days of enrollment.
Evidence:
1. Five children's records were reviewed; none had physical examinations. 2. Staff #1 verified that the physicals were not in the file.
Evidence:
1. Five children's records were reviewed; none had physical examinations. 2. Staff #1 verified that the physicals were not in the file.
Plan of Correction: An email to parents will sent out asking for a physical for each child.
Standard 8VAC20-780-160-A
Based on record review, staff members did not have documentation of TB screening submitted at the time of employment and prior to coming into contact with children.
Evidence:
1. Staff #2, #3, #$ #4 did not have TB screening in their file. Staff #7 had a TB screening dated 10/21/22, the DOH was 5/3/2023.
Evidence:
1. Staff #2, #3, #$ #4 did not have TB screening in their file. Staff #7 had a TB screening dated 10/21/22, the DOH was 5/3/2023.
Plan of Correction: TB screenings will be completed.
Standard 8VAC20-780-240-B
Based on record review, staff had not completed orientation training in subsection C of this section prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities.
Evidence:
Staff #3, (DOH 3/27/23) #6, and #7 (DOH 5/3/23) had no documentation of orientation.
Evidence:
Staff #3, (DOH 3/27/23) #6, and #7 (DOH 5/3/23) had no documentation of orientation.
Plan of Correction: Staff orientation documentation to be transferred and documented on staff orientation model form.
Standard 8VAC20-780-240-E
Based on record review, the center failed to have, within 30 days of the first day of employment, staff must complete orientation training in first aid and cardiopulmonary resuscitation (CPR), as appropriate to the age of the children in care.
Evidence:
Staff #3 was hired 3/27/23, staff #6 DOH 3/27/23 and there was no faid and cpr orientation documentation in the file.
Evidence:
Staff #3 was hired 3/27/23, staff #6 DOH 3/27/23 and there was no faid and cpr orientation documentation in the file.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-280-B
Based on observation, there was a hazardous substance not locked.
Evidence:
There was Lysol under the staff bathroom sink and the cabinet was not locked and the door to the bathroom was not locked.
Evidence:
There was Lysol under the staff bathroom sink and the cabinet was not locked and the door to the bathroom was not locked.
Plan of Correction: Corrected during the inspection.
Standard 8VAC20-780-340-D
Based on record review and interview, the center failed to have in each grouping of children at least one staff member who meets the qualifications of a program leader or program director regularly present. Such a program leader shall supervise no more than two aides.
Evidence:
1. Staff #1 stated and verified that she floated between toddler room #1 and toddler room #2 and that the regular staff in those classrooms were not lead qualified. Staff #3 was acting as a lead teacher in infant room #1 and there was no verification of lead teacher qualifications in the staff record. Staff #6 was acting as the lead teacher in infant room #2 and there was no verification of lead teacher qualifications in the staff record.
Evidence:
1. Staff #1 stated and verified that she floated between toddler room #1 and toddler room #2 and that the regular staff in those classrooms were not lead qualified. Staff #3 was acting as a lead teacher in infant room #1 and there was no verification of lead teacher qualifications in the staff record. Staff #6 was acting as the lead teacher in infant room #2 and there was no verification of lead teacher qualifications in the staff record.
Plan of Correction: Qualifications and training documents will be documented and put into employee files within a week.
Standard 8VAC20-780-500-B
Based on observation, the center failed to have diapers being disposed of in a storage system that is either foot -operated or used in such a a way that neither the staff member's hands nor the soiled diaper touches an exterior surface of the storage system during disposal.
Evidence:
1. There were diaper pails that had to be operated by hand to open in the 2-3's room and in the infant room.
Evidence:
1. There were diaper pails that had to be operated by hand to open in the 2-3's room and in the infant room.
Plan of Correction: New diaper pails that are foot operated will be purchased.
Standard 8VAC20-780-510-E
Based on record review, the center did not follow the required standards for administering medications.
Evidence:
1. Child #6 was given non-prescription medication that was not consistent with the manufacturer's instructions for age, duration and dosage. The pain reliever medication label states it is for only 6 months and up. Child was administered the medication on 4/11/23 and 4/12/23. Child was under 6 months old when administered the medication.
2. Child #6 had an authorization for non prescription medication but it had not been renewed every 10 days and a physician had not provided written authorization for it to be administered longer than 10 days.
Evidence:
1. Child #6 was given non-prescription medication that was not consistent with the manufacturer's instructions for age, duration and dosage. The pain reliever medication label states it is for only 6 months and up. Child was administered the medication on 4/11/23 and 4/12/23. Child was under 6 months old when administered the medication.
2. Child #6 had an authorization for non prescription medication but it had not been renewed every 10 days and a physician had not provided written authorization for it to be administered longer than 10 days.
Plan of Correction: If a child has a medication the parent will obtain written documentation from their physician for the use of the medication.
Standard 8VAC20-780-520-B
Based on observation, the center did not keep sunscreen in accessible to children under five years of age.
Evidence:
1. In the preschool classroom there was a kids sunscreen spray bottle on the floor on top of an opened yellow back pack.
Evidence:
1. In the preschool classroom there was a kids sunscreen spray bottle on the floor on top of an opened yellow back pack.
Plan of Correction: Corrected during inspection. An email will be sent out to parents asking them to not put medication, sunscreen, or diaper cream in their diaper bags.
Standard 8VAC20-780-550-D
Based on record review, the center failed to have a monthly practice evacuation drill.
Evidence:
1. The center was missing an emergency drill for the month of April.
Evidence:
1. The center was missing an emergency drill for the month of April.
Plan of Correction: Perform evacuation drills twice in the month of May.
Standard 8VAC20-780-570-E
Based on observation, the center did not have infant bottles dated and labeled with the child's name.
Evidence:
1. In the infant room there was one bottle with the name but not dated, and another bottle with no name or date.
Evidence:
1. In the infant room there was one bottle with the name but not dated, and another bottle with no name or date.
Plan of Correction: All bottles will be labeled with the child's name and dated.
Standard 8VAC20-780-70
Based on record review and staff interview, the following information was not kept for each staff person:
Evidence:
1. Staff #2 did not have address, phone #, emergency contact info., health info., two references. Staff #3 did not have emerg. contact info., qualifications for position, and one reference. Staff #4 did not have emerg. contact info., two references, health info. Staff #5 did not have emerg. contact info., two references, and health info. Staff #6 did not have emerg. info., health info., two references, or qualifications for the position. Staff #7 did not have emer. info., health info., two references, or qualifications for the position.
Evidence:
1. Staff #2 did not have address, phone #, emergency contact info., health info., two references. Staff #3 did not have emerg. contact info., qualifications for position, and one reference. Staff #4 did not have emerg. contact info., two references, health info. Staff #5 did not have emerg. contact info., two references, and health info. Staff #6 did not have emerg. info., health info., two references, or qualifications for the position. Staff #7 did not have emer. info., health info., two references, or qualifications for the position.
Plan of Correction: The required information will be added to the staff files.