Inspection · 2024-02-12
Date
2024-02-12
Complaint Related
No
Licensing Inspector
Margaret Allworth
(703) 209-3521
(703) 209-3521
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 & Neglect
Inspector Notes
An unannounced renewal inspection was conducted today from 9:30am-1:30pm. There were 51 children directly supervised by 12 staff. The physical plant, 8 staff records, 5 children?s records, medications, evacuation drills, injury reports, emergency supplies, and policies were inspected. Children were observed participating in group play, reading books, playing outside, painting and getting ready for lunch. Diapering and hand-washing procedures were also observed. There was an assortment of age appropriate materials for the children in care. There was an adequate number of staff with current certification in MAT, CPR and First Aid, as well as DHO training. Staff-to-child ratios were in compliance. Areas of non-compliance are identified in the Violation Notice.
If you have any questions regarding this inspection, please contact the Licensing Inspector, Nancy Radcliffe nancy.radcliffe@doe.virginia.gov or 703-268-3728.
Please submit your plan of correction within five business days in order for it to be included on the public website.
Violations
8Standard 22.1-289.035-B-2
Based on review of staff records, not all staff submitted to fingerprinting and obtained an eligible letter of employment before their first day of employment.
Evidence
The first day of employment for staff #2 was 12/4/2023, the fingerprint letter of eligibility was dated 12/14/2023.
Eligibility letter was dated after their first day of employment.
Evidence
The first day of employment for staff #2 was 12/4/2023, the fingerprint letter of eligibility was dated 12/14/2023.
Eligibility letter was dated after their first day of employment.
Plan of Correction: All fingerprints will be secured prior to employee start date.
Standard 22.1-289.035-B-4
Based on review of staff records, the center did not obtain a copy of the results of a criminal history record information check and a search of the child abuse and neglect registry for staff who have lived out of the state of Virginia within the past five years.
Evidence
Staff #1, 2 and 3 do not have documentation of results of a criminal history record information check and a search of the child abuse and neglect registry and have lived outside the state of Virginia within the past five years.
Evidence
Staff #1, 2 and 3 do not have documentation of results of a criminal history record information check and a search of the child abuse and neglect registry and have lived outside the state of Virginia within the past five years.
Plan of Correction: Prior to an employee starting work, we conduct a background check for those who have lived out of state, and those who have only lived in VA--the background check includes:
All national jurisdiction criminal check (including county level data)
FBI/National Criminal Database
Social Security trace
Education Verification
National Sex Offender database
Our check covers seven years, while Virginia's requirement is five years.
No employee is allowed to be on premise until we receive those results. All results were made available to inspectors on the day of inspection. Our understanding is that we received this finding because we contract with a third party vendor as opposed to contacting all state agencies individually by a Brynmor team member. Our investigation is at our expense and is more rigorous than what the state requires.
We have appealed this finding to ask the state to accept our more comprehensive records check procedure. We will continue to conduct background checks per the description for all Brynmor employees, both those who have lived in state and out of state as this issue goes through the appeal process.
All national jurisdiction criminal check (including county level data)
FBI/National Criminal Database
Social Security trace
Education Verification
National Sex Offender database
Our check covers seven years, while Virginia's requirement is five years.
No employee is allowed to be on premise until we receive those results. All results were made available to inspectors on the day of inspection. Our understanding is that we received this finding because we contract with a third party vendor as opposed to contacting all state agencies individually by a Brynmor team member. Our investigation is at our expense and is more rigorous than what the state requires.
We have appealed this finding to ask the state to accept our more comprehensive records check procedure. We will continue to conduct background checks per the description for all Brynmor employees, both those who have lived in state and out of state as this issue goes through the appeal process.
Standard 8VAC20-770-60-C-2
Based on review of staff records, the center did not have a central registry finding within 30 days of employment for all staff.
Evidence
Staff #1 first day of employment 12/4/2023 does not have documentation of a central registry finding available for review during the inspection. There was no follow up on the missing background check within the 30 days, follow up was conducted on 2/2/2024.
Staff #4, first day of employment 12/4/2023 does not have documentation of a central registry finding available for review during the inspection. There is no documentation of follow up on missing background check.
Evidence
Staff #1 first day of employment 12/4/2023 does not have documentation of a central registry finding available for review during the inspection. There was no follow up on the missing background check within the 30 days, follow up was conducted on 2/2/2024.
Staff #4, first day of employment 12/4/2023 does not have documentation of a central registry finding available for review during the inspection. There is no documentation of follow up on missing background check.
Plan of Correction: All paperwork was submitted to Central Registry upon job offer for each employee. We will check-in with Central Registry a minimum of every 30 days until we receive the results. In the meantime, Brynmor, at its own expense, conducts separate full national criminal background and sex offender checks on all employees and obtain results prior to their first day of employment.
Standard 8VAC20-780-140-B
Based on review of children's records, the center did not obtain a physical examination prior to their first day of attendance that was completed within the time period required.
Evidence
The record for child # 1 (3 year old), first day of attendance 10/16/2023, has a physical dated 9/12/2022, which is not within 12 months prior to their first day of attendance.
Evidence
The record for child # 1 (3 year old), first day of attendance 10/16/2023, has a physical dated 9/12/2022, which is not within 12 months prior to their first day of attendance.
Plan of Correction: We will obtain an updated physical record from that child's family and ensure it is in the proper file.
Standard 8VAC20-780-160-A
Based on review of staff records, each staff member did not submit documentation of a negative tuberculosis (TB) screening before their first day of employment.
Evidence
Staff #1, first day of employment 12/4/2023, TB dated 12/8/2023.
Staff #2, first day of employment 12/4/2023, TB dated 3/13/2023
Staff #4, first day of employment 12/4/2023, TB dated 12/6/2024
Staff # 5, first day of employment 1/16/2024, TB dated 1/31/2024
Staff #6, first day of employment 1/16/2024, TB dated 2/2/2024
Evidence
Staff #1, first day of employment 12/4/2023, TB dated 12/8/2023.
Staff #2, first day of employment 12/4/2023, TB dated 3/13/2023
Staff #4, first day of employment 12/4/2023, TB dated 12/6/2024
Staff # 5, first day of employment 1/16/2024, TB dated 1/31/2024
Staff #6, first day of employment 1/16/2024, TB dated 2/2/2024
Plan of Correction: All TB screening will occur within 30 days of the start date of employment.
Standard 8VAC20-780-240-B
REPEAT VIOLATION
Based on review of staff records, all staff did not 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 #2, first day of employment 1/1/6/2024, does not have documentation of orientation available for review.
Based on review of staff records, all staff did not 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 #2, first day of employment 1/1/6/2024, does not have documentation of orientation available for review.
Plan of Correction: All Brynmor staff complete a week of training prior to moving into a classroom. One of the staff records that was reviewed did complete the training; however, we did not properly document it in their files. We will ensure proper documentation exists in all staff records.
Standard 8VAC20-780-280-B
Based on observation, hazardous substances were not kept in a locked place using a safe locking method that prevents access by children.
Evidence
In the Toddler classroom, shaving cream (keep out of reach of children) was located on the bottom shelf of an unlocked cabinet.
Evidence
In the Toddler classroom, shaving cream (keep out of reach of children) was located on the bottom shelf of an unlocked cabinet.
Plan of Correction: Children regularly paint and engage in developmental activities with shaving cream per our HighScope curriculum which is approved by the Virginia State Department of Education. We will ensure shaving cream is stored properly at all times. Corrected during inspection
Standard 8VAC20-780-70
Based on review of staff records, not all records contained the required information.
Evidence
The record for staff #5 & 6 does not contain the name, address and telephone number of a person to be notified in an emergency.
All staff records do not contain the address for the emergency contact.
Evidence
The record for staff #5 & 6 does not contain the name, address and telephone number of a person to be notified in an emergency.
All staff records do not contain the address for the emergency contact.
Plan of Correction: Prior to start date, all staff have their emergency contacts, including addresses, identified in our electronic human resource system. During the time of inspection, our onsite staff was unclear on how to access those records.