Inspection · 2024-02-21
Date
2024-02-21
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
22.1 BACKGROUND CHECKS, CODE, CARBON MONOXIDE
Inspector Notes
An unannounced monitoring inspection for a Conditional License was conducted on 02/21/2024. There were 17 children, ages 4 months-4 years, and 10 staff members present during the inspection. The inspector reviewed compliance in the areas of administration, staff qualifications and trainings, staff and supervision, physical plant, programs, emergencies, and nutrition. The children were observed in arts and craft/learning activities, free choice activities, during lunch, and during rest time; infants were observed sleeping and being fed on demand. A total of 5 children?s records, 5 staff records and 1 medication was reviewed. The inspector discussed the following with center staff: handwashing, sanitizing, required documentation, outdoor play, and program administration. The inspector arrived for the inspection at 9:45 am and departed the center at 12:45 pm.
Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the provider.
Violations
6Standard 22.1-289.035-B-2
Based on document review and staff interviews, the center failed to ensure that no person shall be hired for compensated employment prior to the facility obtaining an employment eligibility letter upon the completion of a fingerprint background check as required by the Code of Virginia.
Evidence:
1. Staff 6 verified that the hire date for Staff 2 was 02/20/2024. There was not an employment eligibility letter available for review during the 02/21/2024 inspection. Staff 2 was observed working during the 02/21/2024 inspection.
2. Staff 6 verified that the hire date for Staff 4 was 12/10/2023. The employment eligibility letter was dated 12/15/2024.
Evidence:
1. Staff 6 verified that the hire date for Staff 2 was 02/20/2024. There was not an employment eligibility letter available for review during the 02/21/2024 inspection. Staff 2 was observed working during the 02/21/2024 inspection.
2. Staff 6 verified that the hire date for Staff 4 was 12/10/2023. The employment eligibility letter was dated 12/15/2024.
Plan of Correction: Will not hire staff until the eligibility letter is received.
Standard 8VAC20-770-60-B
Based on record review, the center failed to ensure that an employee must not be employed until the agency has the person?s completed sworn statement or affirmation.
Evidence:
1. Staff 6 verified that the hire date for Staff 2 was 02/20/2024. The sworn statement in the record for Staff 2 was not dated.
2. Staff 6 verified that the hire date for Staff 4 was 12/10/2023. The sworn statement in the record for Staff 4 was dated 12/18/2023.
Evidence:
1. Staff 6 verified that the hire date for Staff 2 was 02/20/2024. The sworn statement in the record for Staff 2 was not dated.
2. Staff 6 verified that the hire date for Staff 4 was 12/10/2023. The sworn statement in the record for Staff 4 was dated 12/18/2023.
Plan of Correction: Will add the sworn statement to the application to make sure its completed before employment.
Standard 8VAC20-780-130-A
Based on staff interviews, the center failed to obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center.
Evidence: Staff 6 verified that the first date of attendance for Child 2 was 01/03/2024; the immunization record for Child 2 was dated 01/23/2024.
Evidence: Staff 6 verified that the first date of attendance for Child 2 was 01/03/2024; the immunization record for Child 2 was dated 01/23/2024.
Plan of Correction: Will get prior to attendance.
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 sever days of the date of assuming job responsibilities.
Evidence:
1. Staff 6 verified the hire date for Staff 1 was 02/08/2024; the record for Staff 1 did not contain documentation that Staff 1 has completed orientation training. Staff 1 was observed working during the 02/21/2024 inspection.
2. The record for Staff 3 contained a documented hire date of 12/13/2023. The record for Staff 3 did not contain documentation that Staff 3 has completed orientation training. Staff 3 was observed working during the 02/21/2024 inspection.
3. Staff 6 verified the hire date for Staff 4 was 02/10/2024; the record for Staff 4 did not contain documentation that Staff 4 has completed orientation training. Staff 4 was observed working during the 02/21/2024 inspection.
4. Staff 6 verified the hire date for Staff 5was 01/29/2024; the record for Staff 5 did not contain documentation that Staff 5 has completed orientation training. Staff 5 was observed working during the 02/21/2024 inspection.
Evidence:
1. Staff 6 verified the hire date for Staff 1 was 02/08/2024; the record for Staff 1 did not contain documentation that Staff 1 has completed orientation training. Staff 1 was observed working during the 02/21/2024 inspection.
2. The record for Staff 3 contained a documented hire date of 12/13/2023. The record for Staff 3 did not contain documentation that Staff 3 has completed orientation training. Staff 3 was observed working during the 02/21/2024 inspection.
3. Staff 6 verified the hire date for Staff 4 was 02/10/2024; the record for Staff 4 did not contain documentation that Staff 4 has completed orientation training. Staff 4 was observed working during the 02/21/2024 inspection.
4. Staff 6 verified the hire date for Staff 5was 01/29/2024; the record for Staff 5 did not contain documentation that Staff 5 has completed orientation training. Staff 5 was observed working during the 02/21/2024 inspection.
Plan of Correction: Will do orientation with all staff.
Standard 8VAC20-780-60-A
Based on record review, the center failed to ensure that the separate record for each child enrolled contains all of the elements as required by the standards.
Evidence:
1. The record for Child 1 did not contain the following information: the name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (there was no addresses provided for the first designated person); chronic physical problems and pertinent developmental information and any special accommodations needed; and the name of any additional programs or schools that the child is concurrently attending and the grade or class level.
2. The record for Child 2 did not contain the following information: chronic physical problems and pertinent developmental information and any special accommodations needed; previous child day care and schools attended by the child; the name of any additional programs or schools that the child is concurrently attending and the grade or class level; and first date of attendance.
3. The record for Child 3 did not contain the following information: previous child day care and schools attended by the child; and the name of any additional programs or schools that the child is concurrently attending and the grade or class level.
4. The record for Child 4 did not contain the following information: the name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (there were no addresses provided for either designated person); chronic physical problems and pertinent developmental information and any special accommodations needed; previous child day care and schools attended by the child; and the name of any additional programs or schools that the child is concurrently attending and the grade or class level.
5. The record for Child 5 did not contain the following information: allergies and intolerance to medication or any other substances, and actions to take in an emergency situation; and chronic physical problems and pertinent developmental information and any special accommodations needed.
Evidence:
1. The record for Child 1 did not contain the following information: the name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (there was no addresses provided for the first designated person); chronic physical problems and pertinent developmental information and any special accommodations needed; and the name of any additional programs or schools that the child is concurrently attending and the grade or class level.
2. The record for Child 2 did not contain the following information: chronic physical problems and pertinent developmental information and any special accommodations needed; previous child day care and schools attended by the child; the name of any additional programs or schools that the child is concurrently attending and the grade or class level; and first date of attendance.
3. The record for Child 3 did not contain the following information: previous child day care and schools attended by the child; and the name of any additional programs or schools that the child is concurrently attending and the grade or class level.
4. The record for Child 4 did not contain the following information: the name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (there were no addresses provided for either designated person); chronic physical problems and pertinent developmental information and any special accommodations needed; previous child day care and schools attended by the child; and the name of any additional programs or schools that the child is concurrently attending and the grade or class level.
5. The record for Child 5 did not contain the following information: allergies and intolerance to medication or any other substances, and actions to take in an emergency situation; and chronic physical problems and pertinent developmental information and any special accommodations needed.
Plan of Correction: Will get the information from the parents today.
Standard 8VAC20-780-70
Based on record review, the center failed to ensure that staff records contain all of the elements required by the standards.
Evidence:
1.The record for Staff 1 did not contain the following information: job title; date of employment; and documentation that two or more references as to character and reputation as well as competency were checked before employment.
2. The record for Staff 2 did not contain the following information: job title; date of employment; documentation that two or more references as to character and reputation as well as competency were checked before employment; and documentation to demonstrate that the individual possesses the education, certification and experience required by the job position.
3. The record for Staff 3 did not contain the following information: documentation that two or more references as to character and reputation as well as competency were checked before employment (the telephone reference check did not include the date of contact; and signature of person making call).
4. The record for Staff 4 did not contain the following information: job title; date of employment 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 check and the telephone reference check did not include signature of person making call).
5. The record for Staff 5 did not contain the following information: job title; date of employment; and documentation that two or more references as to character and reputation as well as competency were checked before employment.
Evidence:
1.The record for Staff 1 did not contain the following information: job title; date of employment; and documentation that two or more references as to character and reputation as well as competency were checked before employment.
2. The record for Staff 2 did not contain the following information: job title; date of employment; documentation that two or more references as to character and reputation as well as competency were checked before employment; and documentation to demonstrate that the individual possesses the education, certification and experience required by the job position.
3. The record for Staff 3 did not contain the following information: documentation that two or more references as to character and reputation as well as competency were checked before employment (the telephone reference check did not include the date of contact; and signature of person making call).
4. The record for Staff 4 did not contain the following information: job title; date of employment 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 check and the telephone reference check did not include signature of person making call).
5. The record for Staff 5 did not contain the following information: job title; date of employment; and documentation that two or more references as to character and reputation as well as competency were checked before employment.
Plan of Correction: Going forward will have a new hiring process to get all information at hire. Will get the missing information into the records.