Inspection · 2024-07-30
Date
2024-07-30
Complaint Related
No
Licensing Inspector
D'Nae Goodwin
(757) 404-3063
(757) 404-3063
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
8VAC20-800 Administration
8VAC20-800 Personnel
8VAC20-800 Household Members
8VAC20-800 Physical Health of Caregivers and Household members
8VAC20-800 Caregiver Training
8VAC20-800 Physical Equipment and Environment
8VAC20-800 Care of Children
8VAC20-800 Preventing the Spread of Disease
8VAC20-800 Medication Administration
8VAC20-800 Emergencies
8VAC20-800 Nutrition
8VAC20-800 Transportation
8VAC20-820 THE LICENSE
8VAC20-770 Background Checks
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
54.1 Provider must be MAT certified to administer prescription medication.
Inspector Notes
An unannounced, on-site monitoring inspection was initiated and completed on July 30, 2024, as a part of the conditional licensure period. The on-site inspection began at 11:20am and ended at 2:50pm. The inspector reviewed compliance in the areas listed above. There were four children present and two caregivers; the point total was 15. The inspector reviewed four children?s records and three staff records on-site. This inspection included document review, tour of the facility, interviews, and observations. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations are documented on the violation notice issued to the program.
Please complete the plan of correction (POC) and date to be corrected sections for each violation cited on the violation notice. Specify how the deficient practice will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on August 16, 2024. A POC submitted after this date will not appear on the public website.
Violations
12Standard 22.1-289.035-B-3
Based on record review and interview the provider did not ensure that all staff have central registry results.
Evidence:
1.The record for Staff #2 (hired in 5/2024) did not contain central registry results.
2.Staff #1 confirmed that the central registry results for Staff #2 were not in their record.
Evidence:
1.The record for Staff #2 (hired in 5/2024) did not contain central registry results.
2.Staff #1 confirmed that the central registry results for Staff #2 were not in their record.
Plan of Correction: 1.)Provider email CRS and Inspector a Receipt for proof that CRS Requested was submitted for Staff before start date on 7/31/2024 . However, Provider still waiting on results. Provider will continue to send emails to CRS until request is complete. Provider will not start a employee within CRS request in the future until rule change.
Standard 8VAC20-800-150-D-1
Based on observation, record review, and interview the provider did not ensure that an assistant 18 years of age or older who is left alone with children in care has current certification in cardiopulmonary resuscitation (CPR).
Evidence:
1.Upon arrival, Staff #2, an assistant, was observed caring for four children in care.
a. Staff #2 was observed working alone for approximately five minutes.
2. There was no documentation that Staff #2 has current CPR certification.
3. Staff #1 confirmed that Staff #2 does not have current CPR certification.
Evidence:
1.Upon arrival, Staff #2, an assistant, was observed caring for four children in care.
a. Staff #2 was observed working alone for approximately five minutes.
2. There was no documentation that Staff #2 has current CPR certification.
3. Staff #1 confirmed that Staff #2 does not have current CPR certification.
Plan of Correction: 1. Provider Staff has Taken First Aid/CPR course as of 08/03/2024. Provider will ensure all care givers have all certification before being left unattended for any period of time.
Standard 8VAC20-800-150-D-2
Based on observation, record review, and interview the provider did not ensure that an assistant 18 years of age or older who is left alone with children in care has current certification in first aid.
Evidence:
1.Upon arrival, Staff #2, an assistant, was observed caring for four children in care.
a. Staff #2 was observed working alone for approximately five minutes.
2.There was no documentation that Staff #2 has current first aid certification.
3. Staff #1 confirmed that Staff #2 does not have current first aid certification.
Evidence:
1.Upon arrival, Staff #2, an assistant, was observed caring for four children in care.
a. Staff #2 was observed working alone for approximately five minutes.
2.There was no documentation that Staff #2 has current first aid certification.
3. Staff #1 confirmed that Staff #2 does not have current first aid certification.
Plan of Correction: 1. Provider Staff has Taken First Aid/CPR course as of 08/03/2024. Provider will ensure all care givers have all certification before being left unattended for any period of time.
Standard 8VAC20-800-170-B
Based on record review the provider did not ensure that tuberculosis (TB) forms submitted have been completed within the last 30 days.
Evidence:
1.The TB screening in Staff #2?s record (hired in 5/2024) was dated for 12/13/23, which was not within the required 30-day timeframe.
Evidence:
1.The TB screening in Staff #2?s record (hired in 5/2024) was dated for 12/13/23, which was not within the required 30-day timeframe.
Plan of Correction: 1.Provider staff received her screening on 08/03/2024 and is filed in her folder. Provider ensure TB test are done at the appropriate timeframe before hire.
Standard 8VAC20-800-200-C
Based on record review the provider did not ensure that documentation of orientation is signed and dated by the provider and assistant.
Evidence:
1.The records for Staff #2 and Staff #3 did not have documentation to show that orientation was completed, dated and signed by the provider and assistant.
Evidence:
1.The records for Staff #2 and Staff #3 did not have documentation to show that orientation was completed, dated and signed by the provider and assistant.
Plan of Correction: 1.Provider has completed staff orientation. Document and file it in staff folder as of 07/31/2024. Provider will ensure orientation paperwork is in staff folder going forward per standards.
Standard 8VAC20-800-240-A
Repeat Violation
Based on observation and interview the provider did not ensure that areas and furnishings of the family day home are maintained in a safe condition.
Evidence:
1.A television cord was hanging down and in reaching distance from an infant crib.
2.There were a bunch of loose cords on the floor in the entertainment room.
a. Three infants, one who was crawling, were observed in this room.
3.Staff #1 (provider) confirmed that the wires found in the entertainment room and infant room were accessible to the children in care.
Based on observation and interview the provider did not ensure that areas and furnishings of the family day home are maintained in a safe condition.
Evidence:
1.A television cord was hanging down and in reaching distance from an infant crib.
2.There were a bunch of loose cords on the floor in the entertainment room.
a. Three infants, one who was crawling, were observed in this room.
3.Staff #1 (provider) confirmed that the wires found in the entertainment room and infant room were accessible to the children in care.
Plan of Correction: 1.Provider use duct tape and wire taps to secure wires in all areas. Provider will monitor wires for secureness and placement, making sure it is not accessible to children.
Standard 8VAC20-800-530-B
Based on observation the provider did not ensure that cribs when being used by infants have a tight-fitting bottom cover.
Evidence:
1.Three of three infant cribs did not have a tight-fitting bottom. The crib sheets on the mattresses were loose fitting.
Evidence:
1.Three of three infant cribs did not have a tight-fitting bottom. The crib sheets on the mattresses were loose fitting.
Plan of Correction: 1.Provider order new sheets and sheet tighteners to secure and tighten sheets properly. Provider will ensure sheets snuggly fit in the future.
Standard 8VAC20-800-540-B
Based on observation the provider did not ensure that infant walkers are not used at the family day home.
Evidence:
1. There was an infant walker located in the entertainment room of the family day home.
Evidence:
1. There was an infant walker located in the entertainment room of the family day home.
Plan of Correction: 1.Provider removed infant walker from daycare area as of 07/31/2024. Provider advised staff not to use for any reason going forward .
Standard 8VAC20-800-60-A
Based on record review the provider did not ensure that children?s records contain all the required information.
Evidence:.
1.The record for Child #2 was missing one parent?s phone number for their place of employment.
Evidence:.
1.The record for Child #2 was missing one parent?s phone number for their place of employment.
Plan of Correction: 1.Provider spoke to parent and included all important information required for all children in care as of 07/31/2024. Provider will perform a detail check of all enrollment documents going forward to ensure all important information is received per standard
Standard 8VAC20-800-680-B
Based on observation and interview the provider did not ensure that children?s hands are washed with liquid soap and warm running water after diapering.
Evidence:
1.After a diaper change, Child #3 was accompanied, by Staff #2, back into the entertainment room. The child?s hands were not washed.
a. Staff #2 confirmed that Child #3 did not wash their hands after the diaper change.
Evidence:
1.After a diaper change, Child #3 was accompanied, by Staff #2, back into the entertainment room. The child?s hands were not washed.
a. Staff #2 confirmed that Child #3 did not wash their hands after the diaper change.
Plan of Correction: 1.Provider coached staff of the importance of washing hands for both children and staff after each diaper change. Staff confirmed understanding as of 07/31/2024. Provider will monitor staff for improvement of this violation going forward.
Standard 8VAC20-800-70-A
Based on record review the provider did not ensure that before the child?s first day of attendance, parents are provided, in writing, all required information.
Evidence:
1.There was no documentation that the parents of Child #1 received provisions of the family day home?s emergency preparedness and response plan.
Evidence:
1.There was no documentation that the parents of Child #1 received provisions of the family day home?s emergency preparedness and response plan.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-800-760-A-1
Based on observation and interview the provider did not ensure that the first aid kit contained all the required emergency supplies.
Evidence:
1. The first aid kit reviewed did not contain more than one triangular bandage, which is required.
2.Staff #1 (provider) confirmed that the first aid kit only contained one triangular bandage.
Evidence:
1. The first aid kit reviewed did not contain more than one triangular bandage, which is required.
2.Staff #1 (provider) confirmed that the first aid kit only contained one triangular bandage.
Plan of Correction: 1.Provider order another triangular bandage for first aid kit on 08/01/2024. Provider will ensure the correct number of bandages is in first aid kit at all times per standard.