Inspection · 2024-11-04
Date
2024-11-04
Complaint Related
No
Licensing Inspector
Angela Farmer
(276) 608-2283
(276) 608-2283
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.
8VAC20-770 Background Checks
20 Access to minor?s records
22.1 Early Childhood Care and Education
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced, on-site monitoring inspection was initiated on 11/4/2024 and completed on 11/14/2024, as a part of the conditional licensure period. The on-site inspection began at 12:52 pm and ended at 4:10 pm. The inspector reviewed compliance in the areas listed above. There were 52 children present and 19 staff. The inspector reviewed five children?s records and five staff records on-site. This inspection included:document review, tour of the facility,and interviews.
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 violation will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on 11/21/24. A POC submitted after this date will not appear on the public website.
Violations
20Standard 22.1-289.011-F
The license and any other documents required by the Superintendent shall be posted in a conspicuous place on the licensed premises.
The current Conditional license and the Violation Notice dated 9/4/24 was not posted in a conspicuous place.
The current Conditional license and the Violation Notice dated 9/4/24 was not posted in a conspicuous place.
Plan of Correction: License and violation notice are posted.
Standard 22.1-289.035-B-2
Providers must obtain a completed national criminal background check prior to the employees? first day of employment.
Staff #1, who had been employed for two months, did not have a completed national criminal background check.
Staff #1, who had been employed for two months, did not have a completed national criminal background check.
Plan of Correction: All fingerprinting background checks are done.
Standard 22.1-289.035-B-3
The center must request a search of the central registry prior to the employee?s first day of employment.
Staff #2, who had been employed for two months, Staff #4,who had been employed two and a half months, and Staff # 5 who had been employed for four months, did not have a central registry search requested. Staff #2 & 5 were working with the children in the same classroom.
Staff #2, who had been employed for two months, Staff #4,who had been employed two and a half months, and Staff # 5 who had been employed for four months, did not have a central registry search requested. Staff #2 & 5 were working with the children in the same classroom.
Plan of Correction: Central registry searches have been submitted for all staff. Prior to first day, we will request searches.
Standard 22.1-289.035-B-4
The center is required to obtain background checks from any state in which the individual has resided in the preceding five years.
Staff #3, employed for two months, did not have documentation of requesting a central registry check from one state they resided in the past five years and no documentation of requesting a central registry check or criminal history check from a different state.
Staff #3, employed for two months, did not have documentation of requesting a central registry check from one state they resided in the past five years and no documentation of requesting a central registry check or criminal history check from a different state.
Plan of Correction: Employee will have searches requested from out of state.
Standard 8VAC20-780-130-A
SYSTEMIC DEFICIENCY
The center shall obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center.
Child record #5 did not have an immunization record on file. Child #5 has been in care for two months.
The center shall obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center.
Child record #5 did not have an immunization record on file. Child #5 has been in care for two months.
Plan of Correction: Will get requested information from parents.
Standard 8VAC20-780-140-A
SYSTEMIC DEFICIENCY
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.
Child record #5, did not have a physical examination on file. Child #5 has been in care for two months.
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.
Child record #5, did not have a physical examination on file. Child #5 has been in care for two months.
Plan of Correction: Will request physical from parents.
Standard 8VAC20-780-160-A
SYSTEMIC DEFICIENCY
Each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children.
Staff #2 and #5, who have been actively working with children for the past two to four months, did not have documentation of a negative TB screening on file.
Each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children.
Staff #2 and #5, who have been actively working with children for the past two to four months, did not have documentation of a negative TB screening on file.
Plan of Correction: All staff are required to take 2 TB tests per Ballad Health, will get from HR.
Standard 8VAC20-780-240-B
Staff shall complete orientation training prior to working alone with children and no later than seven days of the date of assuming job responsibilities.
Staff #1-4, who have been actively working with children for two months, do not have documentation of orientation training on file.
Staff #1-4, who have been actively working with children for two months, do not have documentation of orientation training on file.
Plan of Correction: New staff will complete orientation and document it upon completion. Staff already hired will document.
Standard 8VAC20-780-280-B
Hazardous substances such as cleaning materials shall be kept in a locked place using a safe locking method that prevents access by children.
A spray bottle containing bleach and water was in an unlocked closet in the Elephant room.
Bleach and laundry detergent were on the counter in the laundry room, and the door was not locked.
A spray bottle containing bleach and water was in an unlocked closet in the Elephant room.
Bleach and laundry detergent were on the counter in the laundry room, and the door was not locked.
Plan of Correction: Teachers are aware they must lock at all times. Laundry detergent locks were installed.
Standard 8VAC20-780-40-M
SYSTEMIC DEFICIENCY
The center shall maintain a current written list of all children?s allergies, sensitivities, and dietary restrictions. This list shall be dated and kept confidential in each room or area where children are present.
The Badger and Panda rooms had food allergies listed. However, the lists were not dated.
The center shall maintain a current written list of all children?s allergies, sensitivities, and dietary restrictions. This list shall be dated and kept confidential in each room or area where children are present.
The Badger and Panda rooms had food allergies listed. However, the lists were not dated.
Plan of Correction: Allergies lists were posted in all rooms & kitchen. The lists will be dated.
Standard 8VAC20-780-500-B
Disposable diapers shall be disposed in a leakproof or plastic line storage system that is either foot-operated or used in such a way the neither the staff member?s hand not the soiled diaper touches an exterior surface of the storage system during disposal.
There were no foot pedal operated trash cans in the Badger rooms.
There were no foot pedal operated trash cans in the Badger rooms.
Plan of Correction: Foot pedal trash cans were purchased for all rooms.
Standard 8VAC20-780-540-E
The following non-medical emergency supplies shall be required on each floor of the building: one working, battery operated flashlight and one working, battery operated radio.
The center did not have a radio or flashlight.
The center did not have a radio or flashlight.
Plan of Correction: Both were purchased and on site.
Standard 8VAC20-780-550-C
SYSTEMIC DEFICIENCY
Emergency evacuation and shelter-in-place procedures or maps shall be posted in a location conspicuous to staff and children.
There were no emergency evacuation and shelter-in-place procedures or maps posted at the center.
Emergency evacuation and shelter-in-place procedures or maps shall be posted in a location conspicuous to staff and children.
There were no emergency evacuation and shelter-in-place procedures or maps posted at the center.
Plan of Correction: Maps are posted in all rooms. Emergency plans are completed and printed.
Standard 8VAC20-780-550-D
SYSTEM DEFICIENCY
The center shall implement a monthly practice evacuation drill.
There were no monthly evacuation drills practiced for September or October 2024.
The center shall implement a monthly practice evacuation drill.
There were no monthly evacuation drills practiced for September or October 2024.
Plan of Correction: Discussed protocol with Ballad Health about implementing firs drills.
Standard 8VAC20-780-550-I
The center shall have posted in a visible place at each telephone, a 911 or local dial number for police, fire and emergency medical services and the number of the regional poison control center.
No emergency numbers were posted at the center.
No emergency numbers were posted at the center.
Plan of Correction: Emergency contact numbers were placed at all phones.
Standard 8VAC20-780-560-F
Centers providing meals and snacks shall follow the most recent, age-appropriate nutritional requirements of the Child and Adult Care Food Program of the United States Department of Agriculture (USDA).
Three of the five required nutritional components were not present at breakfast. Five of the required nutritional components were not present at lunch. Two of the five required nutritional components were not present at snack.
The Pandas classroom had Goldfish and water for snack.
The breakfast menu listed: waffle & juice or muffin & orange juice. The lunch menu listed juice on various days. The snack menu listed water or juice and one other component.
Three of the five required nutritional components were not present at breakfast. Five of the required nutritional components were not present at lunch. Two of the five required nutritional components were not present at snack.
The Pandas classroom had Goldfish and water for snack.
The breakfast menu listed: waffle & juice or muffin & orange juice. The lunch menu listed juice on various days. The snack menu listed water or juice and one other component.
Plan of Correction: We met with a nutritionist from WCPS and created a 2 week alternating menu that is USDA compliant..
Standard 8VAC20-780-570-E
Prepared infant formula shall be refrigerated, dated and labeled with the child?s name.
Two prepared bottles in the Badgers room did not have the date listed.
Two prepared bottles in the Badgers room did not have the date listed.
Plan of Correction: Bottles will be dated with tape, with names.
Standard 8VAC20-780-60-A
SYSTEMIC DEFICIENCY
Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain.
Child?s record # 3 was missing the sex and address of the child. Child record #2 was missing the parents place of work and work phone. Child record?s #2 & 3 are missing the physician?s name and phone number. Child records # 3 & # do not have the first day of attendance listed. Child records # 2, 3, and 4 does not address allergies. Child's record #2 did not have documentation of viewing proof of child's identity and age. All children listed have been in care one to two months.
Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain.
Child?s record # 3 was missing the sex and address of the child. Child record #2 was missing the parents place of work and work phone. Child record?s #2 & 3 are missing the physician?s name and phone number. Child records # 3 & # do not have the first day of attendance listed. Child records # 2, 3, and 4 does not address allergies. Child's record #2 did not have documentation of viewing proof of child's identity and age. All children listed have been in care one to two months.
Plan of Correction: We will talk with Head Start about providing up to date documents. Files will be searched for errors and we will get the needed information.
Standard 8VAC20-780-70
SYSTEMIC DEFICIENCY
The following staff records shall be kept for each staff person.
4-Staff #1-5, who has been actively working at the center for the past one to four months, did not have documentation to demonstrate that the individual possesses the education and experience required by the job description.
Staff # 1-5, who have been actively working with children for up to four months, do not have documentation on file that they meet the qualifications to be a program leader.
2-Documentation of a least two references to character, reputation, and competency are to be checked prior to employment.
Staff #1-4, who have been actively working at the center for the past two months, did not have any completed reference verifications on file.
7-Information, to be kept at the center, about any health problems that may interfere with job responsibilities.
Staff #1-5, who have been actively working at the center for the past two to four months, did not have information at the center regarding any health problems.
The following staff records shall be kept for each staff person.
4-Staff #1-5, who has been actively working at the center for the past one to four months, did not have documentation to demonstrate that the individual possesses the education and experience required by the job description.
Staff # 1-5, who have been actively working with children for up to four months, do not have documentation on file that they meet the qualifications to be a program leader.
2-Documentation of a least two references to character, reputation, and competency are to be checked prior to employment.
Staff #1-4, who have been actively working at the center for the past two months, did not have any completed reference verifications on file.
7-Information, to be kept at the center, about any health problems that may interfere with job responsibilities.
Staff #1-5, who have been actively working at the center for the past two to four months, did not have information at the center regarding any health problems.
Plan of Correction: Director will have staff provide requested documents. The information is on file at Ballad Health HR, but they will not release the requested documents.
Standard 8VAC20-780-90-A
SYSTEMIC DEFICIENCY
A written agreement between the parent and the center shall be in each child?s record by the first day of the child?s attendance.
Child?s records # 2 & 3 did not have a written agreement with the center on file. Child #2 & 3 have been in care for two months.
A written agreement between the parent and the center shall be in each child?s record by the first day of the child?s attendance.
Child?s records # 2 & 3 did not have a written agreement with the center on file. Child #2 & 3 have been in care for two months.
Plan of Correction: Will give model form to Head Start parents to fill out.