Inspection · 2022-08-31
Date
2022-08-31
Complaint Related
No
Licensing Inspector
Jennifer Moore
(540) 430-0384
(540) 430-0384
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 (8VAC20-770)
20 Access to minor's records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
The licensing inspector conducted an unannounced monitoring inspection on Wednesday, August 31, 2022 from 10:00am to approximately 2:00pm. There were a total of 102 children in care in the direct care of 19 staff members. During the inspection, the children and staff were observed participating in a variety of activities. Staff were observed having positive interactions with the children. All areas of the facility including classrooms, kitchen, hallways, and bathrooms were inspected. The required postings were reviewed and found to be in compliance. Medication is administered when required and medication and medication authorizations were reviewed. The center is equipped with toys and supplies and items were available to the children. During the inspection, ten children?s records and ten staff records were reviewed. Additional information was later submitted to the inspector and was reviewed virtually.
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.
Violations
10Standard 8VAC20-770-60-B
Based on a review of ten staff records and interview, the center did not obtain a completed sworn statement or affirmation for three staff members prior to employment.
Evidence: 1) The sworn statement in the record for Staff #2 (employed: 05/26/22) was dated 05/30/22. 2) The sworn statement in the record for Staff #4 (employed: 05/31/22) was dated 06/01/22. 3) The sworn statement in the record for Staff #5 (employed: 02/10/22) was dated 02/17/22. 4) During interview, Staff #11 reported the sworn statements for Staff #2, Staff #4, and Staff #5 were not completed prior to employment.
Evidence: 1) The sworn statement in the record for Staff #2 (employed: 05/26/22) was dated 05/30/22. 2) The sworn statement in the record for Staff #4 (employed: 05/31/22) was dated 06/01/22. 3) The sworn statement in the record for Staff #5 (employed: 02/10/22) was dated 02/17/22. 4) During interview, Staff #11 reported the sworn statements for Staff #2, Staff #4, and Staff #5 were not completed prior to employment.
Plan of Correction: Corrected. In the future, a sworn statement will be on file at the time of employment.
Standard 8VAC20-770-60-C-2
Based on a review of ten staff records and interviews, the center did not ensure that four staff members had a central registry finding within 30 days of employment.
Evidence: 1) The central registry finding in record for Staff #2 (employed: 05/26/22) was dated 07/21/22. 2) The record for Staff #4 (employed: 05/31/22) did not contain a central registry finding. Staff #11 reported the central registry finding for Staff #4 could not be located. 3) The central registry finding in the record for Staff #6 (employed: 01/22/22) was dated 02/28/22. 4) The record for Staff #8 (employed 05/22/22) did not contain a central registry finding. Staff #11 reported the central registry finding for Staff #8 could not be located. 5) During interview, Staff #11 confirmed the results of the central finding for Staff #2 and Staff #6 were not received within the required time frame and the center did not follow up within 30 days of employment.
Evidence: 1) The central registry finding in record for Staff #2 (employed: 05/26/22) was dated 07/21/22. 2) The record for Staff #4 (employed: 05/31/22) did not contain a central registry finding. Staff #11 reported the central registry finding for Staff #4 could not be located. 3) The central registry finding in the record for Staff #6 (employed: 01/22/22) was dated 02/28/22. 4) The record for Staff #8 (employed 05/22/22) did not contain a central registry finding. Staff #11 reported the central registry finding for Staff #8 could not be located. 5) During interview, Staff #11 confirmed the results of the central finding for Staff #2 and Staff #6 were not received within the required time frame and the center did not follow up within 30 days of employment.
Plan of Correction: The missing central registry searches have been submitted to OBI. In the future, the center will maintain documentation of further contact with OBI when a central registry search has not been returned within 30 days of employment.
Standard 8VAC20-780-130-A
Based on a review of ten children?s records and interview, the center did not ensure two children had received the immunizations required by the State Board of Health before the child attended the center.
Evidence: 1) The record for Child #1, date of attendance 08/29/22, did not contain documentation of the child?s immunizations. 2) The immunizations in the record for Child #10, enrolled on 09/07/21, were dated 10/06/21. 3) During interview, Staff #11 confirmed the immunizations for Child #1 and Child #10 were obtained before the children attended the center.
Evidence: 1) The record for Child #1, date of attendance 08/29/22, did not contain documentation of the child?s immunizations. 2) The immunizations in the record for Child #10, enrolled on 09/07/21, were dated 10/06/21. 3) During interview, Staff #11 confirmed the immunizations for Child #1 and Child #10 were obtained before the children attended the center.
Plan of Correction: The missing immunizations were requested and will be filed upon receipt. In the future, immunizations will be required at the time of enrollment.
Standard 8VAC20-780-160-A
Based on a review of ten staff records and interview, the center did not ensure one staff member had documentation of a negative tuberculosis (TB) screening completed within the last 30 calendar days of the date of employment.
Evidence: 1) The TB screening in the record for Staff #4 (employed: 05/31/22) was dated 02/27/22. 2) During interview, Staff #11 confirmed the TB screening in the record for Staff #4 was completed more than 30 calendar days of the date of employment.
Evidence: 1) The TB screening in the record for Staff #4 (employed: 05/31/22) was dated 02/27/22. 2) During interview, Staff #11 confirmed the TB screening in the record for Staff #4 was completed more than 30 calendar days of the date of employment.
Plan of Correction: Moving forward, a TB screening will not be accepted if it?s more than 30 calendars days prior to employment.
Standard 8VAC20-780-160-B
Based on a review of ten staff records, the center did not obtain an acceptable form of documentation of tuberculosis (TB) screening for one staff member.
Evidence: The record of Staff #7 (employed: 02/07/22) contained documentation of a tuberculosis screening that was not signed by a physician, physician's designee, or an official of the local health department.
Evidence: The record of Staff #7 (employed: 02/07/22) contained documentation of a tuberculosis screening that was not signed by a physician, physician's designee, or an official of the local health department.
Plan of Correction: The documentation showing who completed the screening has been requested.
Standard 8VAC20-780-160-C
Based on a review of ten staff records, the center did not ensure two staff members had a repeat tuberculosis (TB) screening at least every two years from the date of the initial screening or testing, or more frequently if recommended by a licensed physician or the local health department.
Evidence: 1) The TB screening in the record for Staff #1 (employed 08/13/21) expired on 4/10/22. 2) The TB screening in the record for Staff #9 (employed: 11/20/19) expired on 11/18/21.
Evidence: 1) The TB screening in the record for Staff #1 (employed 08/13/21) expired on 4/10/22. 2) The TB screening in the record for Staff #9 (employed: 11/20/19) expired on 11/18/21.
Plan of Correction: The staff will complete new TB screenings.
Standard 8VAC20-780-240-A
Based on a review of ten staff records and interview, the center did not ensure six staff members completed The Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.
Evidence: 1) The records for Staff #2 (employed: 05/26/22), Staff #3 (employed: 02/14/22), Staff #5 (employed: 02/10/22), Staff #6 (employed: 01/22/22), Staff #7 (employed: 02/07/22), and Staff #8 (employed: 05/22/22), did not contain documentation of The Virginia Department of Education-sponsored orientation course. 2) During interview, Staff #11 reported the staff members have not completed the training to date.
Evidence: 1) The records for Staff #2 (employed: 05/26/22), Staff #3 (employed: 02/14/22), Staff #5 (employed: 02/10/22), Staff #6 (employed: 01/22/22), Staff #7 (employed: 02/07/22), and Staff #8 (employed: 05/22/22), did not contain documentation of The Virginia Department of Education-sponsored orientation course. 2) During interview, Staff #11 reported the staff members have not completed the training to date.
Plan of Correction: Staff have been reminded to take the training and submit the certificates upon completion.
Standard 8VAC20-780-280-B
Based on observations at the center on 08/31/22, the center did not ensure to keep all hazardous substances such as cleaning materials in a locked place using a safe locking method that prevents access by children.
Evidence: 1) The licensing inspector observed bottles of cleaning solution in unlocked cabinets in the Preschool classroom. 2) The licensing inspector observed a can of air freshener in the bathroom shared by the Toddler and Twos classroom.
Evidence: 1) The licensing inspector observed bottles of cleaning solution in unlocked cabinets in the Preschool classroom. 2) The licensing inspector observed a can of air freshener in the bathroom shared by the Toddler and Twos classroom.
Plan of Correction: Corrected on site.
Standard 8VAC20-780-510-F
Based on a review of three medications on 08/31/22, the center did not ensure that two medication authorizations were available to staff during the entire time they were effective for two out of three children.
Evidence: 1) A prescription medication was observed on site for Child #9, but the authorization to administer the medication expired on 03/13/22. 2) A prescription medication was observation on site for Child #10, but the authorization to administer the medication expired on 09/20/21.
Evidence: 1) A prescription medication was observed on site for Child #9, but the authorization to administer the medication expired on 03/13/22. 2) A prescription medication was observation on site for Child #10, but the authorization to administer the medication expired on 09/20/21.
Plan of Correction: New authorizations were requested.
Standard 8VAC20-780-60-A
Based on a review of ten children?s records and interview, the center did not ensure one child?s record contained all the required information.
Evidence: 1) The record for Child #8 (date of attendance: 07/01/19) did not contain a second emergency contact. 2) During interview, Staff #11 confirmed the record was missing a second emergency contact other than the parents. The record for each child enrolled should contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.
Evidence: 1) The record for Child #8 (date of attendance: 07/01/19) did not contain a second emergency contact. 2) During interview, Staff #11 confirmed the record was missing a second emergency contact other than the parents. The record for each child enrolled should contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.
Plan of Correction: The missing emergency contact will be obtained and the record updated.