Inspection · 2022-08-10
Date
2022-08-10
Complaint Related
No
Licensing Inspector
Arlene Agustin
(804) 629-7519
(804) 629-7519
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 (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced monitoring inspection was conducted on August 10, 2022. The inspector arrived at 10:00 AM and departed at approximately 1:20PM. There were 88 children present and 11 staff members. A sample size of 13 records were reviewed which included 7 children?s records and 6 staff records. The Inspector observed staff and children?s interactions throughout the inspection. Children were observed during group activity, free play indoor and outdoor, handwashing, diapering, lunch and naptime. First aid kits and emergency preparedness documents were observed. Transportation vans were observed. Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented. The violations are listed on the violation notice issued to the center and were reviewed with the site assistant director at the exit interview.
Violations
10Standard 22.1-289.035-B-4
Based on record review and interview, it was determined that the center did not ensure that they obtain a copy of the results of a criminal record and a search of the child abuse and neglect registry or equivalent registry from any state in which the individual has resided in the preceding five years.
Evidence:
1) The record for Staff #2, (date of hire 07/19/2022) did not contain documentation of a completed criminal record check and child abuse and neglect registry check from outside of the state of Virginia. The Virginia Child Abuse registry application indicated by Staff #2 that they previously lived outside of the state of Virginia within the last five years.
2) Staff #1 confirmed the required out of state background checks were not obtained for the staff record for Staff #2.
Evidence:
1) The record for Staff #2, (date of hire 07/19/2022) did not contain documentation of a completed criminal record check and child abuse and neglect registry check from outside of the state of Virginia. The Virginia Child Abuse registry application indicated by Staff #2 that they previously lived outside of the state of Virginia within the last five years.
2) Staff #1 confirmed the required out of state background checks were not obtained for the staff record for Staff #2.
Plan of Correction: The center responded with the following: The out of state background checks will be completed for Staff #2 and information will provided to licensing within 10 business days.
Standard 8VAC20-770-60-B
Based on record review and interview, it was determined that the center did not ensure that the sworn statements were signed and completed prior to working with children.
Evidence:
1. Three of the six staff records reviewed did not have a Sworn Disclosure Statement.
a. Staff #2 (date of hire 7/19/22) did not have a sworn disclosure and was present at the center working with children.
b. Staff #3 (date of rehire 8/8/22) did not have a sworn disclosure and was present at the center working with children.
c. Staff #4 (date of hire 4/18/22) did not have a sworn disclosure and was present at the center working with children.
2. Staff #1, the assistant director, confirmed that Staff #2, Staff #3, and Staff #4 did not have a sworn disclosures in their record.
Evidence:
1. Three of the six staff records reviewed did not have a Sworn Disclosure Statement.
a. Staff #2 (date of hire 7/19/22) did not have a sworn disclosure and was present at the center working with children.
b. Staff #3 (date of rehire 8/8/22) did not have a sworn disclosure and was present at the center working with children.
c. Staff #4 (date of hire 4/18/22) did not have a sworn disclosure and was present at the center working with children.
2. Staff #1, the assistant director, confirmed that Staff #2, Staff #3, and Staff #4 did not have a sworn disclosures in their record.
Plan of Correction: The center responded with the following: Staff #1 was able to print out the form and will have the staff members complete the form today prior to clocking out.
Standard 8VAC20-780-130-A
Based on record review and interview, it was determined that the center did not ensure that each child has received the immunizations required by the State Board of Health before the child can attend the center.
Evidence:
1. Child #2 (date of enrollment 5/24/22) did not have a copy of their immunization records at the center.
2. Staff #1 confirmed there was no immunization record for Child #2.
Evidence:
1. Child #2 (date of enrollment 5/24/22) did not have a copy of their immunization records at the center.
2. Staff #1 confirmed there was no immunization record for Child #2.
Plan of Correction: The center responded with the following: Staff #1 will obtain the immunization record for Child #2.
Standard 8VAC20-780-140-A
Based on record review and interview, it was determined that the center did not ensure that each child have a physical examination before the child's attendance or within 30 days after the first day of attendance.
Evidence:
1. Child #2 (date of enrollment 5/24/2022) did not have a physical examination document to their record.
2. Child #1 (date of enrollment 8/6/2021) did not have a physical examination document to their record.
3. Staff #2 confirmed both Child #1 and Child #2 did not have a physical examination to their record.
Evidence:
1. Child #2 (date of enrollment 5/24/2022) did not have a physical examination document to their record.
2. Child #1 (date of enrollment 8/6/2021) did not have a physical examination document to their record.
3. Staff #2 confirmed both Child #1 and Child #2 did not have a physical examination to their record.
Plan of Correction: The center responded with the following: Staff #1 will obtain the physical examinations for both Child #1 and Child #2.
Standard 8VAC20-780-160-A
8VAC20-780-160. Based on record review and interview, it was determined that the center did not ensure that each staff member submit documentation of a negative tuberculosis screening. 1. Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children. 2. The documentation shall have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician's designee, or an official of the local health department.
Evidence:
1. Staff #4 (date of hire 4/18/22) did not have a tuberculosis screening completed.
2. Staff #2 (date of hire 7/19/22) completed their tuberculosis screening on 8/06/22 which is outside of the required timeframe.
3. Staff #3 (date of hire 8/08/22) completed their tuberculosis screening on 7/26/2021 which is outside of the required timeframe.
4. Staff #1 confirmed that Staff #2, Staff #3, and Staff #4 did not have their tuberculosis screening completed within the required timeframes.
Evidence:
1. Staff #4 (date of hire 4/18/22) did not have a tuberculosis screening completed.
2. Staff #2 (date of hire 7/19/22) completed their tuberculosis screening on 8/06/22 which is outside of the required timeframe.
3. Staff #3 (date of hire 8/08/22) completed their tuberculosis screening on 7/26/2021 which is outside of the required timeframe.
4. Staff #1 confirmed that Staff #2, Staff #3, and Staff #4 did not have their tuberculosis screening completed within the required timeframes.
Plan of Correction: The center responded with the following: Staff #1 will ensure that Staff #4 complete their tuberculosis screening this week. Moving forward, the center will ensure that all screenings are completed timely and prior to working with children.
Standard 8VAC20-780-160-C
Based on record review and interview, it was determined that the center did not ensure that every two years from the date of the initial screening or testing, staff members shall obtain and submit the results of a follow-up tuberculosis screening.
Evidence:
1. Staff #5 (date of hire 10/2/17) has a tuberculosis screening last dated November 2019 and expires November 2021.
2. Staff #1 confirmed that Staff #5 has a tuberculosis screening that is out of compliance.
Evidence:
1. Staff #5 (date of hire 10/2/17) has a tuberculosis screening last dated November 2019 and expires November 2021.
2. Staff #1 confirmed that Staff #5 has a tuberculosis screening that is out of compliance.
Plan of Correction: The center responded with the following: Staff #5 will have her tuberculosis screening completed as soon as possible and provide the documentation of a negative screening to the center.
Standard 8VAC20-780-270-A
8VAC20-780-270 A
Based on observation and interview, it was determined that the center did not ensure that areas and equipment of the center, inside and outside, be maintained in a safe and operable condition.
Evidence:
1. A tricycle on the large playground has a broken and cracked seat which poses an injury and pinching hazard to children.
2. Staff #1 confirmed the broken and cracked seat to the tricycle on the playground.
Based on observation and interview, it was determined that the center did not ensure that areas and equipment of the center, inside and outside, be maintained in a safe and operable condition.
Evidence:
1. A tricycle on the large playground has a broken and cracked seat which poses an injury and pinching hazard to children.
2. Staff #1 confirmed the broken and cracked seat to the tricycle on the playground.
Plan of Correction: Plan of correction: Staff #1 immediately took the tricycle off the playground and will dispose of if it.
Standard 8VAC20-780-580-B
Based on observation and interview, it was determined that the center did not ensure that any vehicle used by the center for the transportation of children shall meet the safety standards set by the Department of Motor Vehicles and shall be kept in satisfactory condition to assure the safety of children.
Evidence:
1. The transportation bus has an expired Virginia State Inspection dated December 2021.
2. Staff #1 confirmed the Virginia State Inspection is expired and is actively being used for transportation of children.
Evidence:
1. The transportation bus has an expired Virginia State Inspection dated December 2021.
2. Staff #1 confirmed the Virginia State Inspection is expired and is actively being used for transportation of children.
Plan of Correction: The center responded with the following: Staff #1 will set up an appointment to have the transportation bus inspected.
Standard 8VAC20-780-60-A
Based on record review and interview, it was determined that the center did not ensure to maintain and keep at the center a separate record for each child enrolled a copy of a name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.
Evidence:
1. Child #1 has only one of the required emergency contacts in their file.
2. Staff #1 confirmed that Child #1 lacked one of the two required emergency contacts in their file.
Evidence:
1. Child #1 has only one of the required emergency contacts in their file.
2. Staff #1 confirmed that Child #1 lacked one of the two required emergency contacts in their file.
Plan of Correction: The center responded with the following: Staff #1 will obtain the emergency contact from the parent at pick up.
Standard 8VAC20-780-70
Based on record review and interview, it was determined that the center did not ensure that staff records have a name, address, and telephone number of a person to be notified in an emergency and be kept at the center.
Evidence:
1. Three of the six staff records reviewed did not have emergency contacts kept at the center.
a. Staff #2 (date of hire 7/19/22) did not have an emergency contact.
b. Staff #3 (date of hire 8/8/22) did not have an emergency contact.
c. Staff #4 (date of hire 4/18/22) did not have an emergency contact.
2. Staff #1 confirmed that Staff #2, Staff #3, and Staff #4 did not have emergency contacts at the center.
Evidence:
1. Three of the six staff records reviewed did not have emergency contacts kept at the center.
a. Staff #2 (date of hire 7/19/22) did not have an emergency contact.
b. Staff #3 (date of hire 8/8/22) did not have an emergency contact.
c. Staff #4 (date of hire 4/18/22) did not have an emergency contact.
2. Staff #1 confirmed that Staff #2, Staff #3, and Staff #4 did not have emergency contacts at the center.
Plan of Correction: The center responded with the following: Staff #1 will obtain emergency contacts for Staff #2, Staff #3, and Staff #4 and place a copy to their records.