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Bon Secours - St. Francis Medical Center
13901 St. Francis Boulevard
Midlothian, VA 23114
(804) 594-4990

Current Inspector: Danielle Morrison (804) 929-3771

Inspection Date: Aug. 28, 2023

Complaint Related: 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)
22.1 Background Checks Code, Carbon Monoxide

Comments:
An unannounced renewal inspection was conducted on August 28, 2023. The inspection began at approximately 11:15 AM and concluded at 1:40 PM. There were 65 children present, ranging in ages from 8 months to 4 years, with 13 staff supervising. Children were observed eating lunch and playing with toys. Today?s lunch included cheeseburgers on a bun, peaches, lima beans, and milk. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. Transportation is not provided. A total of 5 child records, 5 staff records, and 3 board member records were reviewed. 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.

Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to me within 5 business days from today. Please specify how the deficient practice will be or has been corrected. Your plan of correction should contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

If you have any questions about this inspection, please contact the licensing inspector LaTasha Smith at (804) 588-2362.

Violations:
Standard #: 8VAC20-780-60-A
Description: Based on a review of children's records, the center did not maintain all children?s records.

Evidence:
Child #1 records did not have documentation of names of persons authorized to pick up the child.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 8VAC20-780-550-P
Description: Based on record review, the center did not ensure injury report contained all required information.
Evidence: 1. 1 of 3 injury reports, did not contain the date and time parent was notified.

Plan of Correction: Not available online. Contact Inspector for more information.

Disclaimer:

A compliance history is in no way a rating for a facility.

The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.

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