VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Grace Covenant Presbyterian Church
1617 & 1627 Monument Avenue
Richmond, VA 23220
(804) 213-0200

VDSS Contact: Molly Muscat (804) 588-2367

Inspection Date: July 12, 2024

Complaint Related: No

Areas Reviewed:

22.1 Religious Exempt; Background Checks Code; Carbon Monoxide 8VAC20-770 Background Checks

Comments:

An unannounced inspection was initiated on 07/12/2024 and completed on 07/22/2024 in response to a self-report received by the licensing office on 06/18/2024 relating to allegations of supervision. The inspector reviewed 1 child?s record and 6 staff records on-site and electronically on 07/22/2024. This inspection included document review, 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 08/05/2024. A POC submitted after this date will not appear on the public website.

Violations:

Standard #:	22.1-289.031-A-4
Description:	Based on record review, the center failed to ensure that each person in a supervisory position has been certified prior to employment by a practicing physician or physician assistant to be free from any disability which would prevent him from caring for children under his supervision. Evidence: 1. The record for staff #1, date of employment 02/26/24, did not contain documentation of a staff health report. 2. The record for staff #3, date of employment 04/24/24, contained a staff health report dated 07/05/2024.
Plan of Correction:	Policy on Health Form Submission for New Employees All individuals who accept a job offer from Grace will be required to complete and submit a Health Form. This form will be provided either in person or via email on the date the job offer is accepted. The completion and submission of the Health Form are mandatory, and the hiring process will not progress until the form has been received and processed by our Human Resources department.
Standard #:	22.1-289.031-B-2
Description:	Repeat Violation Based on interviews, and documentation review, the center failed to establish and implement procedures to ensure appropriate supervision of all children in care, including daily intake and dismissal procedures to ensure safety of children. Evidence: Interviews and documentation review revealed that Staff #1 intentionally sprayed child #1, age 2 years, in the face with water from a garden hose. Staff #1 was standing close the the child when staff #1 sprayed the child in the face. The water spray from the hose was described as "strong". When the child was sprayed in the face the child began to cry.
Plan of Correction:	Safety Policy for Water Play Ensuring the safety of all participants during water play activities is our top priority. It is imperative that all staff adhere strictly to the established safety rules, which include, but are not limited to, not spraying participants in the face with water. Policy Violation Consequences: Any staff member found to be in violation of the water play safety rules will face immediate termination of employment. Effective immediately, staff will no longer handle the water hose during water play activities. Instead, the hose must be attached to a child-friendly sprinkler. This change ensures a safer and more enjoyable experience for the children.
Standard #:	22.1-289.035-A
Description:	Repeat Violation Based on record review, the center failed to obtain the results of a fingerprint based national criminal record search every five years. Evidence: The record for staff #2, date of employment 12/18/2018, contained fingerprint results dated 12/11/2018. An updated fingerprint based criminal record check was due on or before 12/11/2023.
Plan of Correction:	Notification Timeline: All current staff will be notified 60 days prior to the expiration of any of their required documents. Submission Deadline: Staff must submit proof of document renewal or completion to the center at least 10 days prior to the document's expiration date. Non-Compliance Consequences: If the required documents are not submitted within the specified timeframe, the staff member will not be allowed to return to work until the center has received the necessary documents.
Standard #:	22.1-289.035-B-4
Description:	Based on record review, the center failed to obtain a a criminal record check and a sex offender registry check prior to the first day of employment and a child abuse and neglect check within 30 days of employment from any state that staff have lived in the past 5 years prior to employment. Evidence: The record for staff #6, date of employment 01/02/2024, indicated that staff #6 lived in another state outside of Virginia in the 5 years prior to employment. The record did not contain a criminal record check, a sex offender registry check or a central registry check from that state.
Plan of Correction:	Hiring Process Update Effective immediately, no new hire will be permitted to officially start working for GCCDC until all background checks, including those for out-of-state candidates, are completed and received by GCCDC.
Standard #:	8VAC20-770-40-D-2
Description:	Repeat Violation Based on record review, observation, and interview, the center failed to obtain a sworn statement before the first day of employment and the results of a central registry background check within 30 days of employment. Evidence: 1. The record for staff #1, date of employment 02/26/2024 did not contain the results of a central registry background check. Staff #1 was observed working at the center. Interview with administration confirmed that the record did not contain the results of the central registry background check. 2. The record for staff #1, date of employment 02/26/2024, contained a sworn statement dated 03/20/2024. 3. The record for staff #3, date of employment 04/24/2024 did not contain the results of a central registry background check. Staff #3 was observed working at the center. Interview with administration confirmed that the record did not contain the results of the central registry background check. 4. The record for staff #5, date of employment 08/27/2023, did not contain the results of a central registry background check. Staff #5 was observed working at the center. Interview with administration confirmed that the record did not contain the results of the central registry background check. 5. The record for staff #6, date of employment 01/02/2024, did not contain the results of a central registry background check. Staff #6 was observed working at the center. Interview with administration confirmed that the record did not contain the results of the central registry background check.
Plan of Correction:	Systematic Changes to Prevent Recurrence: a. Policy Review and Revision: Reviewed and updated the center's hiring policies and procedures to ensure that all required documentation, including central registry background checks and sworn statements, are obtained before or within the required timeframes. b. Staff Training: Conducted training for HR personnel and relevant staff on the updated policies and procedures, emphasizing the importance of obtaining and filing necessary documentation before the start date of employment and within 30 days. c. Documentation and Tracking: Implemented a tracking system to monitor the completion and receipt of required documentation. This includes setting up reminders to ensure that background checks and sworn statements are obtained and filed as required. Monitoring and Compliance: A. Internal Audits: Scheduled regular internal audits to review personnel records and ensure compliance with documentation requirements. Audits will be conducted monthly for the next six months. B. Compliance Officer: Designated a compliance officer to oversee the implementation of the corrective action plan and to address any issues or concerns related to documentation and hiring procedures. C. Reporting: Established a procedure for staff to report any issues or concerns related to documentation compliance, ensuring that all concerns are addressed promptly. Follow-Up: Reviewed the effectiveness of the corrective actions after three months and adjusted the plan as necessary based on the findings of the internal audits and feedback from staff. Continuous Improvement: Committed to ongoing review and improvement of hiring practices and documentation processes to ensure continued compliance with all relevant regulations and requirements.