Inspection Date:
May 10, 2021
,
May 17, 2021
,
May 18, 2021
,
May 19, 2021
and
May 20, 2021
Complaint Related:
No
Areas Reviewed:
22VAC40-185 ADMINISTRATION. 22VAC40-185 STAFF QUALIFICATIONS AND TRAINING. 22VAC40-185 PHYSICAL PLANT. 22VAC40-185 STAFFING AND SUPERVISION. 22VAC40-185 PROGRAMS. 22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES. 22VAC40-185 SPECIAL SERVICES. 22VAC40-191 Background Checks (22VAC40-191) 63.2(17) License & Registration Procedures
Technical Assistance:
n/a
Comments:
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia.
A monitoring inspection was initiated on 05/10/21 and concluded on 05/20/21. The director was contacted by telephone to initiate the inspection. There were 79 children present and 19 staff. The inspector emailed the director a list of items required to complete the inspection. The inspector reviewed four children?s records and five staff records submitted by the facility to ensure documentation was complete.
Information gathered during the inspection determined non-compliance(s) with applicable standards or law and violations were documented on the violation notice issued to the facility.
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 the date of receipt. 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 standards, 2) measures to prevent the noncompliance from occurring again, and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s).
The licensing inspector has reviewed with the provider COVID-19 Essential Guidance for Child Care programs.
Based on a review of records and interview, the center did not ensure that two out of five staff submitted documentation of a negative tuberculosis (TB) screening within the required time frame.
Evidence: 1) The record for Staff #2, hired on 04/26/21, did not contain documentation of a negative TB screening. 2) During interview, a member of management reported the TB screening results would not be received until 5/20/21, exceeding 21 days after employment.
3) The record for Staff #3, hired on 02/22/21, contained the results of a negative TB screening that were dated 11/25/19. 4) During interview, a member of management reported there were no other TB screening results on file for Staff #3. Documentation of the screening shall be submitted no later than 21 days after employment or volunteering and shall have been completed within 12 months prior to or 21 days after employing or volunteering.
Plan of Correction:
Per the Center: "Staff #2 has TB test now in file. Staff #3 has apt for test next week and we will have results by 5/31. Going forward, [Assistant Director] will ensure we have TB test in hand before day 1 of employment."
Standard #:
22VAC40-185-70-A
Description:
Based on a review of records and interviews, the center did not ensure five staff records contained the required information.
Evidence: 1) The record for Staff #1, hired on 05/10/21, contained two references that were obtained on 05/12/21. Each staff record should have documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering. 2) During interview, a member of management acknowledged the references for Staff #1 were not obtained prior to hire.
3) The following staff records did not contain written documentation that the individuals had orientation training by the end of their first day of assuming job responsibilities: Staff #1 (DOH: 05/10/21), Staff #2 (DOH: 04/26/21), Staff #3 (DOH: 02/22/21), Staff #4 (DOH: 03/04/21), and Staff #5 (DOH: 05/03/21). 4) During interview, a member of management reported the orientation training was completed, but not documented.
Plan of Correction:
Per the Center: "Going forward staff will have orientation documented day 1 of hire. [Assistant Director] will do orientation with them. References will be done before new teachers start. [Director] will ensure these are completed."
Standard #:
22VAC40-185-550-D
Description:
Based on a review of documents and interview, the center did not implement a monthly practice evacuation drill and a minimum of two shelter-in-place practice drills per year for the most likely to occur scenarios.
Evidence: 1) The licensing inspector observed the emergency drill log for the year 2020. An evacuation drill was not documented for November 2020 or December 2020. 2) The licensing inspector observed the emergency drill log for the year 2021. An evacuation drill was not documented for March 2021 or April 2021. 3) During interview, a member of management reported there were no evacuation drills practiced in November 2020, December 2020, March 2021, or April 2021.
4) There were no shelter-in-place practice drills documented for the year 2020. 5) During interview, a member of management reported the two required shelter-in-place drills were not practiced in 2020.
Plan of Correction:
Per the Center: "Had ad rill on 5/26. Assigned [Staff] to conduct monthly drills and report to [Director] any issues. Shelter in place drill scheduled for next month (June)."
Standard #:
22VAC40-191-60-B
Description:
Based on a review of records, the center did not ensure that one out of five staff had a completed sworn statement prior to hire.
Evidence: 1) The record for Staff #4, hired on 03/04/21, contained a sworn statement that was dated 03/05/21. An employee or volunteer of a licensed or registered child welfare agency or of a family day home approved by a family day system must not be employed or provide volunteer service until the agency or home has the person's completed sworn statement or affirmation.
Plan of Correction:
Per the Center: "Going forward [Assistant Director] or [Director] will ensure teachers fill out sworn statement before 1st day."
Standard #:
63.2(17)-1720.1-B-2
Description:
Based on a review of records and interview, the center did not ensure that four out of five staff obtained fingerprint results prior to hire.
Evidence: 1) The record for Staff #2, hired on 04/26/21, had fingerprint results that were dated 05/06/21. 2) The record for Staff #3, hired on 02/22/21, had fingerprint results that were dated 02/26/21. 3) The record for Staff #4, hired on 03/04/21, had fingerprint results that were dated 03/08/21. 4) The record for Staff #5, hired on 05/03/21, had fingerprint results that were dated 05/10/21. 5) During interview, a member of management confirmed the fingerprint results for Staff #2, Staff #3, Staff #4, and Staff #5 were received after their hire date.
Plan of Correction:
Per the Center: "No staff will be able to start until we have their fingerprints back. [Director] will be responsible for giving teachers their DOH based on the date fingerprints are received."
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
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http://www.dss.virginia.gov/facility/search/cc.cgi