VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Shenandoah University
118 Regency Lakes Drive
Winchester, VA 22603
(540) 665-0991

Current Inspector: Amy Tomblin (804) 629-3923

Inspection Date: Jan. 23, 2020

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. 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-191 Background Checks (22VAC40-191) 32.1 Report by person other than physician 63.2(17) License & Registration Procedures 63.2 Facilities & Programs.

Technical Assistance:

We discussed the requirements for medication records and background checks. The risk assessments for violations were provided. We talked about ensuring that equipment is off limits if the fall zones with resilient surfacing remains frozen during the winter.

Comments:

Thank you for your assistance during today's unannounced renewal inspection conducted from 10:35 AM to 4:05 PM. Today, there were seventy-one children, ages infancy through five years, with twelve staff. I viewed staffing, supervision, interactions with children, equipment, activities, daily routines, posted information, menu/nutrition, infant care and records, diaper ointment, diapering procedures, agency inspection reports, insurance, injury prevention planning, injury records, emergency supplies and drill records, seven records for children, seven staff records, staff qualifications, staff training, seven business entity records, medication, indoor and outdoor areas. The children were provided a variety of age appropriate group experiences and learning activities. Movement activities were provided indoors due to decreased opportunities for outdoor active play during the cold temperatures. The staff were observed providing frequent interactions with children and responding to individual needs for comfort and care. One group enjoyed a teacher's stories as she sat with them during lunch. Recommendation for issuance of the renewed license will be made pending completion and receipt of agency inspection reports. Let me know if you need any assistance or have any questions. 540/430-9259

Violations:

Standard #:	22VAC40-185-510-L
Description:	Based on a review of medication administered at the center, and interviews with staff, the center failed to keep a record of all medication given to children: Evidence: While viewing the medication and associated records for four children. the prescription medication for child 2 was present for long term use and to be administered as needed. According to the administration log, the last administration was on April 4, 2019. Staff members SM1 and SM2 were asked about use of the medication since the transition to this classroom in 2019. The L.I. confirmed that the medication has been administered by staff member SM1 numerous times and as recent as the day before on January 22, 2020. However, the administration log for child 2M has not been used by staff member SM1 to document the amount/type of medication, day, time administered and the name of the staff member.
Plan of Correction:	The M.A.T. certified staff who administer the medication for child 2M will begin using the medication log and document all use. The administrative staff will review the requirements for documenting all administration and use of medication at the center with M.A.T. certified staff. The lead teachers or assigned administrative staff will review the medication and associated records on a regular basis to make sure all medication requirements are in compliance.
Standard #:	22VAC40-191-40-D-1-A
Description:	Based on a review of the background checks for agents and representatives of the business entity, the viewing of correspondence, and an interview with administrative staff, the center failed to obtain the Virginia child protective services finding by the end of the thirty days after one agent assumed a position. Evidence: Business entity representative BE2 began a position as an agent for the applicant on October 30, 2019. The director inquired about the submission of the Virginia Central Registry request on November 14, 2019 and confirmed that the request form had been sent to Richmond from a University office without adding the center's contact information and address. The administrator contacted the agency in Richmond who had no record of receipt of the request. Another request form was mailed to Richmond at the end of November, and returned to the center with a notice about missing information. After the form was submitted again in December, the Virginia central registry finding was processed on January 9, 2020.
Plan of Correction:	In the future, the new business entity requests will be viewed and sent according to instructions on the form and administrative staff will view the forms to make sure they are complete. The requests will be sent in advance of changes with business agents and representatives so that the background checks are obtained no later than thirty days of position changes.