VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Village at Leafspring School at Three Chopt
11005 Three Chopt Road
Richmond, VA 23233
(804) 935-6939

Current Inspector: Lauren Bickford (540) 280-0742

Inspection Date: Oct. 29, 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, including telephone contacts, documents review, interviews and a virtual tour of the program. A monitoring inspection was initiated on 10/29/2021 and concluded on 10/29/2021. The director was contacted by telephone and a virtual inspection was conducted. There were 25 children present with three staff supervising, and three administrators. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of five child records and five staff 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.

Violations:

Standard #:	22VAC40-185-70-A
Description:	Based on a review of five staff records and interviews, the center did not ensure that one staff record contained all the required information. Evidence: 1) The tuberculosis (TB) screening results in the record for Staff #5, hired on 06/21/2021, were dated 08/02/2021. 2) During interview, a member of management acknowledged the TB results for Staff #5 were not obtained within 21 of beginning employment. Staff hired prior to 10/13/2021 were required to obtain TB results within 21 days of beginning employment and such documentation was to be retained in the staff record.
Plan of Correction:	Moving forward, there will be a two-person check system to ensure the required TB test/screenings are obtained within the required time frames for each staff member.
Standard #:	63.2(17)-1720.1-B-4
Description:	Based on a review of five staff records and interview, the center did not ensure that one staff obtained a copy of a sex offender registry check from any state in which the individual had resided in the preceding five years within the required time frame. Evidence: 1) The record for Staff #1, hired on 10/14/2019, indicated the staff had resided in two other states outside of Virginia within the last five years. The record did not contain a sex offender registry check from the states the staff member had resided. 2) During interview, a member of management confirmed the sex offender registry checks from the two states had not been completed for Staff #1. The results of the out-of-state background check searches were required to be obtained by December 31, 2020 for staff hired prior to July 1, 2020.
Plan of Correction:	Management completed the required out-of-state sex offender registry checks from both states during the inspection. Moving forward, there will be a two-person check system to ensure the required background checks are completed within the required time frames.