VIRGINIA DEPARTMENT OF SOCIAL SERVICES

St. Paul Lutheran Church
257-2 East King Street
Strasburg, VA 22657
(540) 465-2393

VDSS Contact: Julie Kunowsky (540) 430-9256

Inspection Date: Aug. 12, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-191 Background Checks for Child Welfare Agencies 63.2 Child Abuse & Neglect 63.2(17) License & Registration Procedures

Comments:

An unannounced monitoring inspection was conducted on 8/12/19 from 10:30 am until 12:30 pm at St. Paul Lutheran Church to review the religious exempt requirements. At the time of the inspection 54 children were present with 13 staff. The sample size consisted of five children's records and five staff's records. Children and staff were observed during indoor and outdoor play, clean-up, diapering, nap, transitions and behavioral guidance. Violations were found during this inspection and are documented on the violation notice. If you have questions or concerns contact the licensing office at (540) 292-5933 for further assistance.

Violations:

Standard #:	22VAC40-191-40-D-2
Description:	Based on record review and interview, the center failed to ensure all staff completed a sworn disclosure statement prior to the first day of employment and a central registry record check within 30 days of employment. Evidence: 1. The records of five staff were reviewed. Staff 3 did not contain a sworn statement or search of central registry results. The start date for staff 3 was 3/8/93. 2. The director reviewed the record and did not find a sworn statement or search of central registry results.
Plan of Correction:	Staff 3 will be required to complete a sworn statement and the paper work for the central registry to be mailed within five days. In the future new staff will be required to complete a sworn statement and documentation for a central registry upon application. The central registry documentation will be mailed upon hire in the future.
Standard #:	63.2(17)-1716-A
Description:	Based on interview and a review of the parent handbook, the center failed to disclose in writing to the parents or guardians of the children in the center the fact that it is exempt from licensure and the qualifications of the personnel. Evidence: 1. The parent handbook was reviewed. There was no information in the parent handbook regarding the center being exempt from licensure and the qualifications of the personnel. 2. The director stated the parent handbook is the only information in writing provided to the parents.
Plan of Correction:	The written disclosure posted at the center contains this information and will be provided to the parents/guardians currently enrolled and will be made part of the parent handbook for future enrollees.
Standard #:	63.2(17)-1716-A-6
Description:	Based on interview, the center failed to provide a written disclosure to parents and guardians of the children in the center advising information regarding the physical facilities, enrollment capacity, health requirements for staff, and public liability insurance. Evidence: 1. The parent handbook was reviewed. The handbook did not contain information regarding the physical facilities, enrollment capacity, health requirements for staff, and public liability insurance. 2. The director stated the parent handbook is the only information in writing provided to the parents.
Plan of Correction:	The written disclosure posted at the center contains this information and will be provided to the parents/guardians currently enrolled and will be made part of the parent handbook for future enrollees.
Standard #:	63.2(17)-1716-A-9
Description:	Based on observation and interview, the center failed to ensure safe sleep guidelines recommended by the American Academy of Pediatrics which advises babies should sleep on their backs on a flat surface free of blankets, pillows, or other soft items until the age of 1 to reduce the risk of SIDS. Evidence: 1. In infant room 1 three infants were observed in cribs wrapped in blankets. 2. One infant was asleep in a reclining swing wrapped in blanket. 3. The director stated all the infants in the classroom were under 12 months.
Plan of Correction:	In the future blankets will not be allowed for any infants under 12 months. If infants fall asleep any place beside their crib they will be moved to their crib.
Standard #:	63.2(17)-1716-B-1
Description:	Based on interviews, the center failed to establish and implement procedures for hand washing by children after diapering. Evidence: 1. A staff member in the one-year-old classroom was observed diapering. The children's hands were not washed after diapering. 2. The director stated they do not have a policy for washing children's hands after diapering or to wash infants hands before eating.
Plan of Correction:	The policy for hand washing will now include: All children's hands must be washed after toileting, diapering and before eating. All staff will be trained on the change.
Standard #:	63.2(17)-1716-B-3
Description:	Based on record review and interview, the center failed to establish and implement procedures to ensure that a daily simple health screening and exclusion of sick children was completed by a person trained to perform such screenings. Evidence: 1. The staff and parent handbook were reviewed. Both contained policies on staff observing children as they arrive each day for medical issues and a policy on when children must be excluded from care. There was no policy on training staff in daily simple health screening. 2. The director stated no staff has obtained training in daily simple health screening.
Plan of Correction:	One staff will take the online class and train the remaining staff. In the future all new staff will be trained in daily health screening upon hire.
Standard #:	63.2(17)-1716-B-6
Description:	Based on interview, the center failed to establish and implement a procedure to ensure that all staff are able to recognize the signs of child abuse and neglect. Evidence: 1. The staff handbook was reviewed. There is no policy regarding staff being trained in recognizing child abuse and neglect. 2. The director stated they do not train staff in recognizing child abuse and neglect.
Plan of Correction:	All staff will be trained in recognizing child abuse and neglect. In the future new staff will be trained in recognizing child abuse and neglect upon hire.
Standard #:	63.2(17)-1720.1-A
Description:	Based on record review and interview, the center failed to have staff update a sworn statement every five years effective 9/1/17. Evidence: 1. The records for five staff were reviewed. Staff 4's record contained a sworn statement dated 1/12/99. 2. The director stated she did not realize the sworn statements had to be updated every five years.
Plan of Correction:	All staff records will be reviewed to ensure all sworn statements and central registry checks have been updated within the last five years. A system will be put in place to ensure they are updated every five years in the future.
Standard #:	63.2(17)-1720.1-B-2
Description:	Based on record review and interview, the center failed to ensure staff hired after 1/22/18 had a fingerprint-based criminal history check determination letter prior to the first day of employment, and that staff hired before 1/22/18 obtained a fingerprint-based criminal history check determination letter by 9/30/18. Evidence: 1. The records of five staff were reviewed. Staff 1's start date was 6/8/17. The fingerprint results are dated 7/24/19. Staff 2's start date was 8/6/18. There are no fingerprint results in the record. Staff 3's start date was 3/8/93. The fingerprint results are dated 7/31/19. Staff 4's start date was 1/27/99. There are no fingerprint results in the record. Staff 5's start date was 5/1/19. The fingerprint results are dated 8/2/19. 2. The director verified all the dates. She just recently realized fingerprints are required.
Plan of Correction:	All existing staff will have an appointment made to get fingerprints within five days. In the future all new staff will not be hired until the fingerprint results are received.