Bethany Lutheran Church
18 Sophia Grace Drive
Fishersville, VA 22939
(540) 942-4361 (3)
VDSS Contact: Michelle Argenbright (540) 848-4123
Inspection Date: Feb. 18, 2020
Complaint Related: No
- Areas Reviewed:
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22VAC40-191 Background Checks for Child Welfare Agencies
63.2 Child Abuse & Neglect
63.2(17) License & Registration Procedures
- Comments:
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An unannounced monitoring visit was conducted on 2/18/20 from 9:30 am until 12:00 pm at Bethany-Trinity Evangelical Lutheran Church to review the religious exempt requirements. At the time of the inspection 42 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 music, free indoor play, hand washing, story time, artistic and educational activities, transitions, pick-up and behavioral management. The violations from the previous inspection were reviewed. One repeat violation was found. The violations from this inspection are documented on the violation notice. If you have questions or concerns contact the licensing inspector at (540) 848-4123 for further assistance.
- Violations:
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Standard #: 22VAC40-191-40-D-2 Description: Based on record review and interview, the center failed to have staff complete a central registry record check by the end of the 30th day of employment.
Evidence:
1. The records of five staff were reviewed. Staff 4's record (start date 9/24/19) does not have a completed central registry.
2. The director was unable to find the central registry background check.Plan of Correction: The paperwork for the central registry will be completed and mailed within ten days. In the future new staff will be required to complete the paperwork for central registry upon hire and the paperwork will be mailed within seven days of hire. The file will be documented. If the results are not received within 30 days the director will follow-up and document the file.
Standard #: 63.2(17)-1716-A Description: Based on observations and interview, the center failed to post the fact that the center is exempt from licensure in a visible location on the premises.
Evidence:
1. A tour of the facility was conducted. No posting of the center's exemption status was found.
2. The director verified they do not have the fact the center is exempt from licensure posted.Plan of Correction: During the inspection the director posted the center's exemption letter.
Standard #: 63.2(17)-1716-A-4 Description: Based on record review and interview, the center failed to ensure all staff have been certified by a practicing physician or physician assistant to be free from any disability which would prevent him/her from caring for children under his/her supervision prior to start date and updated every year.
Evidence:
1. The records for five staff were reviewed. Staff 2's record contained a staff health form dated 2/6/19.
2. The director was unaware the staff health report needed to be updated.Plan of Correction: Staff 2's staff health report will be updated as soon as an appointment can be scheduled. A system will be put into place to alert the director when staff need to update staff health reports.
Standard #: 63.2(17)-1716-B-5 Description: Based on a review of the staff handbook and interview, the center failed to establish and implement a procedure to ensure that all areas of the premises accessible to children are free of obvious injury hazards.
Evidence:
1. In the three-year-old classroom under the sink unlocked in the classroom was a spray bottle of Clorox bleach. There were Clorox wipes on the floor in the bathroom and on the counter by the sink in the classroom which is child height.
2. In the four-year-old classroom a spray bottle of Spic & Span and Clorox wipes were under the cabinet in an unlocked cabinet.
3. The director stated the center's procedure is for all hazardous substances to be kept out of reach of children.Plan of Correction: The director went around the center and moved all hazardous substances out of reach of children and talked to staff during the inspection.
Standard #: 63.2(17)-1720.1-A Description: Based on record review and interview, the center failed to obtain repeat background checks every five years.
Evidence:
1. The records for five staff were reviewed.
Staff 5 has a sworn statement dated 10/28/11 and a central registry dated 11/29/11.
2. The director verified a sworn statement and central registry update had not been completed for staff 5.Plan of Correction: The paperwork for staff 5 was printed for staff 5 to completed the day of the inspection and will be completed and the central registry will be mailed within ten days. In the future a system will be put in place to remind the director when updated background checks are due.
Disclaimer:
A compliance history is in no way a rating for a facility.
The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.
