VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bethany Lutheran Church
18 Sophia Grace Drive
Fishersville, VA 22939
(540) 942-4361 (3)

VDSS Contact: Michelle Argenbright (540) 848-4123

Inspection Date: Sept. 12, 2023

Complaint Related: No

Areas Reviewed:

22.1 Religious Exempt; Background Checks Code; Carbon Monoxide 32.1 Report by person other than physician 54.1 Must be MAT Certified. 63.2 Child abuse and neglect 8VAC20-770 Background Checks

Comments:

An unannounced code compliance inspection was initiated on 09/12/2023 and concluded on 09/12/2023 from 9:30 AM to 12:10 PM. There were 57 children present, ranging in ages from 2 to 5, with 9 staff. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, procedures, and medication. A total of five children?s records and six staff?s 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 facility.

Violations:

Standard #:	22.1-289.031-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. Staff verified they do not have the fact the center is exempt from licensure posted.
Plan of Correction:	Post the exempt from licensure.
Standard #:	22.1-289.031-A-4
Description:	Based on record review and interview, the center failed to ensure each staff member has been certified by a physician, physician assistant, or nurse practitioner to be free from any disability which would prevent him from caring for children under his/her supervision. Evidence: 1. Staff 6 stated the date of hire for staff 7 was 9/5/23. 2. Staff 6 stated staff 7 did not provide the center with a document certified by a physician, physician assistant, or nurse practitioner to stating staff 7 is free from any disability which would prevent him from caring for children under his/her supervision.
Plan of Correction:	The staff already had an appointment with their physician. Going further make sure a report is on file.
Standard #:	22.1-289.031-A-6
Description:	Based on a review of the parent handbook and interview, the center failed to provide a written disclosure to parents and guardians of the children in the center and the general public that includes information regarding the enrollment capacity and food services. Evidence: 1. Staff 6 provided all information given to parents. The information given to parent did not contain information regarding the enrollment capacity and food services. 2. Staff 6 stated the center does not provide information regarding the enrollment capacity and food services to parents.
Plan of Correction:	Provide food and services and enrollment capacity in parent handbook. Letter went to parents of food service reminder for packed lunch and capacity.
Standard #:	22.1-289.031-B-3
Description:	Based on record review and interview, the center failed to establish and implement a procedure in which a daily health screening and exclusion of sick children by a person trained to perform such a screening is conducted daily. Evidence: 1. The five records reviewed did not contain documentation of staff completing training in daily simple health screening. 2. Staff 6 stated there is no staff trained in daily simple health that she is aware of and the center does not have a procedure to conduct daily simple health screenings.
Plan of Correction:	Staff 6 enrolled in a daily health screening & exclusion training class. Teachers will follow as well.
Standard #:	22.1-289.031-B-4
Description:	Based on a review of the staff handbook and interview, the center failed to implement a procedure to ensure all children in the center are in compliance with immunization provisions. Evidence: 1. A review was conducted of five children's records. There were no immunizations in the children's records. 2. The parent handbook stated immunizations are required prior to start at the facility. 3. Staff 6 verified the center does not have immunizations for the five children.
Plan of Correction:	Have parents send immunization and print those that are online. Letters went home to parents and will file when received. Parents told to send no later than 10/1/23.
Standard #:	22.1-289.031-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 two-year-old classroom a can of Lysol spray and Arthritis Pain Relief was on the teacher's desk accessible to children. 2. On the floor in the bathroom between the 2 three-year-old classrooms was several containers of Clorox wipes that were accessible to children. 3. Staff 6 stated the center procedure for hazardous substances for them to be out of reach of children at all times.
Plan of Correction:	Remove Lysol, Arthritis pan Relief, Clorox wipes from accessible reach. Each teacher received the correct requirements on what standards are met.
Standard #:	22.1-289.035-B-4
Description:	Based on record review and interview, the center failed to request a search of central registry background check within the first 30 days of employment, and a criminal history name check prior to the first day of employment for any state in which a staff member resided in the preceding five years. Evidence: 1. The record for staff 2 was reviewed. The date of hire was documented as 8/26/21. The sworn statement states staff 2 lived outside VA within the last five years. No out-of-state background check was in the record. 2. Staff 2 was unaware of any out-of-state background check completed for staff 2.
Plan of Correction:	Send a background check to South Carolina DSS. Corrected & obtained on 9/21/23.