VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Blue Ridge Montessori, Inc.
1071 Woodberry Square Place
Lynchburg, VA 24502
(434) 525-0061

Current Inspector: Kelly Campbell (540) 309-2494

Inspection Date: Oct. 29, 2019

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. 22VAC40-191 Background Checks (22VAC40-191) 63.2(17) License & Registration Procedures

Comments:

An unannounced monitoring inspection was made on 10/29/2019. There were 70 children present in four groupings. Seven children's records and five staff records were reviewed. There were no medications for the children in the licensed program. The inspector arrived at the center at 1:30 pm and departed at 4:00 pm. The inspection was completed on 11/4/19 and emailed to the provider on that date. The children were observed during nap, during outside times, during afternoon snack, and during departures.

Violations:

Standard #:	22VAC40-185-160-A
Description:	Based on record review, the center failed to ensure that each staff member submitted documentation of a negative tuberculosis (TB) screening or test within 21 days after employment or volunteering. Evidence: 1. There was no documentation of a completed TB test or screening in the record for staff #3. Staff #3 had a hire date of 8/5/19. 2. There was no documentation of a completed TB test or screening in the record for staff #4. Staff #4 had a hire date of 10/7/19.
Plan of Correction:	The director will have the staff submit a TB test or screening this week.
Standard #:	22VAC40-185-60-A
Description:	Based on record review, the center failed to ensure that all required information was documented in each child's record. Evidence: 1. The record for child #2 was missing the work phone numbers for the child's mother and father. There was a work place listed for each parent but the space for work phone number was left blank on the child's registration form. 2. The record for child #3 was missing documentation of the work place and work phone number for the mother of the child. The record was also missing documentation of the work place for the father. There was a work phone number documented for the father of child #3. 3. The record of child #4 was missing documentation of the father's work place and work phone number. 4. The record of child #5 was missing documentation of the work place for the mother and father of the child. There were work phone numbers documented but no place of employment.
Plan of Correction:	The assistant director will send a notification to all families with missing information in the child's record to have the information completed. A field will be added to the electronic records system for work place of the parents as there is no space for parents to document this information in the current electronic record for each child,
Standard #:	22VAC40-185-70-A
Description:	Based on record review, the center failed to ensure that staff records contained documentation of all information as required. Evidence: 1. There were no references for staff #4 who had a documented hire date of 10/7/19. Documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering are required for each staff person.There was no address for the emergency contacts documented for staff #4. The name, address, and phone number of a person to contact in an emergency is required. 2. The references for staff #3 were completed on 8/7/19. Staff #3 had a hire date documented as 8/5/19. There was no written information to demonstrate that the individual possesses the education, orientation training, staff development, and/or certification required by the job position of lead teacher. There was no emergency contact for staff #3. The name, address, and phone number of a person to contact in an emergency is required.
Plan of Correction:	The director will have all required information documented in each staff person's record.
Standard #:	22VAC40-185-350-E-1
Description:	Based on observation and interview, the center failed to ensure that the ratio for children birth to 16 months was maintained at all times. Evidence: 1. The inspector observed the infant room during the designated afternoon nap time at approximately 1:55 pm. There were 9 infants and one toddler observed in the nap room with two staff supervising. The ages of the children were two months, two three months old, two six months old, seven months old, eight months old, two 11 months old, and 16 months old. Three of the infants were observed awake; the two month old awake in a swing, one child being fed a bottle by a staff person, one infant mobile on the floor. 2. The lead staff person was asked about the required ratio of one staff for every four children and the staff person stated that the third staff person was on break. According to the lead staff person, the third staff person required for ratio left for break at 1:15 pm.
Plan of Correction:	This was corrected during the inspection. The lead staff person in the infant room had a third staff person come in to meet ratio. The director will have a staff person cover all staff break times in the infant room.
Standard #:	22VAC40-185-550-E
Description:	Based on interview and record review, the center failed to ensure that records of the date of practice drills were maintained for one year. Evidence: 1. The log for emergency evacuation drills (fire drills) was observed. There was no documentation of a drill for May, June, July 2019. According to the director, the drills were practiced but because of turnover in administration, the log was not kept for these drills.
Plan of Correction:	All required emergency drills will be practiced and documented.
Standard #:	22VAC40-191-60-C-2
Description:	Based on record review, the center failed to ensure that there was a complete DSS search of the central registry as a part of the background check requirements within 30 days of employment. Evidence: 1. There was no documentation of a DSS search of the central registry in the record of staff #3. Staff #3 had a hire date of 8/5/19.
Plan of Correction:	The director stated it had been sent and returned to the center for missing information on the form to be completed. According to the director, the search was re-sent with the completed information. The director will keep copies and document dates sent for future searches.
Standard #:	63.2(17)-1720.1-B-3
Description:	Based on record review and interview, the center failed to obtain a copy of the results of a search of the central registry maintained pursuant to ? 63.2-1515 and any child abuse and neglect registry or equivalent registry maintained by any other state in which the individual has resided in the preceding five years for any founded complaint of child abuse or neglect against the staff person. Evidence: 1. Staff #3 had disclosed on the "Sworn Statement or Affirmation" form completed 8/1/19 that the staff person had lived in three other states other than Virginia in the last five years. According to the director, the center had not obtained or requested information from the central registry in the three states identified where the staff person had lived. 2. Staff #2 had disclosed on the "Sworn Statement or Affirmation" form completed 6/17/19 that the staff person had lived in another state other than Virginia in the last five years. According to the director, the center had not obtained or requested information from the central registry in the state in which the staff person had lived.
Plan of Correction:	The director began to send the searches for the states during the inspection and will send all four states a request by the end of the week.