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Bon Secours Family Center @ St. Francis Medical Center
13901 St. Francis Boulevard
Midlothian, VA 23114
(804) 594-4990

Current Inspector: Kandra Brown (804) 662-9038

Inspection Date: Oct. 5, 2016 and Oct. 27, 2016

Complaint Related: Yes

Areas Reviewed:
22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 PHYSICAL PLANT.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 PROGRAMS.
63.2 Child Abuse and Neglect

Technical Assistance:
N/A

Comments:
On September 30, 2016 the department received a complaint regarding forbidden actions. The licensing inspector conducted an unannounced complaint inspection with another local agency on October 5, 2016 at the facility from approximately 9:00am until 11:45am. On October 27, 2016 the licensing inspector returned to the facility and conducted an additional inspection from approximately 1:15pm until 5:30pm. Interviews with staff were completed, observations were made and documentation was reviewed. The preponderance of the evidence gathered during the investigation does support the allegation; therefore, the complaint is determined to be valid. Provider ' Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return it to me within five calendar days from date of receipt. You will need to specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standards, 2) measures to prevent the noncompliance from occurring again, and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). If you have any questions about this inspection, please contact the licensing inspector, Lynn Powers at (804) 662-9790.

Violations:
Standard #: 22VAC40-185-410-1
Complaint related: Yes
Description: Based on staff interviews, it was determined that one staff member used forbidden action by rough handling children who were in care. Evidence: During interviews between the licensing inspector and staff members the following was determined: 1. One staff member stated she had seen Staff #1 ?grab children in the Twos classroom roughly by the upper arm to move children around the room?. The staff member stated the children would sometimes sit down and sometimes the children would cry after Staff #1 grabbed the children by the arm. The staff member stated Staff #1 was seen roughly grabbing children by the arm once or twice a week over a three month period. 2. Another staff member stated the staff had occasionally seen Staff #1 grab children in the Twos classroom by the shoulder to put children in time out. The staff member stated she had seen ?Staff #1 roughly grab children by the arm about a month ago?. 3. A third staff member stated approximately a month ago the staff member saw Staff #1?yank a child by the arm? to get the child over to the diaper changing table. The staff member stated the child began to cry after being ?yanked? by the arm. The staff stated the child was in the Twos classroom.

Plan of Correction: 1. Neither staff member of the two?s classroom are working in our facility. Our own investigation resulted in a founded concern as well. For one staff member there was failure to report in spite of extensive training. The other staff member involved left the program before the investigation was completed. 2. Initial mandated training has been developed and review with each staff members has begun. The training includes the reporting requirements and expectation and reviews forbidden actions and what constitutes abuse. The format is one-on-one with the manager to insure that the staff fully understands. Staff sign that the material has been reviewed. Will complete by December 15, 2016. 3. Mandated training is in progress of development to review positive guidance, tone and voice, reporting expectations, developmentally appropriate expectations and examples of forbidden actions which constitute abuse to be conducted in small groups starting with supervisory staff. All staff will be mandated to attend and must successfully complete the assessment. Management will oversee the development of the material and the successful completion of the program by all staff. Will complete by December 23, 2016. 4. Current ?Case Scenarios? mandated training revised to include additional, specific examples where staff must identify, in their own words, forbidden actions and reporting requirements and licensing standards. Will be checked for understanding. This will be ongoing and annual training; Management will oversee the development of the materials and will work with internal trainer to insure each staff member successfully complete the training. Will complete by December 30, 2016. 5. Revision of materials provided to new staff at orientation and all staff for the annual reorientation to state more explicitly what constitutes abuse and the reporting policies and requirements. This is mandated and reviewed by the supervisor, signed by the staff member and the supervisor and placed in their education record. All staff participates in the ?re-orientation? each July and August with their supervisor. Revisions are being made by management. 6. At the midyear performance review meeting and end of year performance review meetings, staff will have a series of questions related to their understanding of what constitutes abuse and what their responsibilities are for reporting anything that is not consistent with our policies or that may constitute abuse. Management oversees that all supervisors complete the performance review meetings with all staff under their responsibility. The documentation is filed with the employees performance review materials. This will become annual addition to the two required performance meetings. Will complete Mid-Year by February 10, 2017 and End of Year by September 29, 2017. 7. Revisions to our operating manual to state more explicitly what constitutes abuse, as well as, the reporting policies and expectations. Mandated training to review the updates in the manual and a new copy will be provided to all staff. An assessment related to the manual with the updated information and language will also accompany the training and all staff will need to successfully complete the assessment. Will complete by January 6, 2017. 8. A mandated training to be developed and conducted as a review with staff related to positive guidance and supportive guidance, tone and voice, forbidden action, reporting requirements and expectations, our policies and standards and licensing policies and standards, This review will include an assessment that all staff must complete. Management will provide training internally. Will complete by May 19, 2017.

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.

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