Mary Bethune Academy
2249 Halifax Street
Lynchburg, VA 24501
Current Inspector: Victoria E Dawson (540) 309-2674
Inspection Date: Oct. 10, 2018
Complaint Related: No
- Areas Reviewed:
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 PHYSICAL PLANT.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-185 SPECIAL SERVICES.
22VAC40-80 THE LICENSE.
22VAC40-80 THE LICENSING PROCESS.
63.2 Licensure and Registration Procedures
63.2 Facilities and Programs..
An unannounced renewal inspection was completed on 10/10/18. There were 37 children present in four groupings from two months through five years present with nine staff observed directly supervising. Eight children's records and one from the last inspection were reviewed. Seven staff records were reviewed. Two emergency medications were observed. The inspector arrived at the center at 9:30 am and departed at 4:00 pm. The children were observed during free play time in the classrooms, during lunch, and during nap. Infant activities were also observed. There was discussion with the owner/director about the following: the renewal application had not been received and the inspector sent the 30-day reminder letter to the director via email, background check requirements.
Standard #: 22VAC40-185-140-A Description: Based on record review, the center failed to ensure that each child had a physical examination by or under direction of a physician prior to attendance or within 30 days after attendance. Evidence: 1. Children #3,4,7 did not have documentation of a physical examination. The first dates of attendance for each child, respectively are: 9/4/18, 8/13/18, 9/5/18. Plan of Correction: The office personnel will contact each parent to have them provide a physical examination.
Standard #: 22VAC40-185-40-J Description: Based on review of policies and procedures and interview, the center failed to ensure that the injury prevention procedures were updated at least annually based on documentation of injuries and a review of the activities and services. Evidence: 1. The injury prevention plan was reviewed as a part of the parent handbook. The parent handbook revision date on the cover was noted as "5/13." 2. The director stated that there is no documentation of the plan review. Plan of Correction: A folder will be developed for injury reports divided by class and reviewed at least annually.
Standard #: 22VAC40-185-60-A Description: Based on record review, the center failed to ensure that each child's record contained documentation of all required information. Evidence: 1. There was no work phone numbers documented for the mother or the father of children #3 and #4 who were siblings. There was a work place documented for each parent. 2. There was no phone number for the second required emergency contact person for child #5. 3. The addresses for two of two emergency contacts for child #9 were not complete. There was only a city documented for each emergency contact for the child. Plan of Correction: The information will be documented for each child's record.
Standard #: 22VAC40-185-70-A Description: Based on record review, the center failed to ensure that staff records contained all required information. Evidence: 1. The record of staff #5 did not have documentation of one of two required reference prior to hire. 2. The record of staff #6 did not have documentation of references prior to hire. Staff #6 was hired 9/18/18. The references were dated 9/27/18 and 10/5/18. Plan of Correction: The second reference for staff #5 was completed during the inspection. References will be checked prior to employment.
Standard #: 22VAC40-185-550-H Description: Based on observation and interview, the center failed to ensure that there was an emergency plan for the bus that listed route information including evacuation/alternate routes, shelters, and hospitals for sites frequently visited. Evidence: 1. There was no emergency plan for two locations that are regularly visited for field trips. Plan of Correction: The plans will be developed and put in the emergency binder on the bus.
Standard #: 22VAC40-185-560-F Description: Based on observation and interview, the center failed to ensure that a menu was posted with the current week's food to be served. Evidence: 1. The menu for October 1-5 was observed to be posted. There was no menu observed posted for the current week October 8-12. 2. The office personnel stated that the menu was completed by the cook today for the month of October. Plan of Correction: The menu will be posted once it is typed out.
Standard #: 22VAC40-185-580-C Description: Based on observation, the center failed to ensure that all required information was on the bus used for transporting the children. Evidence: 1. There were no emergency numbers posted on the bus. 2. The center's address and phone number was not posted on the bus. Plan of Correction: The emergency numbers were posted and was corrected during the inspection. The address and phone number was posted on the bus during the inspection.
Standard #: 22VAC40-185-580-I Description: Based on observation and interview, the center failed to ensure that before leaving on a field trip, a schedule of the trip's events and location shall be posted an visible at the center site. Evidence: 1. There was no notice of the field trip observed to be posted when a class went on a field trip for the morning. 2. The staff person in charge of the field trip who is the assistant director stated that a notice was not posted. Plan of Correction: A notice of the trip's events will be posted in the future for all field trips.
Standard #: 22VAC40-191-40-D-3-D Description: Based on record review and interview, the center failed to ensure that a Sworn Statement and Criminal Record Check was updated before three years since the last completed checks as a part of the background check. Evidence: 1. According to the owner/director, there is one current Board Officer. This applicant (Board Officer) had last completed a Sworn Statement on 3/19/14 and a Criminal Record Check was last completed 4/17/14. Plan of Correction: The applicant will complete the fingerprint and an updated Sworn Statement.
Standard #: 22VAC40-191-60-C-2 Description: Based on record review, the center failed to ensure that each staff had a completed search of the central registry within 30 days of employment. Evidence: 1. There was no completed search of the central registry for staff #4. Staff #4 was hired 7/11/18. There was no documentation of this search being sent. Plan of Correction: The office personnel stated that this search was resent to the central registry for staff #4. The staff will contact the central registry to check on this.
Standard #: 22VAC40-80-120-E-2 Description: Based on observation, the center failed to ensure that the findings of the most recent inspection of the facility were posted. Evidence: 1. There was an inspection completed at the facility on 9/26/18. The "Violation Notice" for this inspection was not observed posted. Plan of Correction: The director will make sure all "Violation Notices" are posted in the future.
Standard #: 63.2-1720.1-B-2 Description: Based on record review, the center failed to ensure that a staff person had a completed fingerprint as a part of the background check prior to their first day of working. Evidence: 1. Staff #5, #6, and #7 did not have a completed fingerprint record. Staff #5 and #7 were hired 10/8/18, did not have a completed fingerprint, and were observed working during the inspection. Staff #6 was hired 9/18/18 and did not have a fingerprint completed. Plan of Correction: According to the director, all staff have gone to have them completed. No staff will be hired prior to the completion of the fingerprint background check. The director found the fingerprint for staff #7 during the inspection and showed the inspector. This will be printed for the staff file.
Standard #: 63.2-1720.1-B-3 Description: Based on record review and interview, the center failed to ensure that each staff member had authorized the child day center 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 him. Evidence: 1. Staff # 6 disclosed on a Sworn Statement dated 9/4/18 that the staff person had lived in another state other than Virginia within the past five years. The center had not obtained authorization from the staff person to check the central registry in the state in which the staff person resided. Plan of Correction: The central registry will be sent for this staff person.
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