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

Current Inspector: Kelly Adriazola (804) 840-8245

Inspection Date: Sept. 10, 2020

Complaint Related: No

Areas Reviewed:
22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 PROGRAMS.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-185 SPECIAL SERVICES.
22VAC40-80 THE LICENSE.
22VAC40-80 THE LICENSING PROCESS.
22VAC40-191 Background Checks (22VAC40-191)

Technical Assistance:
n/a

Comments:
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia.

A monitoring inspection was initiated on September 10, 2020 and concluded on September 11, 2020. The director was contacted by telephone to initiate the inspection. There were 50 children present and 14 staff. The Inspector emailed the director a list of items required to complete the inspection. The Inspector reviewed 3 children?s records and 3 staff records submitted by the facility to ensure documentation was complete.

Information gathered during the inspection determined non-compliances with applicable standards or law and violations were documented on the violation notice issued to the facility.

If you have any questions regarding this inspection please contact the licensing inspector, Kelly Adriazola at (804) 662-9760.

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 5 business days from today. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measures. Please do not use staff names; list staff by positions only.

Violations:
Standard #: 22VAC40-185-150-B
Description: Based on a review of records on September 11, 2020, the center did not ensure that immunizations and physicals received shall be signed by a physician, his designee, or an official of the local health department.
Evidence: 1. The record of Child #1 contained documentation of immunizations and physical that were not signed or date stamped by a physician, his designee, or an official of the local health department.
2. The record of Child #2 contained documentation of immunizations that were not signed or date stamped by a physician, his designee, or an official of the local health department.

Plan of Correction: Training provided to our folks who check in the children's files of the time of enrollment. Adjusting checklist to reflect signature requirements.

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.

Virginia Quality is a voluntary quality rating and improvement system for early care and education facilities serving children ages birth through pre-K. To find programs participating in Virginia Quality, click here.

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