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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. 28, 2021

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.
22VAC40-80 THE LICENSING PROCESS.
22VAC40-191 Background Checks (22VAC40-191)

Comments:
This inspection was conducted by licensing staff using an alternate remote protocol, including telephone contacts, documents review, and interviews.

A renewal inspection was initiated on September 28, 2021 and concluded on September 29, 2021. The director was contacted by telephone and a virtual inspection was conducted. There were 59 children present, ranging in ages from 3 months to 4 years, with 12 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of 4 child records,4 staff records, and 4 board members 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 program.

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 #: 22VAC40-185-160-B
Description: Based on a review of four staff member's records and interview, the center failed to obtain an acceptable form of documentation of tuberculosis screening for one record.
Evidence: 1. The record of Staff #1 contained documentation of a tuberculosis screening that was not signed by a physician, physician's designee or an official of the local health department. 2. Administration acknowledged the screening was not signed.

Plan of Correction: Corrected on site

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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