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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:
22VAC40-665 STAFF QUALIFICATIONS & TRAINING
22VAC40-665 PHYSICAL PLANT
22VAC40-665 STAFFING & SUPERVISION
22VAC40-665 PROGAMS
22VAC40-665 SPECIAL CARE PROVISIONS & EMERGENCIES
22VAC40-665 SPECIAL SERVICES

Technical Assistance:
Provided guidance on required annual Pre-Service update training

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

A subsidy health and safety (SHSI) inspection was initiated on September 28, 2021 and concluded on September 29, 2021. There were 59 children present with 12 staff supervising. A licensing inspection was also conducted on this date. Both inspections combined cover subsidy health and safety regulations. Only subsidy requirements that are not covered in licensing standards were reviewed during this supplemental inspection.

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 #: 22VAC40-665-580-H
Description: Based on a review of records, the vendor did not ensure that each staff complete the Virginia Annual Health and Safety Update Training by March 1, 2020, and annually thereafter.
Evidence: The most recent completion of the Health and Safety annual training for Staff #1 was dated 8/2/19.

Plan of Correction: Staff member completed training 9/30/21. Training will be added to staff re-orientation packet checklist to prevent this in the future. Director will oversee checklist.

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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