VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Learning Experience
4683 Pouncey Tract Road
Glen allen, VA 23059
(804) 360-4226

Current Inspector: Florence Martus (804) 389-0157

Inspection Date: June 1, 2022

Complaint Related: No

Areas Reviewed:

8VAC20-780 Administration. 8VAC20-780 Staff Qualifications and Training. 8VAC20-780 Physical Plant. 8VAC20-780 Staffing and Supervision. 8VAC20-780 Programs. 8VAC20-780 Special Care Provisions and Emergencies 8VAC20-780 Special Services. 8VAC20-820 THE LICENSE. 8VAC20-770 Background Checks (8VAC20-770) 20 Access to minor's records 22.1 Background Checks Code, Carbon Monoxide 63.2 Child Abuse & Neglect

Technical Assistance:

n/a

Comments:

The licensing inspector conducted an unannounced monitoring inspection on Wednesday, June 1, 2022 from 10:00am to approximately 3:00pm. There were a total of 114 children in care in the direct care of 16 staff members. During the inspection, the children and staff were observed participating in a variety of activities. Staff were observed having positive interactions with the children. All areas of the facility used by the children were inspected. The center is equipped with toys and supplies and items were available to the children. The required postings were reviewed and found to be in compliance. Medication is administered when required and medications were reviewed. During the inspection, ten children?s records and ten staff records were reviewed. Additional information was later submitted to the inspector and was reviewed virtually. 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.

Violations:

Standard #:	22.1-289.035-B-2
Description:	Based on a review of ten staff records and interview, the center did not ensure that one out of ten staff obtained fingerprint results prior to hire. Evidence: 1) The record for Staff #3, hired on 11/08/21, had fingerprint results that were dated 06/09/21. 2) During interview, a member of management reported Staff #3 was terminated from employment in October 2021 and rehired on 11/08/21, but new fingerprint results were not obtained.
Plan of Correction:	Moving forward, fingerprints will be obtained prior to hire. The staff member will obtain new fingerprints.
Standard #:	22.1-289.035-B-4
Description:	Based on a review of ten staff records, the center did not obtain the results of a criminal history record information check and a search of the child abuse and neglect registry or equivalent registry from any state in which two staff members had resided in the preceding five years within the required time frame. Evidence: 1) The record for Staff #5, hired on 03/22/21, indicated the staff had resided in a state outside of Virginia within the last five years. The record did not contain a criminal history record information check or a search of the child abuse and neglect registry from the state. 2) The record for Staff #9, hired on 01/04/22, indicated the staff had resided in two states outside of Virginia within the last five years. The record did not contain a criminal history record information check or a search of the child abuse and neglect registry from the other states. 3) During interview, a member of management confirmed the required out-of-state checks were not obtained for Staff #5 or Staff #9 within the required time frames. The out-of-state criminal history record information check is required to be obtained prior to hire and the out-of-state search for founded complaints of child abuse or neglect is required to be requested within the first 30 days of being hired.
Plan of Correction:	The out of state searches will be initiated and obtained as soon as possible.
Standard #:	8VAC20-770-60-B
Description:	Based on a review of ten staff records and interview, the center did not obtain a completed sworn statement or affirmation for two staff members prior to hire. Evidence: 1) The record for Staff #3, hired on 11/08/21, did not contain a sworn statement. 2) The sworn statement in the record for Staff #9, hired on 01/04/22, was dated 01/07/22. 3) During interview, a member of management reported the sworn statement for Staff #3 could not be located and the sworn statement for Staff #9 was completed after hire.
Plan of Correction:	The sworn disclosures will be obtained prior to hire.
Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of ten staff records and interviews, the center did not ensure that three staff members had a central registry finding within 30 days of employment. Evidence: 1) The central registry finding in record for Staff #1, hired on 03/04/21, was dated 04/18/22. 2) The central registry finding in the record for Staff #3, hired on 11/08/21, was dated 01/19/22. 3) The record for Staff #9, hired on 01/04/22, did not contain a central registry finding. A member of management reported the central registry finding for Staff #9 could not be located. 5) During interview, a member of management confirmed the results of the central finding for Staff #1 and Staff #3 were not received and the center did not follow up within 30 days of employment.
Plan of Correction:	The center will document further contact with OBI when a central registry search is not returned within 30 days of employment. A new request will be submitted for Staff #9.
Standard #:	8VAC20-780-130-E
Description:	Based on a review of ten children?s records and interview, the center did not obtain documentation of additional immunizations once every six months for one child under the age of two years. Evidence: 1) The most recent immunization documentation in the record for Child #4 (12-month-old), enrolled on 08/16/21, is dated 09/27/21. 2) During interview, a member of management confirmed the records did not contain additional immunizations.
Plan of Correction:	The center followed up with the children?s parents to request additional immunizations for the child. All children?s files will be audited and documentation will be due by 06/24/22.
Standard #:	8VAC20-780-160-A
Description:	Based on a review of ten staff records and interview, the center did not ensure two staff members had documentation of a negative tuberculosis (TB) screening within the required time frames. Evidence: 1) The TB screening in the record for Staff #2, hired on 04/11/22, was dated 04/13/22. Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children. 2) The TB screening in the record for Staff #10, hired on 04/18/22, was dated 12/14/21. The documentation shall have been completed within the last 30 calendar days of the date of employment. 3) During interview, a member of management confirmed the documentation was not received within the required time frame.
Plan of Correction:	Staff will have until 6/24/22 to provide a current TB.
Standard #:	8VAC20-780-60-A
Description:	Based on a review of ten children?s records and interview, the center did not ensure one child?s record contained all the required information. Evidence: 1) The record for Child #4, enrolled on 04/04/22, did not contain a second emergency. 2) During interview, a member of management confirmed the record did not contain a second emergency contact. Each child record should contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.
Plan of Correction:	The emergency contact will be obtained. All children?s files will be audited and documentation will be due by 06/24/22.
Standard #:	8VAC20-780-70
Description:	Based on a review of ten staff records and interviews, the center did not ensure that six staff records contained all the required information. Evidence: 1) The references in the record for Staff #1, hired on 03/04/22, were taken over the phone. The references do not contain dates of contact and one of the references does not have documentation on signature of person making the call. 2) The references in the record for Staff #2, hired on 04/11/22, were taken over the phone. The references do not contain dates of contact and one reference does not have documentation on signature of person making the call. 3) The record for Staff #3, hired on 11/08/21, did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment. 4) The record for Staff #6, hired on 01/04/22, were taken over the phone. The references do not contain dates of contact. 5) The record for Staff #7, hired on 04/12/22, were taken over the phone. One of the references does not contain dates of contact. 6) The record for Staff #8, hired on 02/16/22, were taken over the phone. The references do not contain dates of contact.
Plan of Correction:	Moving forward, all required components will be documented when obtaining references over the phone.
Standard #:	8VAC20-780-240-A
Description:	Based on a review of ten staff records and interviews, the center did not ensure one staff had completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment. Evidence: 1) The record for Staff #8, hired on 02/16/22, did not contain documentation that the staff had completed the Virginia Department of Education-sponsored orientation course. 2) During interviews, a member of management reported Staff #8 did not complete the course within 90 calendar days of employment.
Plan of Correction:	The staff will have the training completed by 06/24/22
Standard #:	8VAC20-780-280-B
Description:	Based on observations at the center on 06/01/22, the center did not ensure to keep all hazardous substances such as cleaning materials in a locked place using a safe locking method that prevents access by children. Evidence: 1) In the Preschool 1B classroom, the licensing inspector observed unlocked cleaning supplies. A bottle of bleach/water solution was observed in the bathroom, unlocked.
Plan of Correction:	Corrected on site.
Standard #:	8VAC20-780-510-F
Description:	Based on a review of eight medications and interviews on 06/01/22, the center did not ensure that two medication authorizations were available to staff during the entire time they were effective for three out of five children. Evidence: 1) Two medications were observed for Child #2, but no medication authorizations were present for the medications. 2) One of the medications observed for Child #5 did not have a medication authorization present. 3) Two medications were observed for Child #7, but no medication authorizations were present for the medications. 4) During interview, a member of management reported the authorizations for these medications were not present.
Plan of Correction:	Parents were given new forms to complete and to return no later than 6/24/22
Standard #:	8VAC20-780-550-H
Description:	Based on a review of documents and interview, the center did not maintain a record of the dates of the practice drills for one year. Evidence: 1) The licensing inspector observed the emergency drill log for the year 2021 and 2022. An evacuation drill was not documented for the month of May 2022. 2) During interview, a member of management reported the drill was conducted, but it was not documented as required.
Plan of Correction:	All drilsl will be documented moving forward.