VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Life Time Fitness - Sterling
44610 Prentice Drive
Sterling, VA 20166
(703) 433-0256

Current Inspector: Maria Robles-Lopez (703) 397-3827

Inspection Date: June 26, 2023

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. 8VAC20-820 THE LICENSING PROCESS. 8VAC20-820 HEARINGS PROCEDURES. 8VAC20-770 Background Checks (8VAC20-770) 20 Access to minor?s records 22.1 Background Checks Code, Carbon Monoxide 63.2 Child Abuse & Neglect

Comments:

A renewal inspection was conducted on 06/26/2023 between the hours of approximately 10:30 am and 2:50 pm. There were 88 children present, ranging in ages from 4 years to 12 years, with 12 staff supervising. Children and staff were observed while playing in the pool, transitioning to and from the pool area, eating lunch, playing in the gym. 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 and 5 staff 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. If you have any questions regarding this inspection, please contact the Licensing Inspector, Maria Robles at maria.robles@doe.virginia.gov.

Violations:

Standard #:	22.1-289.011-F
Description:	Based on review of required posted documents, the program did not ensure that all required documents related to the terms of the license were posted on the premises of the program. Evidence: 1) On the date of inspection, the findings of the most recent inspection of the facility (07/28/2022) were not posted. 2) The inspection notice posted was dated 06/29/2022.
Plan of Correction:	Most recent was posted.
Standard #:	22.1-289.035-B-2
Description:	Based on record review, the program did not ensure to obtain a fingerprint-based criminal history check determination letter prior to first day of employment for one staff person. Evidence: 1) The record for Staff #5 (start date 05/22/2023) did not contain the results of a criminal history check or documentation that a criminal history check had been requested.
Plan of Correction:	Employee was removed from schedule until completed. Employee had fingerprints done on 6/27.
Standard #:	8VAC20-780-160-C
Description:	Based on record review, the program did not ensure that employees obtain and submit the results of a follow-up tuberculosis (Tb) screening at least every two years. Evidence: 1) A current Tb screening was due for Staff #2. The Tb screening form in the record for Staff #2 was dated 06/04/2021.
Plan of Correction:	Staff member will have new Tb test done.
Standard #:	8VAC20-780-40-M
Description:	Based on documentation review, the program did not maintain, in a way that is accessible to all staff who work with children, a current written list of all children's allergies, sensitivities, and dietary restrictions documented in the allergy plan required in 8VAC20-780-60 A 8. This list shall be dated and kept confidential in each room or area where children are present. Evidence: 1) On the date of inspection, a current written list of all children's allergies, sensitivities, and dietary restrictions was not available for review.
Plan of Correction:	List of allergies was made and posted.
Standard #:	8VAC20-780-60-A-8
Description:	Based on record and documentation review, the program did not ensure to maintain a written care plan for each child with a diagnosed food allergy, to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction. Evidence: 1) Child #8's physical examination documents a food allergy and there is emergency medication available in the center. An allergy plan for Child #8's food allergy was not available for review.
Plan of Correction:	Parent was given correct forms and asked to fill out and return by 06/29.
Standard #:	8VAC20-780-80-A
Description:	Based on observation and interview with staff, the program did not ensure to maintain, for each group of children, a written record of daily attendance that documents the arrival and departure of each child in care as it occurs. Evidence: 1) An electronic record of daily attendance is kept for the program. However, a written record for each group of children that documents the arrival and departure of each child in care as it occurs was not available.
Plan of Correction:	Implement written system for arrival and departure of children.
Standard #:	8VAC20-780-245-J-3
Description:	Based on medication and documentation review and interview with staff, the program did not ensure that any child for whom emergency medications (such as albuterol, glucagon, and epinephrine auto injector) have been prescribed shall always be in the care of a staff member who posses certification to administer medication. Evidence: 1) Child #4 through Child #9 had emergency medication in the center. Staff members directly supervising their care were not MAT certified. There are three MAT certified staff in the program but Child #5 through Child #11 are not assigned to their care.
Plan of Correction:	Ask corporate to set up another MAT training for more staff to get certified.
Standard #:	8VAC20-780-510-F
Description:	Based on medication and documentation review, the program did not ensure that medication authorization shall be available to staff during the entire time it is effective. Evidence: 1) There was no medication authorization form available for review for the medications for Child #5, Child #6 and Child #9.
Plan of Correction:	Parent was given correct forms and asked to fill out and return by 06/30.
Standard #:	8VAC20-780-510-G
Description:	Based on medication review, medication was not labeled with the child's name, the name of the medication, the dosage amount, and the time or times to be given. Evidence: 1) Medication for Child #5, Child #6 and Child #8 was not labeled with the required information.
Plan of Correction:	Medication has been labeled.
Standard #:	8VAC20-780-510-P
Description:	Based on medication review, the program did not ensure that when a medication expires, the parent shall be notified that the medication needs to be picked up within 14 days or the parent must renew the authorization. Medications that are not picked up by the parent within 14 days shall be disposed of by the center. Evidence: 1) There was medication in the center for Child #5 with an expiration date of 03/2023 and for Child #9, with expiration dates of 08/2022, 05/2023 and 10/2022.
Plan of Correction:	Parents have been notified and taken home expired medication.
Standard #:	8VAC20-780-550-D
Description:	Based on documentation review, emergency evacuation procedures were not practiced monthly. Evidence: 1) On the date of inspection, the 2022 emergency drills log provided for review, did not have an evacuation (fire) drill documented for the month of August 2022.
Plan of Correction:	Practice emergency evacuation procedures.
Standard #:	8VAC20-780-550-E
Description:	Based on documentation review and interview with the provider, shelter-in-place procedures were not practiced a minimum of twice per year. Evidence: 1) On the date of inspection, the 2022 emergency drills log provided for review, had a shelter-in-place drill documented for the month of July 2022, however, a second shelter-in-place drill for the year 2022 was not documented.
Plan of Correction:	Practiced shelter-in-place drill.
Standard #:	8VAC20-780-550-P
Description:	Based on record review, 14 out of 15 written record of children's serious and minor injuries reviewed did not contain all required information. Evidence: 1) One record contained only one of the two signatures required. 2) 14 records did not contain the date and time when parents were notified and how the parent was notified.
Plan of Correction:	Notify parents of each incident and document times.