VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Holy Tabernacle Church of Deliverance
14749 Warwick Boulevard
Newport news, VA 23608
(757) 877-1100

VDSS Contact: Michele Patchett (757) 439-6816

Inspection Date: Jan. 24, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-191 Background Checks for Child Welfare Agencies 63.2(17) License & Registration Procedures 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:

Sight and Sound Supervision of children

Comments:

Licensing Inspector arrived at 9:15 am and departed at 2:45 pm to conduct a Subsidy Health and Safety Inspection. At the time of the tour there were 32 children, ages three months through 11 years old in care with five staff. Children were playing with electronic games and playing freely. The infants were observed being held and during diapering. The sample size was six staff records and five children's records. The outdoor play area was not inspected due to inclement weather.

Violations:

Standard #:	22VAC40-191-40-D-2
Description:	Based on record review, in one of six staff records reviewed, the vendor did not ensure that staff have a central registry record check by the end of their 30th day of employment. Evidence: The Director confirmed that there was not a central registry finding for Staff #4 (date of hire 6/3/19).
Plan of Correction:	Director will correct the situation today and turn in the paperwork Monday to the Office of Background Investigations.
Standard #:	22VAC40-665-520-B
Description:	Based on record review, in four of five children's records reviewed, the vendor did not ensure that each child's record was documented with all required information. Evidence: The following information had not been documented in each child's record: Child #1, Child #3 and Child 5-one parent's home address Child #4-complete work address for one parent
Plan of Correction:	The children's records will be corrected by the end of the day.
Standard #:	22VAC40-665-530-1
Description:	Based on record review, in five of six staff records reviewed, the vendor did not ensure that each staff record contained all required information. Evidence: The records for Staff #1, Staff #2, Staff #4, Staff #5 and Staff #6 did not include documentation of their date of employment.
Plan of Correction:	The files will be corrected beginning today and completed by Monday the 27th.
Standard #:	22VAC40-665-540-A
Description:	Based on record review, in four of six staff records reviewed, the vendor did not ensure that staff shall be evaluated by a health professional and be issued a statement that the individual is determined to be free of communicable tuberculosis (TB). Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children. The documentation shall have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician's designee, or an official of the local health department. Evidence: 1. The Director confirmed that there was no documentation of a TB screening for Staff #1 (date of hire 6/2/19), Staff #2 (date of hire 6/17/19) and Staff #5 (date of hire 6/21/19). 2. The TB screening submitted for Staff #4 was dated 8/2/17 which was more than 30 days prior to the staff member's hire date of 6/3/19.
Plan of Correction:	We will contact the doctor and have them to update the TB screening questionnaire by Wednesday.
Standard #:	22VAC40-665-540-B
Description:	Based on record review, in one of six staff records reviewed, the vendor did not ensure that staff receive subsequent TB screenings at least every two years from the date of the initial screening. Evidence: The Director confirmed that the TB screenings for Staff #6 (date of hire 9/2009) was more than two years old and was dated 8/28/17.
Plan of Correction:	We will contact the doctor and have them to update the TB screening questionnaire by Wednesday.
Standard #:	22VAC40-665-580-D
Description:	Based on record review, in six of six staff records reviewed, the vendor did not ensure that orientation training for staff shall be completed on the following facility specific topics prior to the staff member working alone with children and within seven days of the date of employment or the date of subsidy vendor approval. Evidence: The Director confirmed that there was no documentation of orientation training for all six staff records reviewed.
Plan of Correction:	Director will correct those items no later than Wednesday, the 29th.
Standard #:	22VAC40-665-580-E-1
Description:	Based on record review, in two of six staff records reviewed, the vendor did not ensure that staff must have current certification in cardiopulmonary resuscitation (CPR) appropriate to the age of children in care that shall include an in-person competency demonstration. Evidence: The following staff members did not have current CPR training: Staff #2-CPR training expired 9/25/19 Staff #4-CPR training expired 11/3/19
Plan of Correction:	Both staff members will attend the next available CPR/First Aid training.
Standard #:	22VAC40-665-580-E-2
Description:	Based on record review, in two of six staff records reviewed, the vendor did not ensure that staff have current first aid training. Evidence: The Director confirmed that the following staff members did not have current first aid training: Staff #2-first aid training expired 9/25/19 Staff #5-first aid training expired 11/3/19
Plan of Correction:	Both staff members will attend the next available CPR/First Aid training.
Standard #:	22VAC40-665-610-A
Description:	Based on observation and inspection of the facility, the vendor did not ensure that areas and equipment of the center, inside and outside, shall be maintained in a clean, safe, and operable condition. Evidence: The following was observed in the center: 1. In the main room there was visible and moveable gray dust on two ceiling vent covers. The cords from the television to the surge protector were dangling down and needed to be secured to prevent the children from pulling or tripping over them. The green wall had an approximate 12" gash with areas of chipped and peeling paint underneath and beside it. 2. In the second bathroom in the hallway, the black rubber baseboard was detached from the wall. 3. In the Baby room, the phone jack box had become detached from the wall and was hanging down to the floor.
Plan of Correction:	All building violations will be corrected no later than January 31st.
Standard #:	22VAC40-665-610-C-2
Description:	Based on observation and inspection of the facility, the vendor did not ensure that electrical outlets shall have protective covers. Evidence: The Director confirmed that there were two uncovered outlets in the Baby room. In the main room, there were three uncovered outlets in the surge protector by the television and four uncovered outlets in the surge protector by the table.
Plan of Correction:	The outlets in the Baby Room were immediately corrected. Both surge protectors will be covered by Monday, the 27th.
Standard #:	22VAC40-665-620-A
Description:	Based on observation and inspection of the facility, the vendor did not ensure that hazardous substances such as cleaning materials, insecticides, and pesticides shall be kept in a locked place using a safe locking method that prevents access by children. If a key is used, the key shall not be accessible to children. Evidence: The Director confirmed the following unlocked hazardous substances labeled keep out of reach of children and caution or warning: 1. One bottle of liquid hand soap on the sink in the first bathroom in the hallway. 2. One can of odor neutralizing spray and one bottle of liquid hand soap in the Back Bathroom.
Plan of Correction:	All items have been secured.
Standard #:	22VAC40-665-740-B-6
Description:	Based on observation and inspection of the facility, the vendor did not ensure that disposable diapers shall be disposed in a leak-proof or plastic-lined storage system that is either foot-operated or used in such a way that neither the staff member's hand nor the soiled diaper touches an exterior surface of the storage system during disposal. Evidence: A diaper change was observed where the staff member did not dispose of the soiled diaper in the appropriate diaper disposal storage system. The staff member confirmed as to putting the soiled diaper in a plastic grocery bag and placing it on the shelf in the bathroom before disposing of it outside.
Plan of Correction:	Effective immediately the foot receptacle will be utilized for soiled diapers.
Standard #:	22VAC40-665-740-B-8
Description:	Based on observation and inspection of the facility, the vendor did not ensure that the diapering surface shall be used only for diapering or cleaning children, and it shall be cleaned with soap and at least room temperature water and sanitized after each use. Evidence: The staff member confirmed that there was a package of wipes stored on the diaper pad. A diaper change was observed and the staff member did not clean the diapering surface with soap and water, nor did the staff member sanitize the surface after the diaper change. The staff member wiped the surface with a disinfectant wipe after changing the child.
Plan of Correction:	Effective immediately we will the utilize the proper cleaning solution for diaper changes. A labeled bottle for cleaning and a labeled bottle for sanitizing will be in place by Monday the 27th and stored in a locked area.
Standard #:	22VAC40-665-770-B-5
Description:	Based on review, the vendor did not ensure that the emergency preparedness plan had been updated to include all required procedural components. Evidence: The Director confirmed that the emergency preparedness plan did not include continuity of operations procedures to ensure that essential functions are maintained during an emergency.
Plan of Correction:	The continuity of operations procedures will be added no later than the 31st.
Standard #:	22VAC40-665-780-A-3
Description:	Based on observation and staff interview, the vendor did not ensure that lockdown procedures shall be practiced at least annually. Evidence: The Director confirmed that there was no documentation of a lockdown drill practiced in 2019.
Plan of Correction:	A lockdown drill will be practiced this year.
Standard #:	63.2(17)-1720.1-B-2
Description:	Based on record review, in two of six staff records reviewed, the vendor did not ensure that staff submit to fingerprinting prior to being employed. Evidence: The Director confirmed that there was no documentation of fingerprint results for Staff #2 (date of hire 6/17/19) and Staff #5 (date of hire 6/21/19).
Plan of Correction:	The Director will schedule both fingerprints for Monday the 27th.