VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Ms. Mary Almy
1315 Coltrane Dr
Portsmouth, VA 23701
(757) 541-3144

Current Inspector: Trisha Brown (757) 404-2601

Inspection Date: Nov. 19, 2021 and Nov. 23, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-111 Administration 22VAC40-111 Personnel 22VAC40-111 Household Members 22VAC40-111 Physical Health of Caregivers and Household Members 22VAC40-111 Caregiver Training 22VAC40-111 Physical Environment and Equipment 22VAC40-111 Care of Children 22VAC40-111 Preventing the Spread of Disease 22VAC40-111 Medication Administration 22VAC40-111 Emergencies 22VAC40-111 Nutrition 22VAC40-111 Transportation 22VAC40-111 Nighttime Care 22VAC40-191 Background Checks for Child Welfare Agencies 54.1 Provider must be MAT certified to administer prescription medication. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, including telephone contacts, documents review, interviews and a virtual tour of the program A monitoring inspection was initiated on 11/19/21 and concluded on 11/23/21. The provider was contacted by telephone to initiate the inspection. There were 3 children present and 1 caregiver. The inspector emailed the director/provider a list of items required to complete the inspection. The Inspector reviewed 2 children?s records and 2 caregiver records, along with any requested program records submitted by the facility to determine if required documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law and violations were documented on the violation notice issued to the program.

Violations:

Standard #:	22VAC40-111-90-A
Description:	Based on a review of two children's files, it was determined that the provider did not ensure that documentation was obtained to show that each child has been adequately immunized according to the requirements of the Code of Virginia and applicable State Board of health regulations prior to attendance in the family day home. Evidence: 1. The record for child #2 did not contain an immunization record. 2. Caregiver #1 acknowledged that the record for child #2 did not contain documentation of an immunization record.
Plan of Correction:	The provider responded: The parent of child #1 provide a copy of an immunization record from the doctor that showed she refused shots for her child. I will check to see if it is for a religious reason and if so have her complete the required documentation. All children's files will be reviewed to ensure they contain an immunization record. New children to the family day home will have documentation of an immunization record on file prior to enrollment enrollment.
Standard #:	22VAC40-111-140-B-3
Description:	Based on a review of two caregiver records, it was determined the provider did not ensure that there is a caregiver present with a current certification in cardiopulmonary resuscitation (CPR), as appropriate to the age of the children in care, from the American Red Cross, American Heart Association, American Safety and Health Institute, or the National Safety Council, or current CPR certification issued within the past two years by a community college, a hospital, a rescue squad, or a fire department. Evidence: 1. The record for caregiver #1 contained a CPR certification that expired on October 31, 2021. 2. Caregiver #1 confirmed there was no caregiver present with a current certification in CPR.
Plan of Correction:	The provider responded: I am scheduled to complete a course for certification in CPR on 12/8/21.
Standard #:	22VAC40-111-140-B-4
Description:	Based on a review of two caregiver records, it was determined the provider did not ensure that there is a caregiver present with a current certification in first aid from the American Red Cross, American Heart Association, American Safety and Health Institute, or the National Safety Council, or current first aid certification issued within the past three years by a community college, a hospital, a rescue squad, or a fire department. Evidence: 1. The record for caregiver #1 contained a first aid certification that expired on October 31, 2021. 2. Caregiver #1 confirmed there was no caregiver present with a current certification in first aid.
Plan of Correction:	The provider responded: I am scheduled to complete a course for certification in first aid on 12/8/21.
Standard #:	22VAC40-111-180-A
Description:	Based on a review of two caregiver records, it was determined that the provider did not ensure that at least every two years from the date of the first initial screening or testing, staff members shall obtain and submit the results of a follow-up tuberculosis screening. Evidence: 1. The record for caregiver #1, contained documentation of TB screening that was dated 11/17/19. 2. Caregiver #1 confirmed that she had not completed an updated TB screening.
Plan of Correction:	The provider responded: Caregiver #1 will complete an updated TB screening.