Ms. Deanna Southern
41 Winding Way Road
Boones mill, VA 24065
(540) 334-5437
Current Inspector: Rebecca Forestier (540) 309-2835
Inspection Date: March 26, 2024
Complaint Related: No
- Areas Reviewed:
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8VAC20-800 ADMINISTRATION
8VAC20-800 PERSONNEL
8VAC20-800 HOUSEHOLD MEMBERS
8VAC20-800 PHYSICAL HEALTH OF CAREGIVERS AND HOUSEHOLD MEMBERS
8VAC20-800 CAREGIVER TRAINING
8VAC20-800 PHYSICAL EQUIPMENT AND ENVIRONMENT
8VAC20-800 CARE OF CHILDREN
8VAC20-800 PREVENTING THE SPREAD OF DISEASE
8VAC20-800 EMERGENCIES
8VAC20-800 NUTRITION
8VAC20-770 BACKGROUND CHECKS
22.1 BACKGROUND CHECKS, CODE, CARBON MONOXIDE
- Comments:
-
An unannounced monitoring inspection was conducted on 03/26/2024. There were 12 non-resident children and 1 resident child, ages 8 months-5 years, totaling 31 points, and 3 caregivers present during the inspection. The inspector reviewed compliance in the areas of administration, personnel, household members, caregiver training, physical environment and equipment, care of children, preventing the spread of disease, emergencies, nutrition, and background checks. A total of 5 children?s records and 5 caregiver records were reviewed. The children were observed in organized group activities and in free choice play. The inspector arrived for the inspection at 9:00 am and departed at 10:45 am.
Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the provider.
- Violations:
-
Standard #: 22.1-289.035-A Description: REPEAT VIOLATION
Based on record review, the provider failed to ensure that all caregivers shall undergo a background check in accordance with the Code of Virginia prior to employment and every five years thereafter.
Evidence: The most recent search of the central registry for Caregiver 4 was dated 12/12/2018; there was not a follow-up search of the central registry obtained by 12/12/2023.Plan of Correction: Will use the portal to submit the request.
Standard #: 22.1-289.035-B-2 Description: Based on document review, the provider failed to ensure that no person shall be hired for compensated employment prior to the facility obtaining an employment eligibility letter upon the completion of a fingerprint background check as required by the Code of Virginia.
Evidence:
1. The record for Caregiver 3 contained a documented hire date of 11/02/2023; the employment eligibility letter for Caregiver 3 was dated 11/09/2023.
2. The record for Caregiver 5 contained a documented hire date of 11/08/2023; the employment eligibility letter for Caregiver 5 was dated 11/09/2023.Plan of Correction: Will make completing fingerprints part of the application/interview/hiring process.
Standard #: 8VAC20-770-60-B Description: Based on record review, the provider failed to ensure that an employee must not be employed until the agency has the person?s completed sworn statement or affirmation.
Evidence: The record for Caregiver 5 contained a documented hire date of 11/08/2023. The sworn statement in the record for Caregiver 5 was dated 11/09/2023.Plan of Correction: Will make completing the sworn statement part of the application/interview/hiring process.
Standard #: 8VAC20-770-60-C-2 Description: Based on record review, the provider failed to obtain the findings from a search of the central registry within 30 days of employment.
Evidence:
1. The record for Caregiver 3 contained a documented hire date of 11/02/2023. The search of the central registry for Caregiver 3 was dated 01/26/2024.
2. The record for Caregiver 5 contained a documented hire date of 11/08/2023. There was not a search of the central registry available for Caregiver 5.Plan of Correction: Will start using the portal to submit requests.
Standard #: 8VAC20-800-170-A Description: Based on record review, the provider failed to obtain from each caregiver at the time of hire, a report documenting the absence of tuberculosis in a communicable form.
Evidence:
1. The record for Caregiver 3 contained a documented hire date of 11/02/2023. The tuberculosis screening/test was dated 11/08/2023.
2. The record for Caregiver 5 contained a documented hire date of 11/08/2023. The tuberculosis screening/test was dated 11/09/2023.Plan of Correction: Will make getting a TB test part of the application/interview/hiring process.
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.
