Mary Bethune Academy
2249 Halifax Street
Lynchburg, VA 24501
Current Inspector: Victoria E Dawson (540) 309-2674
Inspection Date: March 29, 2016
Complaint Related: No
- Areas Reviewed:
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 PHYSICAL PLANT.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-185 SPECIAL SERVICES.
22VAC40-80 THE LICENSE.
63.2 Licensure and Registration Procedures
22VAC40-191 Background Checks (22VAC40-191)
An unannounced renewal inspection was conducted on 3/29/2016. There were 42 children total in care with nine staff present. The inspector arrived at 1:00 P.M. and departed the program at 5:00 P.M. The inspector reviewed five children's and six staff's records during the inspection. All policies and procedures were reviewed and a building walkthrough was conducted inside and outside.
Children were observed during: nap, snack, outside time, quiet activities, afternoon snack, departure on bus and play time.
Discussion with site director and director about: using the work study students as staff unless a complete records is obtained, moving the violation notice to an area that is conspicuous to the public, and program lead qualifications.
Standard #: 22VAC40-185-130-B Description: Based on review of five children's records, the center failed to ensure that all children under the age of two years had additional immunizations documented.
1. The inspector found that children # 2 and # 3 needed updated immunizations. Child # 2 date of birth is 1/16/2014 and the most recent immunization was dated 3/23/2015. Child # 3 date of birth is 5/22/2013 and the most recent immunization records were dated 12/3/2014.
Plan of Correction: The director will obtain a new updated immunization record and will monitor all records for completeness.
Standard #: 22VAC40-185-160-A Description: Based on review of three staff records, the center failed to ensure that all TB screenings were completed within 21 days of hire or completed 12 months prior to employment.
1. The inspector found that staff # 1 was hired on 3/2/2016 and did not have a TB screening within 21 days of hire.
Plan of Correction: The director will have the staff person to obtain a TB screening as soon as possible.
Standard #: 22VAC40-185-60-A Description: Based on review of five children's records, the center failed to ensure that all records were complete. Evidence: 1. The inspector found that child # 3 did not have a physician or phone number completed. Plan of Correction: The office staff person will have the parent to complete the missing portion and will monitor all records.
Standard #: 22VAC40-185-70-A Description: Based on review of six staff records, the center failed to ensure that all records were complete.
1. The inspector found that staff # 1 and 6 did not have the two required references and job title, and 2. Staff # 1 did not have a start date.
Plan of Correction: The office staff person will obtain the missing information and will monitor all staff records.
Standard #: 22VAC40-185-280-B Description: Based on observation of the children's restroom, the center failed to ensure that all chemicals were locked. Evidence: 1. The inspector found that a spray can of Lysol sitting on a high shelf not locked and not accessible to the children in care. Plan of Correction: The director will remind staff to check all shelves in the restroom and will lock all chemicals.
Standard #: 22VAC40-185-340-F Description: Based on observation of the infant and toddler rooms, the center failed to ensure that all children under 10 years were in sight and sound supervision.
1. The inspector entered the infant room and found two staff present. The staff person assigned to be in the toddler room during nap was sitting in the rocking chair in the infant room. There were five toddlers sleeping in the next room with no staff present. Once the inspector entered the room the assigned staff person left the rocking chair and entered the toddler room.
Plan of Correction: The director will meet with the infant staff and will ensure that this does not happen again. All areas will be monitored.
Standard #: 22VAC40-185-540-A Description: Based on observation of the bus, the center failed to ensure that all required items were in the first aid kit. Evidence: 1. The inspector found that the bus's first aid kit was missing the following: thermometer, scissors, and tweezers. Plan of Correction: The director will add the missing items to the first aid kit and will have the bus driver to monitor.
Standard #: 22VAC40-185-550-H Description: Based on review of the bus, the center failed to ensure that the emergency documents for the bus were found.
1. The inspector found that all address for the children using the transportation was documented, but routes were not in the binder for frequently driven routes.
Plan of Correction: The director and the bus drivers will work together to document all routes traveled for transportation of children and routes necessary for the standard.
Standard #: 22VAC40-191-40-D-1-C Description: Based on review of six staff records, the center failed to ensure that all background checks were completed and returned within the required time frame.
1. The inspector found that staff # 5 was hired on 9/2005 and on the day of inspection did not have the repeat CPS, CRC and sworn disclosure. The CPS was completed on 2/13/2013, CRC was completed on 2/12/2013, and the sworn disclosure was completed on 9/1/2015.
Plan of Correction: The director will submit the forms and will monitor all time lines.
Standard #: 63.2-1720-F Description: Based on review of staff records and observation, the center failed to ensure that staff were not left alone with children without a returned CRC check.
1. The inspector found that staff # 1 was alone with five toddlers on the day of the inspection. Review of staff # 1's record found that there was not a returned CRC. Hire date was not documented, the date signed on the sworn disclosure was 3/2/2016.
Plan of Correction: The director will rearrange schedules to ensure staff with out a returned CRC are not left alone with children.
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.Virginia Quality is a voluntary quality rating and improvement system for early care and education facilities serving children ages birth through pre-K. Eligible child care facilities must be fully licensed, licensed exempt and a VDSS subsidy vendor, or a voluntary registered day home and a VDSS subsidy vendor. Only programs enrolled in Virginia Quality will display a rating. Virginia Quality contact information for your region is available at the following link Regional Contacts.