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Mary Bethune Academy
2249 Halifax Street
Lynchburg, VA 24501
(434) 847-4221

Current Inspector: Victoria E Dawson (540) 309-2674

Inspection Date: Nov. 6, 2017

Complaint Related: No

Areas Reviewed:
22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 PHYSICAL PLANT.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 PROGRAMS.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-185 SPECIAL SERVICES.
22VAC40-80 THE LICENSE.
22VAC40-191 Background Checks (22VAC40-191)

Comments:
An unannounced monitoring inspection was completed on 11/6/17. There were 32 children present in four groupings from nine months through four years old with nine direct care staff present and the administrative office personnel also present. Five children's records and five staff records were reviewed. One emergency medication was observed. The inspector arrived at the center at 1:00 pm and departed at 5:30 pm. The children were observed during free play times, during nap, during afternoon snack, during story time, and during outside time. There was discussion with the director about the following: new Sworn Statement form, upcoming health inspection, shelter-in-place drills and documentation, ensuring all substitute containers are properly labeled (new bottles), documentation of the resilient surfacing for the infant/toddler playground, having documentation maintained of program lead qualifications.

Violations:
Standard #: 22VAC40-185-130-A
Description: Based on record review, the center failed to ensure that documentation of immunizations required by the State Board of Health were obtained before the child can attend the center. Evidence: 1. Child #2 had a documented start date of 10/2/17. The print date on the form of the electronic immunization record was 10/7/17. The handwritten date where they physician signed the immunization record was 10/9/17. 2. Child #5 had a documented start date of 2/21/17. The print date on the form of the electronic immunization record was 7/10/17. The handwritten date where the physician signed the immunization record was 7/10/17.

Plan of Correction: Immunization records will be obtained before the children begin attending in the future.

Standard #: 22VAC40-185-140-A
Description: Based on record review, the center failed to ensure that all children had a physical examination completed by or under the direction of a physician within 30 days after enrollment (or prior to enrollment based on the age of the child). Evidence: 1. There was no physical examination in the record of child #4 who was 22 months old at the time of the inspection. The child's first date of attendance was documented as 9/6/17 and would have needed a physical by 10/6/17. 2. There was no physical examination in the record of child #5 who was nine months old at the time of the inspection. The child's first date of attendance was 2/21/17.

Plan of Correction: The administrative staff will contact the parents to get a current physical.

Standard #: 22VAC40-185-70-A
Description: REPEAT VIOLATION Based on record review, the center failed to ensure that staff records were complete with documentation of required information. Evidence: 1. There were no references in the record of staff #4 or staff #5. The hire dates for the staff were 10/13/17 and 11/6/17, respectively. Both staff were observed working during the inspection. Documentation of two references are required prior to hire. 2. There was no hire date documented for staff #5. According to administrative staff, the staff person's first day was today. Staff #5 was observed working in a classroom when the inspector arrived at the center.

Plan of Correction: The hire date for staff #5 was corrected (documented) during the inspection. The references will be called immediately.

Standard #: 22VAC40-185-240-A
Description: Based on record review, the center failed to ensure that there was documentation of orientation for staff as required by the end of the first day of assuming job responsibilities. Evidence: 1. There was no documentation of orientation training for staff #4 or staff #5. The hire dates were 10/13/17 and 11/6/17, respectively. Both staff were observed working during the inspection in a classroom. The orientation training is required to cover job responsibilities, policies and procedures of the center, emergency procedures, confidentiality, supervision of children, and other areas.

Plan of Correction: The staff will have the orientation training completed tomorrow and for future staff by the end of their first day.

Standard #: 22VAC40-185-240-D-1
Description: Based on record review and interviews with staff, the center failed to ensure that in order to safely perform medication administration practices listed in 22 VAC 40-185-510, whenever the center has agreed to administer prescribed medications the administration shall be performed by a staff member or independent contractor who has satisfactorily completed a training program for this purpose approved by the Board of Nursing and taught by a registered nurse. The required course to be completed by staff to administer medications is Medication Administration Training (MAT) specifically developed for child day programs. Evidence: 1. There was a prescription inhaler medication observed for a three year old child in care. The medication was as needed to be given for breathing problems (wheezing, etc). The child was observed in care during the inspection after 2:45 pm. The administrative staff person stated this child is typically picked up between 4:30 pm and 5:30 pm. The child was at the center at 5:00 pm and was observed outside playing. 2. The administrative staff was asked about MAT staff with current certification. There was one staff present on the date of the inspection from 6:30 am until 2:30 pm. This staff person was observed to leave the center at approximately 2:45 pm on the date of the inspection. 3. According to the MAT staff person, the afternoon MAT staff person was scheduled to be off today and there was no other trained staff person present at the center.

Plan of Correction: The administrative staff person stated that she was working to get trained in MAT in order to be an extra staff person who is scheduled daily from 8:30-5:30. The director will try to get a renewal completed for a staff person within a week or so. The center staff will inform the mother that she will be called if a trained staff person is not present.

Standard #: 22VAC40-185-500-A
Description: REPEAT VIOLATION Based on observation, the center failed to ensure that hand washing was practiced as required. Evidence: 1. There was a nine month old infant who was observed to be given a bottle of prepared formula at approximately 3:25 pm. ` Neither the staff person nor the child washed their hands prior to eating or prior to the staff person feeding the child. Both the staff person and the child were observed playing on the floor with toys and other children prior to this feeding.

Plan of Correction: The inspector reminded the staff person during the inspection of the requirement. A second lead staff person will help with reminders to other staff for this requirement.

Standard #: 22VAC40-185-550-C
Description: Based on observation, the center failed to ensure that the shelter-in-place was noted on the posted emergency maps. Evidence: 1. There was no indication of the location for shelter-in-place on the posted emergency maps.

Plan of Correction: The director will add the location to the map.

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.

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.

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