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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: May 7, 2018

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.
22VAC40-80 THE LICENSING PROCESS.
22VAC40-191 Background Checks (22VAC40-191)

Comments:
An unannounced monitoring inspection was completed on 5/7/18. There were 32 children present. Five children's records and two records from the previous inspection were reviewed. Five staff records and one from the previous inspection were reviewed. Three medications were observed. The inspector arrived at the center at 8:30 am and departed at 2:45 pm. The children were observed during outside times and during lunch. There was discussion with the administrator about the following: upcoming renewal inspection and policies/procedures related to this inspection, playground safety plan/procedures and observation of the playground time during the inspection.

Violations:
Standard #: 22VAC40-185-140-A
Description: Based on record review, the center failed to ensure that each child had a physical examination. Evidence: 1. Children #6 and #7 did not have a physical examination. The children's first dates of attendance were 9/6/17 and 2/21/17, respectively. Children #6 and #7 did not have a physical examination at the last inspection, November 2017. Children #6 and #7 are two years old and 15 months, respectively.

Plan of Correction: The administrator will ask the parent to submit a physical examination.

Standard #: 22VAC40-185-160-C
Description: Based on record review, the center failed to ensure that staff had an updated tuberculosis (TB) test at least every two years since the date of the last inspection. Evidence: 1. The last completed TB test for staff #6 was 4/22/16.

Plan of Correction: The administrator called during the inspection and scheduled a TB test for tomorrow .

Standard #: 22VAC40-185-60-A
Description: Based on record review, the center failed to ensure that documentation of all required information was complete in each child's record. Evidence: 1. The record of child #1 was missing documentation of and address for two of two required emergency contacts. The emergency contacts listed had a phone number and a city listed for those listed. A name, address, and phone number is required for two emergency contacts for the child. 2. The record of child #2 was missing documentation for 2016 and 2017 that the parent had confirmed that all required emergency information in the child's record was current. 3. The record of child #5 was missing documentation of the mother's work phone number. The mother had a work place listed and no phone number to the work place (the space for the work phone number was left blank). 4. The administrator confirmed all missing information in the children's records during the inspection.

Plan of Correction: The administrator will have the parents document all required information and update information in the childrens' records.

Standard #: 22VAC40-185-70-A
Description: Based on record review, the center failed to ensure that staff records contained documentation of all required information. Evidence: 1. The record for staff #1 was missing written information to show that the staff person had the training or education required by the job position. Staff #1 was a program lead. 2. The record of staff #5 was missing documentation of two references. Staff #5 was hired 11/6/17 and was working during the inspection. The administrator verified that staff #5 did not have references completed. Two references are required prior to hire.

Plan of Correction: The references will be obtained for staff #5. Documentation will be made for staff #1.

Standard #: 22VAC40-185-240-A
Description: Based on record review and interview, the center failed to ensure that there was documentation of the required orientation training for staff by the end of their first day of assuming job responsibilities. Evidence: 1. There was no documentation of the required orientation training for staff #5 that is required by the end of the first day of assuming job responsibilities. 2. Staff #5 was interviewed and stated that she did not receive any formal orientation training.

Plan of Correction: Staff #5 will receive orientation and it will be documented.

Standard #: 22VAC40-185-260-A
Description: Based on observation of posted inspections and interview, the center failed to ensure that there was an annual fire inspection report completed. Evidence: 1. The last fire inspection that was posted on the bulletin board with other inspections was observed to be completed 4/19/17. 2. The administrator stated that another fire inspection report was not available and had not been done.

Plan of Correction: The director called during the inspection to schedule a fire inspection.

Standard #: 22VAC40-185-510-E
Description: Based on observation, the center failed to ensure that all medication was labeled with the child's name, the dosage amount and the time/times to be given. Evidence: 1. An over-the-counter cough medication for child #1 was not labeled with the dosage amount and time/times to be given.

Plan of Correction: The medication will be sent home today.

Standard #: 22VAC40-185-510-N
Description: Based on record review, the center failed to ensure that when an authorization for medication expires, the parent was notified to be picked up within 14 days or disposed of by the center. Evidence: 1. There was an over-the-counter medication observed for child #1. The authorization was signed by the parent 2/14/18 with an end date 2/26/18. The medication should have been returned by March 12, 2018.

Plan of Correction: The administrator will return the medication to the parent today.

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 map on the main floor where the care of children was taking place.

Plan of Correction: This was corrected during the inspection.

Standard #: 22VAC40-185-550-D
Description: Based on documentation of posted emergency drill documentation, the center failed to ensure that there was documentation of monthly evacuation drills and two shelter-in-place drills annually. Evidence: 1. There was no documentation that an evacuation drill (fire drill) was completed for December 2017. 2. There was no documentation of two shelter-in-place drills completed for 2017.

Plan of Correction: The administrator will make sure drills are practiced and documented as required.

Standard #: 22VAC40-185-550-M
Description: Based on record review, the center failed to ensure that all required documentation was made on injury reports for children. Evidence: 1. Injury reports for child #4 dated 9/21/17 and 11/22/17 did not have documentation of the time, date, or method of notification to the parent of the injuries from these dates. 2. Injury reports for child #6 dated 9/11/17, 9/15/17, 10/6/17, 12/27/17, 3/5/18, and 4/25/18 did not have documentation of the time, date, or method of notification to the parent of the injuries from these dates. 3. Injury reports for child #7 dated 8/17/17 10/12/17, 3/14/18 did not have documentation of the time, date, or method of notification to the parent of the injuries from these dates.

Plan of Correction: The administrator will review all injury reports prior to filing them in the children's records.

Standard #: 22VAC40-185-560-F
Description: Based on observation and interview, the center failed to ensure that center-provided meals followed the most recent, age-appropriate nutritional requirements of a recognized authority such as the Child and Adult Care Food Program of the United States Department of Agriculture (USDA). Evidence: 1. The menu was observed and showed breakfast having two components. USDA requires breakfast to have three components. 2. The daily schedule also showed breakfast as a meal for the morning. 3. The administrator confirmed that the breakfast contained two components.

Plan of Correction: The center will add a fruit each day for breakfast.

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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