Bethany Lutheran Church

Handwashing by staff and children before and after toileting and diapering.

“Staff was observed changing a diaper. Child did not wash hands after diapering was completed.”

Rule 22.1-289.031-B-1.

Ensuring that all children in the center are in compliance regarding the immunizations of children against certain diseases.

“Child 2 and Child 5 did not have documentation of immunizations in file.”

Rule 22.1-289.031-B-4.

Ensuring that all areas of the premises accessible to children are free of obvious injury hazards.

“Hazardous substances policies state that “they should be kept inaccessible to children”. There was a staff key chain that had pepper spray that was accessible to children. In an unlocked closet, there was a bottle of Goo Gone that was on a counter accessible to children.”

Rule 22.1-289.031-B-5.

Upon enrollment of a child in a regulated child day program, shall require that the person enrolling the child present the regulated child day program with the proof of the child’s identity and age.

“Child 6 did not have evidence of proof of child’s identity and age in child’s file.”

Rule 22.1-289.049-A.

Based on record review and interview, the center failed to implement a procedure to ensure that all staff are able to recognize the signs of child abuse and neglect.

“Evidence: The record for staff 5, employment date 07/01/2024 did not have documentation of staff 5 completing training in recognizing the signs of child abuse and neglect. Staff 5 was working in a classroom with children and stated she had not taken the class yet. The center’s procedure is for staff to take the class on recognizing the signs of child abuse and neglect prior to working with children.”

Rule 22.1-289.031-B-6.

22.1-289.031-A

“Based on observations and interview, the center failed to post the fact that the center is exempt from licensure in a visible location on the premises. Evidence: 1. A tour of the facility was conducted. No posting of the center’s exemption status was found. 2. Staff verified they do not have the fact the center is exempt from licensure posted.”

Rule 22.1-289.031-A.

Based on record review and interview, the center failed to ensure each staff member has been certified by a physician, physician assistant, or nurse practitioner to be free from any disability which would prevent him from caring for children under his/her supervision.

“Evidence: 1. Staff 6 stated the date of hire for staff 7 was 9/5/23. 2. Staff 6 stated staff 7 did not provide the center with a document certified by a physician, physician assistant, or nurse practitioner to stating staff 7 is free from any disability which would prevent him from caring for children under his/her supervision.”

Rule 22.1-289.031-A-4.

Based on a review of the parent handbook and interview, the center failed to provide a written disclosure to parents and guardians of the children in the center and the general public that includes information regarding the enrollment capacity and food services.

“Evidence: 1. Staff 6 provided all information given to parents. The information given to parent did not contain information regarding the enrollment capacity and food services. 2. Staff 6 stated the center does not provide information regarding the enrollment capacity and food services to parents.”

Rule 22.1-289.031-A-6.

Based on record review and interview, the center failed to establish and implement a procedure in which a daily health screening and exclusion of sick children by a person trained to perform such a screening is conducted daily.

“Evidence: 1. The five records reviewed did not contain documentation of staff completing training in daily simple health screening. 2. Staff 6 stated there is no staff trained in daily simple health that she is aware of and the center does not have a procedure to conduct daily simple health screenings.”

Rule 22.1-289.031-B-3.

Based on a review of the staff handbook and interview, the center failed to implement a procedure to ensure all children in the center are in compliance with immunization provisions.

“Evidence: 1. A review was conducted of five children’s records. There were no immunizations in the children’s records. 2. The parent handbook stated immunizations are required prior to start at the facility. 3. Staff 6 verified the center does not have immunizations for the five children.”

Rule 22.1-289.031-B-4.

Based on a review of the staff handbook and interview, the center failed to establish and implement a procedure to ensure that all areas of the premises accessible to children are free of obvious injury hazards.

“Evidence: 1. In the two-year-old classroom a can of Lysol spray and Arthritis Pain Relief was on the teacher’s desk accessible to children. 2. On the floor in the bathroom between the 2 three-year-old classrooms was several containers of Clorox wipes that were accessible to children. 3. Staff 6 stated the center procedure for hazardous substances for them to be out of reach of children at all times.”

Rule 22.1-289.031-B-5.

Based on record review and interview, the center failed to request a search of central registry background check within the first 30 days of employment, and a criminal history name check prior to the first day of employment for any state in which a staff member resided in the preceding five years.

“Evidence: 1. The record for staff 2 was reviewed. The date of hire was documented as 8/26/21. The sworn statement states staff 2 lived outside VA within the last five years. No out-of-state background check was in the record. 2. Staff 2 was unaware of any out-of-state background check completed for staff 2.”

Rule 22.1-289.035-B-4.

Based on record review and interview, the center failed to implement a procedure to ensure all staff are trained to recognize signs of child abuse and neglect prior to working with children.

“Evidence: 1. Staff 1’s start date, per the director, was 8/23/21. The certificate of completion of training in recognizing child abuse and neglect is dated 11/29/21. 2. Staff 3’s start date, per the director, was 8/10/21. The certificate of completion of training in recognizing child abuse and neglect is dated 11/29/21.”

Rule 22.1-289.031-B-6.

Based on record review and interview, the center failed to obtain fingerprint-based criminal history check determination letters prior to the first day of employment.

“Evidence: 1. The director advised staff 1’s date of hire was 8/23/21. 2. The fingerprint-based criminal history check determination letter is dated 9/20/21.”

Rule 22.1-289.035-B-2.

Based on record review and interview, the center failed to have a completed central registry record check by the end of the 30th day of employment.

“Evidence: 1. The director stated the hire date for staff 1 was 8/23/21 2. The record for staff 1 did not contain documentation of the findings of a central registry background check. 3. The director stated the central registry background check was completed for staff 1 but she cannot locate it. The staff cover sheet for the staff file has a check beside central registry.”

Rule 8VAC20-770-40-D-2.