Bon Secours - St. Francis Medical Center

Documentation of additional immunizations is required once every six months for children under the age of two years.

“Child #3 immunization record was due to be updated over 6 months ago.”

Rule 8VAC20-780-130-E.

Providers must obtain a completed national criminal background check prior to the employee’s first day of employment.

“Staff #1 had a completed national criminal background check dated 4 days after her date of employment.”

Rule 22.1-289.035-B-2.

Providers must obtain a completed national criminal background check prior to the employee’s first day of employment.

“Staff #1 had a completed national criminal background check dated 4 days after her date of employment.”

Rule 22.1-289.035-B-2.

The center is required to obtain background checks from any state in which the individual has resided in the preceding five years.

“The center did not request a search of the child abuse and neglect registry or sex offender registry check from one state (North Carolina) for Staff #4, who has been employed for more than 3 months and was working with children at the time of the inspection.”

Rule 22.1-289.035-B-4.

Based on observations, the center did not ensure that areas and equipment of the center, inside and outside, shall be maintained in a clean, safe and operable condition.

“Evidence: 1. During the inspection, peeling wallpaper was observed in 3 places in the preschool (PS2) classroom on the wall on the right side of the classroom. 2. Staff acknowledged the peeling wallpaper in the classroom and stated a work order could be placed to repair the peeling areas.”

Rule 8VAC20-780-270-A.

Based on a review of medications, the center did not ensure that all medications was kept in the original container with the direction label attached.

“Evidence: Child #1’s Children’s Benadryl did not have the original box containing the direction label.”

Rule 8VAC20-780-510-H.

8VAC20-780-550-P

“Based on record review, the center did not ensure injury report contained all required information. Evidence: 1. 1 of 3 injury reports, did not contain the date and time parent was notified.”

Rule 8VAC20-780-550-P.

Based on a review of children’s records, the center did not maintain all children’s records.

“Evidence: Child #1 records did not have documentation of names of persons authorized to pick up the child.”

Rule 8VAC20-780-60-A.

8VAC20-780-70

“Based on record review, the center did not ensure that staff records contain written information to demonstrate that the individual possesses the education and experience required by the job position. Evidence: The records for staff #3 (date of hire: 6/4/21) and staff # 5 (date of hire: 1/7/2022) do not contain documentation to demonstrate that they possess the education and/or experience required for the program leader position.”

Rule 8VAC20-780-70.

8VAC20-780-140-B

“Based on a review of children records on March 3, 2022, the center did not ensure a physical exam that was completed prior to a child’s first date of attendance was not dated within 3 months prior to attendance for a child that 16 months old at the time of enrollment. Evidence: Child #2 was 16 months of age on their first date of enrollment on 11/12/21 and documentation of the physical exam was dated 7/22/21.”

Rule 8VAC20-780-140-B.