Virginia Commonwealth University Health System Authority - NS

The center shall maintain a written record of children’s serious and minor injuries in which entries are made the day of occurrence.

“One of five injury reports reviewed did not contain future action to prevent recurrence of the injury.”

Rule 8VAC20-780-550-P.

Repeat violation

“A record shall be kept for each staff person that contains the required information. The records of Staff #1, Staff #2, Staff #3, Staff #4, Staff #5, and Staff #6 did not contain information about any health problems that may interfere with fulfilling the job responsibilities which is to be kept at the center.”

Rule 8VAC20-780-70.

The operational responsibilities of the licensee shall include ensuring that the center’s activities, services, and facilities are maintained in compliance with these standards, the center’s own policies and procedures that are required by these standards, and the terms of the current license issued by the department.

“The center’s procedures to prevent use of outdated medication include a monthly check of medications. Child #2 had an emergency medication that expired over two months ago. Administration acknowledged the monthly checks had not been completed recently.”

Rule 8VAC20-780-40-E.

Nonprescription drugs and over-the-counter skin products shall not be kept or used beyond the expiration date of the product.

“In the toddler classroom. one sunscreen was kept that expired approximately 10 months ago. In the twos classroom, five diaper creams were kept that expired between two and 17 months ago.”

Rule 8VAC20-780-520-A.

A written care plan is required for each child with a diagnosed food allergy, to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction.

“Child #5, who has been enrolled for two months, has a diagnosed food allergy and did not have a written care plan in their file.”

Rule 8VAC20-780-60-A-8.

Repeat violation

“A record shall be kept for each staff person that contains the required information. The records of Staff #1 and Staff #2 each did not contain an emergency contact address and health information required to be kept on site.”

Rule 8VAC20-780-70.

8VAC20-790-600-D-1

“All staff who work directly with children shall have within 90 days of the date of employment or 90 days shall obtain current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. The training shall include an in-person competency demonstration. Staff #5 did not have current certification in CPR. The CPR certification expired in May 2025. Staff #5 has been employed for more than 17 months.”

Rule 8VAC20-790-600-D-1.

8VAC20-790-600-D-2

“All staff who work directly with children shall have within 90 days of the date of employment or 90 days from subsidy vendor approval shall obtain current certification in first aid appropriate to the ages of children in care. Staff #5 did not have current certification in first aid. The first aid certification expired in May 2025. Staff #5 has been employed for more than 17 months.”

Rule 8VAC20-790-600-D-2.

8VAC20-780-510-L

“Medication, except for those prescriptions designated otherwise by written physician’s order, including refrigerated medication and staff’s personal medication, shall be kept in a locked place using a safe locking method that prevents access by children. A bottle of Children’s Tylenol for Child #6 was in an unlocked cabinet in Room #2.”

Rule 8VAC20-780-510-L.

22.1-289.035-A

“The center is required to have employees undergo a background check every five years. The record for Staff #3 contained a completed national criminal background registry check that was overdue by a one year and four months. The completed central registry finding and sworn statement were overdue by a two years and five months.”

Rule 22.1-289.035-A.

8VAC20-780-280-B

“Hazardous substances such as cleaning materials, insecticides, and pesticides shall be kept in a locked place using a safe locking method that prevents access by children. Three classrooms had unlocked cleaning chemicals in unlocked cabinets. The cleaning chemicals were labeled ?Caution: Keep out of the reach of children?.”

Rule 8VAC20-780-280-B.

8VAC20-780-500-B

“Disposable diapers shall be disposed in a leakproof or plastic-lined storage system that is either foot-operated or used in such a way that neither the staff member’s hand nor the soiled diaper touches an exterior surface of the storage system during disposal. A staff member in the Infant room lifted the top of the trashcan with their hand to dispose of a diaper.”

Rule 8VAC20-780-500-B.

8VAC20-780-70

“Staff records shall be kept for each staff person with all of the required information. The record for Staff #3 did not contain documentation to demonstrate that the individual possesses the education and training. Staff #3 has worked at the center for over 14 years. The record for Staff #4 did not contain documentation to demonstrate that the individual possesses the education and training. Staff #4 has worked at the center for over 1 year 10 months.”

Rule 8VAC20-780-70.

8VAC20-780-280-B

“Based on observations, the center did not ensure all hazardous substances such as cleaning materials, were kept in a locked place using a safe locking method that prevented access by children. Evidence: During the inspection, The Older Infants, Toddler, and Threes/ Fours classrooms had cabinets containing cleaning materials. The cabinets were unlocked. Children were observed in the classrooms during the inspection.”

Rule 8VAC20-780-280-B.

8VAC20-780-500-A

“Based on observation, the center did not ensure two children’s hands were washed with soap and running water after toileting and any contact with blood, feces, or urine. Evidence: Two children were observed having their diapers changed in the Two’s/ Three’s classroom. After the diaper change was completed, the children resumed playing in the classroom. The children’s hands were not washed while the inspectors were observing the classroom.”

Rule 8VAC20-780-500-A.

8VAC20-780-510-F

“Based on a review of three medications and medication authorization reviews, the center did not ensure one medication authorization was available to staff during the entire time the medication was effective. Evidence: A medication was observed at the center for Child #7. A medication authorization was dated for August 4, 2022 through August 3, 2023. Attendance rosters indicated Child #7 is currently attending the center.”

Rule 8VAC20-780-510-F.

8VAC20-780-510-G

“Based on observation and documentation review, the center did not ensure medication was labeled with the child’s name, the name of the medication, the dosage amount, and the time or times to be given. Evidence: A prescription medication for Child #10 was on site at the center. The medication was not labeled with the child’s name, the dosage amount and the time or times to be given. Attendance rosters indicated Child #10 is currently attending the center.”

Rule 8VAC20-780-510-G.

REPEAT VIOLATION Based on a review eight children’s records and interview with the site director, the center failed to ensure physical examinations were obtained before the child’s attendance or within 30 days after attendance.

“Evidence: 1. The record for Child #3 (first date of attendance 8/8/2022) did not include the required physical examination. 2. The record for Child #6 (first date of attendance 8/7/2023) did not include the required physical examination. 3. The record for Child #7 (first date of attendance was 8/28/2023) did not include the required physical examination. 4. During an interview, the site supervisor acknowledged the records did not document a physical examination.”

Rule 8VAC20-780-140-A.

Based on interview and documentation review, the center did not have evidence of liability insurance coverage during the inspection.

“Evidence: 1. During the inspection, Staff #2 acknowledged not having documentation of liability insurance. 2. The center did not provide insurance information during the inspection or upon request.”

Rule 8VAC20-780-40-H.

Based on a review of documentation and interview, the center did not ensure to maintain documentation of emergency evacuation drills that included all required information.

“Evidence: The 2023 evacuation drills were reviewed. The drills did not include: the identity of the person conducting the drill, the method used for notification of the drills, number of staff participating, number of children participating, any special conditions simulated, the time it took to complete the drill, and the weather conditions.”

Rule 8VAC20-780-550-G.

Based on record review and interview, the center failed to ensure that the separate record for each child enrolled contained all of the elements as required by the standards.

“Evidence: 1. The records for Child #2 (date of attendance: 5/3/2021) and Child #7 did not document the address of one of the designated people to call in an emergency if a parent cannot be reached. 2. The records for Child #6 and Child #7 failed to include; written agreements between the parent and the center as required by 8VAC20-780-90. 3. The record for Child #8 did not contain a written care plan for diagnosed food allergy.”

Rule 8VAC20-780-60-A.

Based on a review seven children’s records and interview with the site director, the center failed to ensure physical examinations were obtained before the child’s attendance or within 30 days after attendance.

“Evidence: Child #1?s first date of attendance was 11/7/2022 and the record for Child #1 did not include the required physical examination. During an interview, the site supervisor acknowledged the record did not document a physical examination.”

Rule 8VAC20-780-140-A.

Based on review of five staff records and interview, the center failed to ensure an employee completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.

“Evidence: Staff #2 was hired on 8/8/2022 and has not completed the required training. During an interview with the site supervisor, it was acknowledged that Staff #2 has not completed the required training.”

Rule 8VAC20-780-240-A.

Based on review of five staff records and interview, the center did not ensure staff received orientation training in First Aid and cardiopulmonary resuscitation (CPR) as appropriate to the age of the children in care within 30 days of the first day of employment.

“Evidence: Staff #1 was hired on 02/06/203. Staff #1 has not received orientation training in First Aid and cardiopulmonary resuscitation (CPR). During an interview, the site supervisor acknowledged Staff #1 has not completed the required orientation training.”

Rule 8VAC20-780-240-E.

Based on review of five staff records and interview, the center failed to ensure staff completed annually a minimum of 16 hours of training appropriate to the age of children in care.

“Evidence: Staff #4 (date of employment: 10-3-2010) record did not document 16 annual training hours were completed for the 2021-2022 year. During an interview with the site director, it was acknowledged that Staff # 4?s record did not document the required 16 hours of annual training.”

Rule 8VAC20-780-245-A.

Based on observation and interview, the center did not ensure that all hazardous substances were kept in a locked place using a safe locking method that prevents access by children.

“Evidence: There was one can of Porch, Floor and Patio Wood and Concrete paint with the warning: keep out of reach of children and can cause serious illness, especially in children, stored on the bottom shelf of a rack in the open art area accessible to children. During an interview, the site supervisor, observed and acknowledged the paint was not properly stored.”

Rule 8VAC20-780-280-B.

Based on observations and interview, the center failed to ensure that there was resilient surfacing in all fall zone areas that complies with the minimum safety standards when tested in accordance with the procedures described in the American Society for Testing and Materials.

“Evidence: The center had approximately one inch of wooden mulch, decomposed mulch and dirt underneath and throughout the fall zones for the preschool play equipment. During an interview, the site supervisor acknowledged the amount of mulch throughout the playground area was out of compliance.”

Rule 8VAC20-780-330-B.

8VAC20-780-130-A

“Based on a review of documentation, the center did not ensure to obtain immunization records for each child on or before the first day of attendance for 1 out of 6 children’s files reviewed. Evidence: Child #5?s record (age 3 years), enrollment date 11/26/19, did not contain evidence of immunization records upon enrollment or any updated immunizations.”

Rule 8VAC20-780-130-A.

8VAC20-780-140-A

“Based on a review of documentation, the center did not ensure to obtain a physical for each child within 30 days after the first day of attendance for 1 out of 6 children’s files reviewed. Evidence: Child #5?s record (age 3yrs) date of enrollment 11/26/19, did not contain evidence of an original physical exam or any updated physical exams.”

Rule 8VAC20-780-140-A.

8VAC20-780-260-A

“Based on a review of documentation, and interview, the center did not provide to the Licensing Inspector an annual fire inspection report. Evidence: The last fire inspection was dated 03/09/2021. The Director stated that he had tried to call to schedule it but they had not come out yet.”

Rule 8VAC20-780-260-A.

Based on review of staff records, the center did not obtain documentation of a tuberculosis screening for one staff record. .

“Evidence: Staff #4, hired 08/08/2021, did not have documentation of a tuberculosis screening on file. Staff hired prior to 10/13/2021 had 21 days from hire to obtain documentation of a tuberculosis screening.”

Rule 8VAC20-780-70.