Portsmouth Catholic Regional School

8VAC20-780-160-A

“Each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children. The TB screening for staff 1 was completed seventeen days after she began employment.”

Rule 8VAC20-780-160-A.

8VAC20-780-260-A

“The center shall provide an annual fire inspection report from the appropriate fire official having jurisdiction. The fire inspection for the center is overdue by a month and a half.”

Rule 8VAC20-780-260-A.

8VAC20-780-510-I

“Prescription medication may be administered as long as the medication is maintained in the original, labeled container. There is an emergency medication for a child being stored at the center that was not in it’s original, labeled container.”

Rule 8VAC20-780-510-I.

Documentation shall be maintained of emergency evacuation, shelter-in-place and lockdown drills that include all the required information.

“The drill log for the center did not include the time of the drills for the months of August 2024 - January 2025, nor did it include the number of staff and children participating and the weather conditions for drills conducted in November 2024 and January 2025.”

Rule 8VAC20-780-550-G.

A written agreement between the parent and the center shall be in each child’s record by the first day of the child’s attendance. The agreement shall be signed by the parent and include a statement that the parent will inform the center within 24 hours or the next business day after his child or any member of the immediate household has developed any reportable communicable disease, as defined by the State Board of Health, except for life threatening diseased which must be reported immediately.

“Five out of five children’s records reviewed did not contain the parental agreement statement regarding reportable household communicable diseases.”

Rule 8VAC20-780-90-A.

22.1-289-036-B-4

“Based upon review of staff records, the facility has not ensured that they obtain the results of a criminal history record before having responsibility for the safety and well-being of children. Evidence: The record for staff 5 indicated a hire date of 8/9/2023. Results of a criminal history record were not obtained until 8/15/2023.”

Rule 22.1-289-036-B-4.

8VAC20-770-60-B

“Based upon review of staff records, the facility has not ensured that an employee must not be employed without a completed sworn statement or affirmation. Evidence: The record for staff 5 indicated a hire date of 8/9/2023. The sworn disclosure or affirmation statement was not completed and signed until 8/14/2023.”

Rule 8VAC20-770-60-B.

8VAC20-780-160-A

“Based upon review of staff records, the facility has not ensured that documentation of a negative tuberculosis (TB) screening obtained within 30 days prior to employment. Evidence: The record provided for staff 5 indicated a date of employ of 8/9/2023. Results of a negative TB screening was not obtained until 8/20/2023.”

Rule 8VAC20-780-160-A.

8VAC20-780-240-I

“Based upon review of newly hired staff, the facility has not ensured that the documentation of orientation training includes all required information. Evidence: The provided documentation of orientation training of staff 5, employed on 8/9/2023, did not include all required training topics.”

Rule 8VAC20-780-240-I.

8VAC20-780-270-A

“Based upon observation, the facility has not ensured that areas of the outside area of the facility are maintained to be safe. Evidence: There is an open metal ring protruding around an approximate six inch hole in the sidewalk area where the preschool children were observed walking to the outdoor playground. This is a potential tripping hazard.”

Rule 8VAC20-780-270-A.

8VAC20-780-330-B

“Based upon measurements obtained, the facility has not ensured that where playground equipment is provided, resilient surface complies with the minimum safety standards of the American Society for Testing and Materials Standards for compressed loose fill depth. Evidence: 1. The depth of the pea gravel taken under several areas of the chin-up bars and horizontal ladder bars measured at 4 inches or less. 2. The depth of the hardwood mulch under several the balance beams measured at 4 inches or less.”

Rule 8VAC20-780-330-B.

8VAC20-780-550-P

Rule 8VAC20-780-550-P.

Based on interview and a review of medication, the center did not ensure that the center’s procedures for administering medication shall include methods to prevent use of outdated medication.

“Evidence: 1. There is an EpiPen prescribed to a child in care being stored at the center with an expiration date of November 2022. 2. The school nurse confirmed that the EpiPen was expired.”

Rule 8VAC20-780-510-E.

Based on record review and interview, the center did not ensure that they obtain the results of the fingerprint based background check prior to the first day of employment.

“Evidence: 1. The record for staff 1 (date of hire: 8/18/22) does not contain documentation of a completed fingerprint based national criminal history record check. 2. Center management confirmed that a fingerprint based national criminal history record check was not completed for staff 1.”

Rule 22.1-289.035-B-2.

Based on record review and interview, the center did not ensure that each staff member shall submit documentation of a negative tuberculosis screening.

“Evidence: 1. The record for staff 1 (date of hire: 8/18/22) does not contain documentation of a negative tuberculosis screening. 2. Center management confirmed that the record for staff 1 is lacking documentation of a negative tuberculosis screening.”

Rule 8VAC20-780-160-A.

Based on record review and interview, the center did not ensure that a qualified program director or a qualified back-up program director who meets one of the director qualifications shall regularly be on site at least 50% of the center’s hours of operation.

“Evidence: 1. Staff 2 (date of hire: 9/25/17) stated she is the center’s program director and that she was promoted from lead teacher to program director in the spring of 2022. 2. Staff 2 does not meet the qualifications for the job title of program director. 3. Staff 2 and staff 6 (school principal) confirmed that staff 2 does not meet the qualifications for the position of program director.”

Rule 8VAC20-780-200-A.

Based on record review and interview, the center did not ensure that children’s records contain all the required information.

“Evidence: 1. The record for child 1 (date of enrollment: 8/25/22) does not contain the work phone number and place of employment of each parent. 2. Center management confirmed that the record for child 1 is lacking the parent’s employment information.”

Rule 8VAC20-780-60-A.

Based on record review and interview, the center did not ensure that staff records contain all the required information.

“Evidence: 1. The records for staff 1, staff 2, staff 3, staff 4 and staff 5 do not contain the address of a person to be notified in an emergency. 2. Center management confirmed that the records for staff 1, staff 2, staff 3, staff 4 and staff 5 are lacking the addresses for the emergency contacts.”

Rule 8VAC20-780-70.

Based on interview, the center did not ensure that there shall always be at least one staff member on duty who has obtained within the last three years instruction in performing the daily health observation of children.

“Evidence: The center director stated that there is no one in the building during the aftercare program from 3:00pm until 6:00pm with daily health observation training.”

Rule 8VAC20-780-245-L.

Based on record review and interview, the center did not ensure that each child’s record contains all the required information.

“Evidence: 1. The record for child 1 (date of enrollment: 8/24/21) does not contain the work phone number and place of employment of each parent who has custody. 2. The center director confirmed that the record for child 1 does not contain the work phone number and place of employment for each parent.”

Rule 8VAC20-780-60-A.

Based on record review and interview, the center did not ensure that each staff’s record contain all the required information.

“Evidence: 1. The record for staff 1 (date of hire: 11/1/16) does not contain documentation that two or more references as to character and reputation as well as competency were checked before employment. 2. The center director confirmed that the record for staff 1 is lacking documentation of the required reference checks.”

Rule 8VAC20-780-70.