The program manager shall update the staff roster in the NHCIS portal within 5 business days when the individuals as described in (b) above are no longer working in the program or part of the household, with the date they left the program.

The licensing coordinator's review of the staff roster identified one staff member who no longer works at the program. The individual's departure occurred within five days of the visit; however, their status had not been updated or end-dated in the system as of December 1, 2025, which exceeds the five-day window. Corrective action: Employee has been end dated. To ensure this is compliant in the future, all employees who are terminated or leave their position will be end dated within 5 days.

He-C 4002.40(n) · Correction status not published

The documentation described in (d) above shall be on file on the first day the child is in attendance at the program or, pursuant to 45 CFR § 98, 41(a)(1)(i)(C), for children experiencing homelessness or for children in foster care within 60 days of the first date of attendance, to allow families or persons responsible for their care to obtain and provide documentation of immunizations.

The licensing coordinator’s review of 7 children’s files revealed that there was no record of immunizations on file for one child for the first day of the child's attendance. Corrective action: The record was added to the file. The files will be audited monthly to ensure all documents are current and have not lapsed.