Ms. Sharon Gregory

22VAC40-111-60-B · Based on review, provider did not ensure 1 of 2 children's records has documentation of required information.

Evidence: The record for child #1 (start date November 1, 2021) did not have parents' employment addresses and the address for the second emergency contact.

8VAC20-800-800-B · The provide shall review the emergency plan at least annually and update the plan as needed. The most recent plan available for review was dated 2014.

8VAC20-800-780-B · The provider is required to annually review with enrolled children's parents the information is correct and obtain the parent's signed acknowledgement of the review.

The records for child #1, child #3 and child #4 did not contain the parent's signed acknowledgement of a review of the emergency information in the past 12 months. This annual documentation is overdue by more than 3 years for child #1, more than 2 years for child #3 and more than 3 years for child #4.

8VAC20-800-180-A · Based on review, facility did not ensure 1 of 2 caregivers has an updated negative TB test screening ever 2 years.

Evidence: The record for caregiver #2 has a most recent TB test dated 3/7/2022 which is more than 2 years old.

8VAC20-800-830-B · Based on review and interview, provider did not ensure shelter-in-place procedures are practiced a minimum of twice per year.

Evidence: There was documentation of one shelter-in-place drill in 2023. Provider confirmed a second drill was not conducted.

8VAC20-800-60-B · Based on review, provider did not ensure 3 of 5 children's records have documentation of required information.

Evidence: The following was found during record review: 1. The record for child #1 (start date 9/20/2022) did not have a complete address for one of the emergency contacts. 2. The record for child #2 (start date date 6/17/2019) had a most recent review of information in 2021. 3. The record for child #5 (start date 9/8/2020) did not have father's employment address, father's employment phone number, insurance plan number and a most recent review of information in 2021.

8VAC20-800-100-A · Based on review, provider did not ensure 1 of 3 children?s records has a physical examination prior to the child?s attendance or within 30 days after the first date of attendance.

Evidence: The record for child #2 (start date 9-20-2022) did not have a physical exam.