Ms. Sandra Nicholas

22VAC40-111-100-A · Based on a review of two children's records and interview, the provider did not obtain documentation of a physical examination by or under the direction of a physician prior to one child's attendance or within 30 days after the first day of attendance.

Evidence: 1) The record for Child #1, enrolled on 06/08/2021, did not contain a physical examination. 2) During interview, Caregiver #1 reported the physical examination for Child #1 has not been received to date.

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22VAC40-665-230-H · Based on a review of records and interview, the vendor did not ensure that one caregivers who works directly with children completed the department's health and safety update course by the required deadline.

Evidence: 1) The record for Caregiver #2, hired on 06/26/2019, does not contain a certificate of completion of the Annual Health and Safety Update Training. The training should have been completed within 1 year. 3) During interview, Caregiver #1 acknowledged Caregiver #2 did not complete the required Annual Health and Safety Update Training by the required deadline.

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22.1-289.035-B-1 · The provider is required to obtain a completed sworn statement prior to the employee's first day of employment. The sworn statement for Staff #3, who is currently working, did not have a completed sworn statement.

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8VAC20-790-250-F · Caregivers who work directly with children are required to complete the department's updated health and safety course. Caregiver #2 is over due to complete the department's health and safety update course by two years.

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22.1-289.057-A · The program is required to submit to VDH and implement a plan to test potable water for lead.

The program did not have evidence of a testing plan submitted to VDH and/or the program did not have evidence of the implementation of the required testing plan.

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8VAC20-800-780-B · (Repeat Violation) Annually, the provider shall review with the parent the emergency contact information required in each child?s record to ensure the information is correct and shall obtain the parents signed acknowledgment of the review.

1. Records for children #3, and #4 did not have a parent?s signature for an annual review of the emergency contact information. Child #3 and #4 had been in care for over a year without any annual review. 2. The provider verified that an annual review had not been completed for child #3 and child #4.

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8VAC20-800-780-B · Based on record review, the provider did not ensure to annually review with the parent the emergency contact information required in 8VAC20-800-60 B 2 to ensure the information is correct, and to obtain the parent's signed acknowledgment of the review.

Evidence: The record for child # 3 did not contain an annual review.

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8VAC20-770-40-D-1-a · Based on record review and interview, the provider failed to ensure that all staff shall undergo background checks every five years.

Evidence: 1. The staff record for Staff #1 contained a central registry background dated 6/8/2018. Staff #1 should have undergone a criminal background check on or before 6/8/2023. 2. The provider verified that a central registry background check had not been completed.

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8VAC20-800-830-C · Based on record review and interview with the provider, the provider failed to maintain documentation of emergency evacuation.

Evidence: 1. There was no documentation of emergency evacuations drills January 2023 ? July 2023. 2. The provider stated that drills were completed but she was unable to provide documentation that verified drills were done.

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8VAC20-800-840-B · Based on record review, the injury report did not include all required information.

Evidence: The injury report completed by the provider did not include when and how the parents were notified, the time the incident occurred, actions to prevent future occurrences of similar incidents, and the parent and provider?s signature.

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8VAC20-800-60-B · Based on a review, the provider failed to ensure that all required information was documented in children's record.

Evidence: 1. Child #2's record did not contain a signed written authorization for emergency medical care should an emergency occur and the parent cannot be located. Date of enrollment was 04/12/2021. 2. The provider confirmed that the parent did not sign the emergency medical authorization form.

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8VAC20-800-830-B · Based on interview, it was determined that the provider has not conducted at least two shelter- in -place drills. Evidence: There was no documentation of shelter-in-place drills completed.

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