Ashley Durgin

Regulation 3.3.6.1: The FCCP shall maintain a record of the date of each evacuation drill as required in the rules in section 3.6.2 of these regulations that includes the number of children, staff evacuated, time taken to evacuate, and notation of the drill conducted while children were sleeping or resting. Evacuation records shall be kept for two (2) years.

“The evacuation drill log was not completed as required. The provider said they complete evacuation drills but forgets to write them down on the form. Corrective Action: During this visit the provider moved the evacuation drill log from the back of a binder and posted it on the bulletin board so there would be a visual reminder and easy access to the form to document practiced drills. Confirm by email that evacuation drills will be logged as required moving forward.”

Regulation 7.4.4: All staff, with the exception of substitutes, shall complete fifteen (15) clock hours of annual professional development activities as required in the rule 7.4.2 of these regulations.

“The provider did not show documentation of having completed the fifteen (15) hours of annual professional development in BFIS. When asked to provide documentation of completed professional development by end of the day Monday, April 14th, the provider was not able to provide the documentation. Corrective Action: By 5/2/2025 send all training certificates from 6/20/2023 and 6/20/2024 to Northern Lights at CCV and copy Licensor [name] Irwin. If the hours completed do not add up to the required fifteen(15) hours then develop a plan that describes how the missing hours will be made up along with the additional fifteen (15) hours of professional development that are due by 6/20/2025 and send iit to Licensor [name] Irwin.”

Correction date in the state record: May 7, 2025

Regulation 5.10.1.2.4: The FCCP shall ensure that each floor of the home, and in the corridor to access the home in an apartment building, has an operating smoke detector as well as a smoke detectors in the immediate vicinity where children sleep. The FCCP shall ensure carbon monoxide monitors are located outside of rooms were children sleep.

“During the visit, it was noted that two children were asleep in rooms on the second level of the home, the doors to those rooms were closed and there were not smoke detectors inside those rooms or a Carbon Monoxide detector outside of those rooms. Corrective Action: Immeidately plan to install smoke detectors in every room where children sleep and carbon monoxide detectors outside of rooms where children sleep. In the corrective action email, include details of how the program has come back into compliance with this rule and a system to routinely check the operating condition and expiry dates and replacing the detectors as necessary moving forward.”

Correction date in the state record: Apr 17, 2024

Regulation 3.3.6.1: The FCCP shall maintain a record of the date of each evacuation drill as required in the rules in section 3.6.2 of these regulations that includes the number of children, staff evacuated, time taken to evacuate, and notation of the drill conducted while children were sleeping or resting. Evacuation records shall be kept for two (2) years.

“While the provider attested to performing monthly evacuation drills, the evacutaion drill log was not provided during this visit. Corrective Action: Immediately plan to conduct and record monthly evacuation drills and to keep the logs with all required information on site and readily available for review for at least two years.”

Correction date in the state record: Apr 17, 2024

Regulation 3.6.2.1: The FCCP shall have a written evacuation diagram with evacuation routes posted on each level of the home that is used by the children.

“During the visit, there were no evacutaion diagrams posted on each level of the home used by children. Corrective Action: Immediately plan to create and post evacuation diagrams on each level of the home used by children. In the corrective action email, provide details of how the program has come back into compliance and a system for routinely checking and ensuring that evacuation diagrams are posted and visible during all hours of operation moving forward.”

Correction date in the state record: Apr 17, 2024

Regulation 6.2.1.2: At no time shall the total number of children in care exceed ten (10) during Option one (1): Year Round Care or twelve (12) children for Option two (2): Summer Vacation.

“Upon arrival to the program at approximately 9:05 AM, there were a total of twenty (20) children signed in on the attendance sheet, including twelve (12) children under school age. The provider and Staff A were present and caring for the children. The provider's four (4) children, including one (1) child under school age, and the school-aged child of Staff A were upstairs and unattended by an adult. The provider and Staff A did have access to video and audio surveillance of the upstairs space. A review of attendance records reflected that fourteen (14) to twenty-two (22) children were in attendance with two (2) staff on a total of twenty-three (23) days between June 26 and August 28, 2023. The provider and Staff A stated that until 08/21/2023, Staff A typically arrived at the program at 9:00 AM each day. Attendance records show that the provider was alone with ten (10) to twenty (20) children, including seven (7) to eleven (11) children younger than school age, prior to Staff A's arrival on all twenty-three (23) days previously mentioned. On fourteen (14) of those days, the children present prior to Staff A's arrival included three (3) children under twenty-four (24) months of age. This does not fall within the confines of this rule. This is a serious violation. Corrective Action: As discussed, immediately plan to reduce the number of children in care to twelve (12) or less at any given time when using the chart for 6.2.1.7 and ten (10) or less when using the chart for rule 6.2.1.6. Further, develop a plan to meet the ratio requirements of the chart listed for rule 6.2.16 and/or 6.2.1.7 moving forward. When using the chart for rule 6.2.1.7 during summer vacation, this means that no more than ten (10) children, including no more than two (2) children under the age of twenty-four (24) months and no more than six (6) children under school age, shall be in care with one (1) provider and no more than twelve (12) children, including no more than six (6) children under school age, shall be in care with two (2) providers moving forward. When using the chart for rule 6.2.1.6 during year round care, this means no more than ten (10) children, including no more than two (2) children under the age of twenty-four (24) months and no more than six (6) children under school age, shall be in care with one (1) provider and no more than ten (10) children, including no more than six (6) children under school age, shall be in care with two (2) providers moving forward. As this is a serious violation, develop a program improvement plan. As discussed, develop a comprehensive schedule, including the names or initials and ages of children, and days and hours they will attend and submit that schedule in writing for approval by Licensor [name] by 08/29/2023. Plan to strictly maintain the allowable ratios laid out in the chart for rule 6.2.1.7 when choosing to utilize this option for summer vacation, and to strictly maintain the allowable ratios laid out in the chart for rule 6.2.1.6 at all other times moving forward. Include in the ratios portion of your program improvement plan: 1. Statements from the Provider and Staff A attesting to the fact that you have read and fully understand and your responsibility for strictly adhering to the ratio requirements as laid out in section 6.2 of regulation, 2. Details of the communication, including information about the ratio requirements clearly laid out in regulation and notification the violation noted in this this site visit report, between the program and all families enrolled at the time of the visit on 08/28/2023, by 09/05/2023, 3. How individual child schedules will be decided on based on current enrollment and staffing schedules, including a clear policy about how attendance will be handled and families will be notified if a staff member is running late or will be out for the day when numbers exceed the allowable ratios for one staff member, or any time a child's arrival and attendance would exceed the allowable ratios moving forward. In the policies and handbook portion of your program improvement plan, include details of how ratio requirements as laid out in regulation will be utilized to develop and enforce practices and policies for the program moving forward. Plan to develop clear written policies about all of the information previously mentioned and submit those polices to Licensor [name] for approval by 09/05/2023 and to continue to correspond with Licensor [name] and make further revisions in a timely manner, until such a time when Licensor [name] states full approval by the Division. Once approved, plan to revise your family handbook to include these policies and to make the revised handbooks available to all enrolled families, making them aware of the sections which have been revised, in a timely manner and by a date agreed upon by the provider and Licensor [name], and finally to make the most current copy of the family handbook available to all newly enrolled families moving forward.”

Correction date in the state record: Sep 18, 2023

Regulation 3.3.7.5: The FCCP shall maintain a current list of the staff, persons who reside in the FCCH, and non-parental volunteers, as applicable, in BFIS. Any changes shall be reported through BFIS within five (5) working days of the change.

“Upon arrival at the program, Staff B was observed feeding an infant a bottle. Staff A stated Staff B is their assitant and has been working with Staff A since August 2022. Review of BFIS shows Staff B is not listed on the program's Associated Parties list. Corrective Action: Immediately submit a Records Check Authorization form to the Division to start the process of adding Staff B to the Associated Parties list. Ensure staff B does not work within the program until the required Records Check Authorization has been submitted.”

Correction date in the state record: May 27, 2023

Regulation 7.1.2.1: The FCCP shall have successfully completed pediatric first aid and CPR prior to being licensed and must remain currently certified.

“Review of Staff A's BFIS Credential Account as well as staff files on site revealed Staff A's CPR/ First Aid certifications expired in 11/22. Corrective Action: Immediately complete an acceptable CPR/First Aid course. Create a system to track CPR/First Aid expiration going forward to ensure timely renewal.”

Correction date in the state record: Apr 2, 2024

Regulation 7.4.4: All staff, with the exception of substitutes, shall complete fifteen (15) clock hours of annual professional development activities as required in the rule 7.4.2 of these regulations.

“Review of BFIS Credential Account for Staff A as well as files on site revealed Staff A has not completed any of the required fifteen (15) professional development hours for the annual period of 06/20/2021 thru 06/20/2022. Corrective Action: For the annual period of 06/20/2022 thru 06/20/2023, ensure a total of thirty (30) professional development hours are completed. This thirty (30) hours is the fifteen (15) hours required for 06/20/2022 through 06/20/2023 in addition to the fifteen (15) missing hours for 06/20/2021 thru 06/20/2022. Provide a plan for completion as well as a plan for ensuring compliance to this rule moving forward.”

Correction date in the state record: Apr 2, 2024

Regulation 3.3.6.1: The FCCP shall maintain a record of the date of each evacuation drill as required in the rules in section 3.6.2 of these regulations that includes the number of children, staff evacuated, time taken to evacuate, and notation of the drill conducted while children were sleeping or resting. Evacuation records shall be kept for two (2) years.

“The provider said that they had been practicing monthly evacuation drills but that she had not been documenting them as required. Corrective Action: Ensure all required documentation is completed and maintained. Submit confirmation that evacuation drills are being documented and the location where documentation will be maintained.”

Correction date in the state record: Apr 17, 2023

Regulation 5.1.2: General Health Examinations: Within forty-five (45) days of enrollment the FCCP shall obtain documentation of the child's age appropriate well care exam from the parent. Documentation shall include information regarding any health conditions and medications that may impact the care of the child.

“A review of five (5) randomly selected files for children that had been enrolled more than 45 days showed they were missing documentation of a general health exam. Ashley shared that she has not been in the practice of requesting documentation of general health exams. Corrective Action: Review all children's files and obtain missing general health exam documentation by 11/23/2020. Submit a program improvement plan detailing how general health exams will be obtained for newly enrolled children moving forward. Send this plan and confirmation that all documentation of the most recent up-to-date general health exam to this licensor by 11/23/2020.”

Correction date in the state record: Nov 19, 2020

Regulation 3.6.3: Emergency preparedness Training: Within 365 days of opening a FCCH, the FCCP shall attend emergency preparedness training which shall include content specifically related to sheltering in place in the event of an emergency in which the FCCP and children present need to remain in the FCCH for an extended period.

“Ashley acknowledged that she has not taken the required Emergency Preparedness Training. Corrective Action: Complete an Emergency Response Plan Training by 11/23/2020. The Emergency Preparedness training available online at: https://training.fema.gov/is/courseoverview.aspx?code=is-36. Once the training is completed, send to Northern Lights at CCV to be put into the BFIS Quality and Credentialing account. Email confirmation to this licensor when this has been completed.”

Correction date in the state record: Nov 12, 2020

Regulation 7.1.2.1: The FCCP shall have successfully completed pediatric first aid and CPR prior to being licensed and must remain currently certified.

“Ashley confirmed that her CPR and First Aid certification expired in July. Corrective Action: Identify and plan to complete a CPR and first aid training. If you need assistance finding a training, you may reach out to your Northern Lights at CCV (NLCCV) resource advisor, [name] at (802) 828-0621 or joanne.rouleau01@ccv.edu. Once you have completed the training, send your certificate with a cover sheet to NLCCV to be added to your BFIS quality and credentialling account. Create a plan which will prompt you to sign up for and attend CPR and first aid training prior to the expiration of the certificate to remain currently certified moving forward. Send this plan and confirmation that you have renewed your first aid and CPR certification to this licensor by 11/23/2020”

Correction date in the state record: Nov 12, 2020

Regulation 3.3.7.3: Within six (6) months of initial date of employment, the FCCP and all staff shall maintain an up-to-date BFIS Quality and Credential Account. Documentation, verification of qualifications, and all annual professional development activities as specified in the rules sections 7.3 and 7.4 of these regulations shall be submitted to NLCDC to be verified and maintained in BFIS.

“The provider's BFIS Quality and Credentialing Account does not reflect updated documentation for required professional development. Corrective Action: By 11/23/2020, submit documentation of completed professional development, VT Mandated Reporter training, and the VT Orientation to Northern Lights at CCV. The Verification Cover Sheet can be found at: https://northernlightsccv.org/resource/verification-cover-sheet/ Send confirmation that documentation has been submitted this licensor by 11/23/2020.”

Correction date in the state record: Nov 12, 2020

Regulation 5.10.1.2.5: There shall be at least one (1) easily accessible dry chemical fire extinguisher which has at least a 2-A: 10BC classification. This fire extinguisher shall be maintained in operating condition. It shall bear an official tag, properly signed, attesting to current operating condition.

“The fire extinguisher accessible to the program bears an inspection tag dated from 2016. Corrective Action: Have the fire extinguisher properly inspected, the inspection tag dated, and the name of the inspector noted. Send confirmation by email that this has been completed. Create a system to ensure the fire extinguisher is inspected annually as required.”

Correction date in the state record: Aug 29, 2018