Donna Doaner

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.

“Two (2) staff members who have been employed at the program for more than six (6) months do not have complete and or up to date BFIS quality and credential accounts. Documents that are missing include CPR/First Aid certificates. The missing documents were verified during the site visit; this violation was cited because these trainings were completed but not submitted to BFIS. This is separate from the violation cited for staff not completing training. This is a repeat violation and was previously cited on 8/29/2019 and 5/31/2029. Corrective Action: Submit the missing documents to Northern Lights at CCV so that they can be uploaded to BFIS and send the licensor confirmation of submission by 8/20/2026. Status: Appeal Period.”

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.

“Two (2) staff members were missing 1.5 professional development hours. The provider confirmed the staff members had not completed the training. This is a repeat violation and was previously cited on 12/12/2023 and 8/28/2019. Corrective Action: The two (2) staff members must complete 1.5 professional development hours. Submit the completed professional development training certificates to Northern Lights and send submission confirmation to the licensor by 8/20/2026. Status: Appeal Period.”

Regulation 4.7: The FCCP shall establish written policies and procedures. Written information provided to parents of all children enrolled in the FCCH shall include, at minimum: * Assurance that parents have access to the FCCH and their child(ren) without prior notice and have access to their children's records as required in the rule 3.3.4.6 of these regulations; * A description of information needed from parents for child's enrollment file as required in rules in section 3.3.4.1 of these regulations; * A typical daily schedule of activities; * Information about fees and payment policies; * Information about hours of operation and closings; * Procedures for signing children in and out; * Procedures for emergencies as required in the rules in section 3.6 of these regulations; * Information about the nutrition, meals and meal preparation at the FCCH; * Safe sleep policies, as applicable; * No smoking policy; * Information about results from the test for lead in the drinking water and any plan for remediation; * FCCH policies on field trips, other off-site activity and transportation; * FCCH health policies including illness exclusions, administration of medication, and immunizations; * FCCH policies and practice regarding positive guidance and behavior management; * Assurance that confidentiality of child and family information is maintained; * Information about the requirement to report suspected child abuse and/or neglect as required in the rules in section 3.2 of these regulations; * Assurance that non-discrimination and respect for each child's family and culture is maintained; * FCCH approach to ensure wholesome growth and positive developmental experiences for children enrolled; * FCCH policies related to the inclusion of children with special needs and disabilities; * A description of religious activities, if any; * Information on how to access these FCCH regulations and other information about child development online; * Information concerning complaint procedures; * Information about the Child Care Consumer Line, including the telephone number (1-800-649-2642); and * FCCH policies and procedures related to the expulsion of children.

“On 08/07/2025 a violation was cited to this rule as the Provider's handbook was ;acling twenty (20) of the twenty-four (24) components required by this rule. After reminders to the Provider via email, a handbook was submitted on 01/08/2026. Upon review, the handbook was still lacking the twenty (20) components that had been previously identified as missing. This was also discussed with the provider during a 09/24/2024 compliance visit at which time an email was sent to the provider detailing the missing components. This is a repeat violation. Corrective Action: By 01/23/2026 connect with the System for Program Access to Resources and Quality Supports (SPARQS). With SPARQS support, develop a handbook that includes all components as required by this rule. In the corrective action email provide evidence of your correspondence with SPARQS.”

Correction date in the state record: Jan 30, 2026

Regulation 3.3.3: The FCCP shall establish a system for taking attendance, including documentation of the time when each child arrives and departs each day he/she attends the FCCH. The FCCP shall save all daily attendance records identifying the hours of children s attendance for at least twelve (12) months from the date that care is provided.

“Provider statements reflected that attendance to include documentation of children's arrival and departure times, had not been recorded the day of this visit nor for at least three (3) days prior. Corrective Action: Immediately develop a system to document each child's arrival and departure times, in the moment, each day. Develop a system to maintain all daily attendance records for at least twelve (12) months. In the corrective action email provide details and photo evidence of the systems that have been developed to ensure compliance moving forward.”

Correction date in the state record: Sep 16, 2025

Regulation 4.7: The FCCP shall establish written policies and procedures. Written information provided to parents of all children enrolled in the FCCH shall include, at minimum: * Assurance that parents have access to the FCCH and their child(ren) without prior notice and have access to their children's records as required in the rule 3.3.4.6 of these regulations; * A description of information needed from parents for child's enrollment file as required in rules in section 3.3.4.1 of these regulations; * A typical daily schedule of activities; * Information about fees and payment policies; * Information about hours of operation and closings; * Procedures for signing children in and out; * Procedures for emergencies as required in the rules in section 3.6 of these regulations; * Information about the nutrition, meals and meal preparation at the FCCH; * Safe sleep policies, as applicable; * No smoking policy; * Information about results from the test for lead in the drinking water and any plan for remediation; * FCCH policies on field trips, other off-site activity and transportation; * FCCH health policies including illness exclusions, administration of medication, and immunizations; * FCCH policies and practice regarding positive guidance and behavior management; * Assurance that confidentiality of child and family information is maintained; * Information about the requirement to report suspected child abuse and/or neglect as required in the rules in section 3.2 of these regulations; * Assurance that non-discrimination and respect for each child's family and culture is maintained; * FCCH approach to ensure wholesome growth and positive developmental experiences for children enrolled; * FCCH policies related to the inclusion of children with special needs and disabilities; * A description of religious activities, if any; * Information on how to access these FCCH regulations and other information about child development online; * Information concerning complaint procedures; * Information about the Child Care Consumer Line, including the telephone number (1-800-649-2642); and * FCCH policies and procedures related to the expulsion of children.

“Upon review of the Provider's Family Handbook it was identified that twenty (20) of the twenty-four (24) components required by this rule were missing. The lacking requirements were discussed during a previous visit on 09/24/2024. Corrective Action: Review and revise the handbook to include all components required by this rule. Provide a revised copy to your Licensor by 09/17/2025.”

Correction date in the state record: Jan 30, 2026

Regulation 5.10.1.1.2: The FCCP shall ensure that children are protected from choking hazards presented by cords on window coverings, electric or electronic appliances or equipment and telephone cords.

“In the living room, several electrical cords were observed to be loose and accessible to children below an entryway table. In the "back room," two (2) electrical cords were observed to be loose and accessible to children; one belonging to a telephone and the other to an air conditioner. Corrective Action: Immediately ensure that children are protected from choking hazards presented by cords. In the corrective action email include photo evidence that the identified cords have been secured or otherwise made inaccessible to children.”

Correction date in the state record: Sep 16, 2025

Regulation 2.3.10.5: The FCCP shall be responsible for compliance with all applicable state and federal laws even when they are more stringent than the rules in this set of FCCH regulations.

“Upon review of Vermont Department of Health's lead in drinking water testing database it was identified that this Provider's water has not been tested since 06/06/2019. Provider statements reflected that they have completed testing more recently. Documentation to support this was unable to be prodcued at the time of the visit. As of 08/19/2025 no supporting documentation has been provided. Corrective Action: Immediately discontinue the use of tap water for consumption. Contact the Vermont Department of Health to initiate the process of lead water testing. Develop a system to ensure water is tested for lead every three (3) years moving forward, as required. In the corrective action email provide evidence of correspondence with the Vermont Department of Health regarding water testing, and details of the system developed to ensure timely testing moving forward. For more information regarding lead in drinking water you may email LeadChildCare@vermont.gov or call 802-863-7220.”

Correction date in the state record: Sep 16, 2025

Regulation 3.2.3: It is the responsibility of the FCCP to ensure that staff and partner staff working with children in the FCCH understand that abuse and/or neglect of children is against the law and that all child care workers are legally required to report suspected child abuse or neglect as specified in the rule 3.2.2 of these regulations.

“Upon review of staff BFIS Quality and Credential accounts it was identified that Staff A and Staff B are not reflected to have completed training in Mandated Reporting. The Provider was unable to produce documentation to support that Staff A or B had completed this training at the time of the visit, but stated that they would fax the documentation to CDD. A reminder phone call to the provider was made on 08/13/2025. As of 08/20/2025, supporting documentation has not been received. Corrective Action: By 09/03/2025, ensure that both Staff A and Staff B complete Protecting Vermont's Children: Reporting Abuse and Neglect. This training can be accessed by visiting this webpage: https://northernlightsccv.org/. If you need additional assistance you may reach out to the Northern Lights Resource Advisor for the area at Ammie.Collins@ccv.edu. Submit the certificates of completion to Northern Lights at CCV with cover sheets, to be processed and reflected acurately in BFIS. Copy Licensor [name] on the submission email.”

Correction date in the state record: Sep 16, 2025

Regulation 5.10.1.10.3: All poisonous or toxic materials shall be inaccessible to children.

“In an unlocked cupboard beneath the kitchen sink the following materials were observed: A bottle of ant/roach killer, a container of S.O.S. cleaning product, and two (2) other spray bottles of cleaning material. The cupboard is accessible to children. Corrective Action: Immediately make all identified materials inaccessible to children. In the corrective action email provide photo evidence of how the materials beneath the sink have been made inaccessible to children and will remain so moving forward.”

Correction date in the state record: Sep 16, 2025

Regulation 5.4.1.4: Cots, mats, and mattresses shall be nonporous or have nonporous coverings. Each child shall be provided clean, individual bed linens either by the FCCP providing them or requiring parents to provide them. No child shall nap directly on nonporous coverings.

“Two (2) children were observed sleeping directly on nonporous surfaces with no bed linens. One (1) child, who was asleep on a nap mat, did not have any bed linens. Another child sleeping in a pack-n-play had a blanket covering their body, but no sheet or linens between their body and the nonporous surface. Corrective Action: Immediately ensure that each enrolled child is provided clean, individual bed linens so not to sleep directly on nonporous surfaces. Develop a system to ensure that each child is provided these bed linens for resting daily. In the corrective action email provide photo evidence that each child has their own individual linens and details of the system developed to ensure compliance moving forward.”

Correction date in the state record: Sep 16, 2025

Regulation 5.10.1.1.1: The FCCP shall ensure that children are protected from electrical outlets, such as by using protective covers, tamper-proof outlets, or other devices manufactured for this purpose.

“A total of seven (7) electrical outlets were observed bearing no protective covers or other devices manufactured for this purpose, and were not tamper-proof outlets. The electrical outlets were accessible to children. Five (5) of the outlets were in the "back room" which was occupied by children during the visit. Two (2) outlets were in the kitchen and within reach of children. Corrective Action: Immediately ensure that children are protected from electrical outlets by making them inaccessible to children. In the corrective action email provide photo evidence that all seven (7) identified outlets have been made inaccessible to children.”

Correction date in the state record: Sep 16, 2025

Regulation 5.4.2.3: The FCCP and staff shall ensure that infants sleep in cribs or port-a-cribs. Infants shall not be placed to sleep on soft surfaces, such as a couch or sofa, pillow, quilts, sheepskins or blankets. Infants shall not be placed in car seats, swings, high chairs, jumping chairs or similar equipment for sleep. A child that falls asleep in this type of equipment shall be gently transferred to a crib or port-a-crib as soon as feasible.

“Upon arrival an infant was observed sleeping in a rocking seat for approximately fifteen (15) minutes. Provider statements reflected that the infant does not typically sleep in the seat but that they did not want to awaken them at this time. Corrective Action: Immediately discontinue the practice of allowing infants to sleep in rocking seats or other similar equipment. Develop a system that ensures infants sleep in cribs or port-a-cribs and, if an infant is to fall asleep in the identified equipment, that they are gently transferred to a crib or port-a-crib as soon as feasible. In the corrective action email provide details of the system developed to ensure compliance moving forward.”

Correction date in the state record: Sep 16, 2025

Regulation 7.3.1: A Registered FCCP that operates a registered FCCH shall ensure and maintain documentation that he/she is at least eighteen (18) years of age, is a high school graduate or has completed a GED, and meets or exceeds one (1) of the following qualifications prior to licensure or within twelve (12) months of initial licensure: * At least a Vermont Early Childhood Career Ladder Level One (1) Certificate or higher; or * At least successful completion of the Fundamentals for Early Childhood Professionals' course; or * At least a current CDA (Child Development Association Credential) from the National Council for Professional Recognition); or * At least a Child Care Certificate from Community College of Vermont; or * At least successful completion of twelve (12) college credits in content consistent with the core knowledge areas identified by NLCDC.

“Upon review of the Provider's BFIS Quality and Credential account it was identified that [name] is not qualified to operate a Registered FCCH. Provider statements reflect that they have not obtained a High School Diploma or GED, nor completed Fundamentals for Early Childhood Professionals. A variance was granted to this rule 08/31/2017 which required Donna to complete a High School Diploma or GED program and complete Fundamentals for Early Childhood Professionals. That variance expired 06/31/2018. On 08/29/2019, a violation was cited to this rule as the qualification requirements had not been met. This is a repeat violation. Corrective Action: By 09/17/2025 submit a Program Improvement Plan that identifies that following 1) How the Provider intends to obtain qualifications as required by this rule, to include a high school diploma or a GED as well as one of the additional identified requirements 2) A comprehensive timeline in which qualifications will be met, and 3) Documentation to support any registration or enrollment to coursework, training programs, or classes that will be completed to obtain qualifications.”

Correction date in the state record: Sep 16, 2025

Regulation 5.10.3.3: Safe Use Zones For all play equipment that is thirty (30) inches or higher from the ground, including climbing equipment, slides, swings and other similar equipment, the FCCP shall ensure that the surface under and around the equipment, included recommended use zones, is of approved resilient material that protects children if they fall. * Materials in the use zone shall consist of wood chips, pea stone, mulch, engineered wood fibers, sand, safety-tested shredded or rubber like material or rubber mats designed for protective cushioning; * Materials used in the use zone shall follow the recommendations listed in the most recent publication of U.S. Consumer Product Safety Commission's Public Playground Safety Handbook regarding critical depth of tested materials determined by the height of the highest climbing surface of the equipment; * Materials used in the use zone shall be installed and maintained according to the manufacturer's instructions; * If the loose material such as sand, mulch, or shredded rubber is used in use zones, the FCCP shall ensure that the material is raked regularly and replenished to maintain depth and resilience; and * If the resilient material in use zones freezes, the FCCP shall ensure that the children will not play on the equipment until the resilient material has thawed and is once again resilient.

“No cushioning material was observed beneath two (2) climbing structures within the outdoor play yard. Both structures would allow children to reach more than thirty (30) inches off the ground. Corrective Action: As discussed, immediately discontinue use of the two (2) tall structures in the play yard. Before continuing use cushioning as recommended by the U.S. Consumer Product Safety Commission's Public Playground Safety Handbook must be present under and around both structures. By 12/16/2024 submit photo evidence that the structures have been removed from the playground. In addition indicate whether the structures will remain permanantly removed or include a plan to place cushioning material as weather permits. Include the type of cushioning material that will be used and the projected date of installation.”

Correction date in the state record: Jun 24, 2025

Regulation 3.6.1.1: The FCCP shall develop and maintain a written Emergency Response Plan to respond to a full range of emergencies both natural and man-made. A complete plan shall include how the FCCP will address and manage the following situations and responsibilities: * Evacuations or other emergencies such as leaving the premises and lockdown situations; * Specific concerns related to the location of the program, such as proximity to a nuclear reactor, an area prone to flooding or power loss; * Notifying the local authorities of the emergency; * A system for notifying the parents of the emergency; * Notifying the local emergency planning committee regarding the location of the FCCH and using the committee as a resource in emergency planning for the program; * A system of identifying the children and staff present at the time of the emergency and maintaining knowledge of their whereabouts; * A system for handling infants, toddlers, and children with special needs; * An established evacuation meeting location within walking distance of the FCCH; * A system to account for all children and staff at evacuation meeting place; * An process for relocation if necessary including safe transportation; * A system for sheltering in place if the FCCP and children present need to remain in the FCCH for an extended period; and * Staff chain of command and individual staff roles and responsibilities, (if applicable) during emergencies.

“Provider stated that no Emergency Response Plan had been developed for the program. Corrective Action: Develop an Emergency Response Plan that includes all components required by this rule. By 12/16/2024, submit the plan developed to Licensor [name] via email.”

Correction date in the state record: Jun 24, 2025

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.

“No professional development hours were reflected in BFIS between 10/28/2022 and 10/28/2023. When asked if any certificates were held on site, the provider indicated that she had not completed professional development in that time frame. Corrective Action: Develop a plan to complete the 15 hours of professional development for this time period, as well as ensuring an additional 15 hours will be completed for the 10/28/2023-10/28/2024 time period. Send completion certificates for missing 15 hours of professional development to sarah.crosier@vermont.gov by 1/26/2024. The currently required 15 hours will be assessed at the next annual compliance visit.”

Correction date in the state record: Jan 23, 2024

Regulation 6.1.4.4.5: Screen time shall not exceed thirty (30) minutes daily per child or group of children except for school age children using technology to complete homework assignments, and a once per month two (2) hour movie.

“The television was playing children's cartoons for more than one hour during the licensing visit. Corrective Action: Ensure that each child or group of children has no more than 30 minutes of screen time each day. A reminder that screen time can never be a plan for children under the age of two. Develop a plan to identify when screen time will be used and how you will ensure that no more than 30 minutes is offered. Email this plan to sarah.crosier@vermont.gov.”

Correction date in the state record: Jan 25, 2024

Regulation 3.3.3: The FCCP shall establish a system for taking attendance, including documentation of the time when each child arrives and departs each day he/she attends the FCCH. The FCCP shall save all daily attendance records identifying the hours of children s attendance for at least twelve (12) months from the date that care is provided.

“No attendance has been recorded since 11/15/2023. Corrective Action: Immediately begin to record attendance with accurate entry and exit times for each child. Develop a plan to ensure follow through with recording these items. Send a photo of attendance records for December 13-December 31 to sarah.crosier@vermont.gov by 1/5/2024.”

Correction date in the state record: Jan 24, 2024

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.

“The provider and staff have not maintained current CPR and First Aid certification. Prior certification expired 9/30/2023. Corrective Action: Immediately complete Infant and Child CPR and Pediatric First Aid. Links to courses meeting this requirement may be found on the Northern Lights website. Upon completion, send the certificates to professional.development@ccv.edu for entry into BFIS accounts. Copy sarah.crosier@vermont.gov on those emails. Develop a plan to ensure that renewal of certification happens prior to the current certification expiring.”

Correction date in the state record: Feb 6, 2024

Regulation 7.1.2.2: The FCCP shall ensure that at least one (1) responsible adult who has successfully completed and is currently certified in pediatric first aid and infant and child CPR is on the premises at all times children are present.

“No staff member on site maintains a current First Aid and CPR certifiate. Corrective Action: Immediately complete Infant and Child CPR and Pediatric First Aid. Links to courses meeting this requirement may be found on the Northern Lights website. Upon completion, send the certificates to professional.development@ccv.edu for entry into BFIS accounts. Copy sarah.crosier@vermont.gov on those emails. Develop a plan to ensure that renewal of certification happens prior to the current certification expiring.”

Correction date in the state record: Jan 25, 2024

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.

“Of the three (3) files reviewed, two (2) were missing the annual health exam. Corrective Action: Review all children's files and ensure they contain the health exam. Ensure all children have the health exam within forty-five (45) days after enrollment.”

Correction date in the state record: Jan 27, 2023

Regulation 5.4.1.1: The FCCP shall ensure that each child, except school age children, has an individual crib, port-a-crib, cot, mat, or bed that is safe for the child's age and development, in good repair, and used by only one child each day. No child shall nap directly on the floor or on furniture not designed for sleeping. Cribs or port-a-cribs shall be used for children under the age of twelve (12) months. Children shall not nap in cribs or port-a-cribs if they are physically able to climb out unassisted.

“Upon arrival Child A was observed sleeping on the couch where they remained during the visit. The Provider stated they fell asleep while watching a tv show. Corrective Action: Ensure children sleep in cribs, port-a-cribs, cots, mats or beds appropriate for their age. When children fall asleep on furniture not designed for sleep, ensure they are moved to an approved device.”

Correction date in the state record: Jan 27, 2023

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 extinguisher was last inspected in March 2021 and expired in March 2022. Corrective Action: Ensure there is new fire extinguisher or one that has been inspected, and bears the official tag indicating the date it was serviced. Develop a system to ensure that this is maintained.”

Correction date in the state record: Jan 27, 2023

Regulation 3.6.2.2: The FCCP shall ensure that evacuation drills are conducted at least once a month, and children and staff are evacuated in less than three (3) minutes.

“Upon request to see evacuation drill logs, Provider A stated that they had not been doing evacuations. When asked how long ago the last drill was completed, Provider A was unable to recall. Corrective Action: Ensure evacuation drills are completed monthly as required by this rule. For the months of February through July, complete an additional drill. Ensure each drill is documented as required per rule 3.3.6.1.”

Correction date in the state record: Nov 7, 2022

Regulation 5.10.3.3: Safe Use Zones For all play equipment that is thirty (30) inches or higher from the ground, including climbing equipment, slides, swings and other similar equipment, the FCCP shall ensure that the surface under and around the equipment, included recommended use zones, is of approved resilient material that protects children if they fall. * Materials in the use zone shall consist of wood chips, pea stone, mulch, engineered wood fibers, sand, safety-tested shredded or rubber like material or rubber mats designed for protective cushioning; * Materials used in the use zone shall follow the recommendations listed in the most recent publication of U.S. Consumer Product Safety Commission's Public Playground Safety Handbook regarding critical depth of tested materials determined by the height of the highest climbing surface of the equipment; * Materials used in the use zone shall be installed and maintained according to the manufacturer's instructions; * If the loose material such as sand, mulch, or shredded rubber is used in use zones, the FCCP shall ensure that the material is raked regularly and replenished to maintain depth and resilience; and * If the resilient material in use zones freezes, the FCCP shall ensure that the children will not play on the equipment until the resilient material has thawed and is once again resilient.

“The playground area has structures that are over thirty (30) inchess off the ground. The program does not have any cushioning material as required. Corrective Action: Discontinue use of the outdoor play structures that are over thirty (30) inches off the ground until sufficient cushioning material is in place meeting this rule.”

Correction date in the state record: Oct 21, 2019

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.

“Provider C stated he has a high school diploma but was unable to locate it. Provider B had verification of his high school diploma. Neither Provider B or C have their high school diploma documented in their Bright Futures account. A previous violation was cited for this on 5/31/2019 with corrective action due by 7/24/2019. Corrective Action: Submit high school diplomas to Northern Lights to reflect qualifications for both Provider B & C.”

Correction date in the state record: Oct 2, 2019

Regulation 7.3.1: A Registered FCCP that operates a registered FCCH shall ensure and maintain documentation that he/she is at least eighteen (18) years of age, is a high school graduate or has completed a GED, and meets or exceeds one (1) of the following qualifications prior to licensure or within twelve (12) months of initial licensure: * At least a Vermont Early Childhood Career Ladder Level One (1) Certificate or higher; or * At least successful completion of the Fundamentals for Early Childhood Professionals' course; or * At least a current CDA (Child Development Association Credential) from the National Council for Professional Recognition); or * At least a Child Care Certificate from Community College of Vermont; or * At least successful completion of twelve (12) college credits in content consistent with the core knowledge areas identified by NLCDC.

“Provider A confirmed that she has not obtained qualifications as a family childcare provider. A previous variance was approved permitting Provider A to continue to provide care while obtaining required qualifications by 6/31/2018. Provider A did not complete this requirement. Corrective Action: Submit a program improvement plan that identifies the steps Provider A will take to obtain qualifications. In this plan, provide documentation to support any course work, trainings or classes that will be attended.”

Correction date in the state record: Oct 21, 2019

Regulation 2.3.8.3: The FCCP shall ensure that the FCCP; all individuals residing in the home; staff; and any individuals who are left alone with children have met ongoing background check requirements by submitting at least once every five (5) years a Records Check Authorization form to the Division and as required shall submit to fingerprinting.

“On 5/31/2019 the program was cited with a violation as Provider A, B & C had not completed the required fingerprinting process. As of 8/29/2019 Provider A confirmed that this had not been completed. Corrective Action: From your Bright Futures account, print the fingerprint authorization forms for Provider A, B and C. Schedule and complete the fingerprinting process by the due date. Advise Licensor [name] when the fingerprinting process has been completed.”

Correction date in the state record: Sep 5, 2019

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.

“Upon review of professional development documentation, it was noted that Provider A did not complete any professional development between 8/17/2018-8/16/2019. Provider A confirmed this during the visit. Corrective Action: Submit a program improvement plan that identifies how Provider A will ensure that required professional development is completed on a yearly basis. Ensure that between 8/17/2019-8/16/2020 that fifteen (15) hours of professional development is completed and submitted to Northern Lights.”

Correction date in the state record: Sep 12, 2019

Regulation 3.3.4.1: The FCCP shall maintain a complete and up-to-date enrollment file on-site for each child enrolled in the FCCH. A complete file shall contain, at minimum, the following information: * A completed child's admission form signed and dated by the parent that includes the first date the child attended the FCCH and the days and hours the child is regularly scheduled to attend the FCCH; * The child's name, current home address and current home telephone number; * The child's date of birth; * Name, address and all applicable current telephone numbers for parents; * Name, address and all applicable current telephone numbers for at least two (2) other people designated by the parents as emergency contacts; * Names for all persons authorized to pick the child up from the FCCH; * Record of an annual physical and health history as required in the rule 5.1.2 of these regulations that includes the name and telephone of the child's primary health care and dental care providers (if the child has a dental care provider); * A description of any special medical, developmental, emotional or educational needs of the child including allergies, existing illnesses or injuries, previous serious illnesses or injuries and any prescribed medication including those for emergency situations; * Written authorization from the parent for the FCCP to be able to obtain emergency medical care and transportation; * Child's immunization record or Vermont Department of Health approved exemption document as required in the rules in section 5.1.3 of these regulations; * Written permission from parents for the FCCP to transport the child, if transportation is provided, as required in section 5.10.6.6.1 of these regulations; * Written permission from parents for child to participate in swimming activities, if swimming activities are a part of the program, as required in the rule 5.10.5.1 of these regulations; * If applicable, a copy of court orders on custody and visitation arrangements as required in the rule 3.5.4 of these regulations; and * If applicable, any obvious injuries discovered and documented on daily health check as required in the rule 5.3.2 of these regulations.

“Upon review of files for Child X and Y, documentation was found to be incomplete. Child X and Y were missing annual health exams, addresses for their emergency contacts, a schedule of when they attend, permission to be transported in the event of an emergency, and their home address. There is a section for doctors and dentist on your intake form, but parents didn't complete those portions. A previous violation was cited for incomplete children's files on 5/31/2019. Provider A did not provide corrective action as required. Corrective Action: Update your enrollment form to gather all required information from parents. Create a system and advise Licensor [name] of this system ensuring all required documentation is obtained and in each child's file.”

Correction date in the state record: Oct 21, 2019

Regulation 5.1.4: The FCCP shall submit a Vermont Child Care Immunization Report at least once every 365 days to the Vermont Department of Health, Immunization Office as required by 18 V.S.A. SS 1120 - 1129.

“Between 11/5/2018 and 12/21/2018, CDD sent 2 separate emails to all programs, 1 reminder letter using US Postal Service, 1 reminder letter sent through the program's BFIS account, and a final email reminder. This communication provided the link to be used and CDD contact information for questions or challenges with submitting the report. Corrective Action: Submit a program improvement plan that identifies the steps that will be taken to ensure that the 2019 annual immunization report will be filed between 11/1/2019 - 12/31/2019.”

Correction date in the state record: May 31, 2019

Regulation 3.3.4.1: The FCCP shall maintain a complete and up-to-date enrollment file on-site for each child enrolled in the FCCH. A complete file shall contain, at minimum, the following information: * A completed child's admission form signed and dated by the parent that includes the first date the child attended the FCCH and the days and hours the child is regularly scheduled to attend the FCCH; * The child's name, current home address and current home telephone number; * The child's date of birth; * Name, address and all applicable current telephone numbers for parents; * Name, address and all applicable current telephone numbers for at least two (2) other people designated by the parents as emergency contacts; * Names for all persons authorized to pick the child up from the FCCH; * Record of an annual physical and health history as required in the rule 5.1.2 of these regulations that includes the name and telephone of the child's primary health care and dental care providers (if the child has a dental care provider); * A description of any special medical, developmental, emotional or educational needs of the child including allergies, existing illnesses or injuries, previous serious illnesses or injuries and any prescribed medication including those for emergency situations; * Written authorization from the parent for the FCCP to be able to obtain emergency medical care and transportation; * Child's immunization record or Vermont Department of Health approved exemption document as required in the rules in section 5.1.3 of these regulations; * Written permission from parents for the FCCP to transport the child, if transportation is provided, as required in section 5.10.6.6.1 of these regulations; * Written permission from parents for child to participate in swimming activities, if swimming activities are a part of the program, as required in the rule 5.10.5.1 of these regulations; * If applicable, a copy of court orders on custody and visitation arrangements as required in the rule 3.5.4 of these regulations; and * If applicable, any obvious injuries discovered and documented on daily health check as required in the rule 5.3.2 of these regulations.

“Of the files reviewed, there were files with missing or incomplete information inlcuding admission date and schedule, two (2) emergency contacts, authorized people to pick children up, and dentists. In addition, permission authorizing children to be transported during a medical emergency was not received from parents and/or guardians. Corrective Action: Ensure each child's files contains each component as indicated by this regulation. Obtain any missing or incomplete information from parents/guardians for those children who's files are incomplete.”

Correction date in the state record: Oct 21, 2019

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.

“Staff A stated that Staff D is no longer working in the program however Staff D is still listed on the Associated Parties list. Corrective Action: In your Bright Futures account, enter an end date for Staff D to remove her from your Associated Parties list. If you decided to continue to have her listed in the Associated Parties list, be certain requirements of regulation 2.3.8.3 and 3.3.7.3 are met.”

Correction date in the state record: Jun 17, 2019

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 quality and credential accounts within Bright Futures are missing required documentation for Staff A, B, & C. All staff are missing verification of their qualifications for the role they serve within the program. Staff A indicated that she has not obtained her high school diploma or fully completed the Fundamentals course work as stated in her approved variance. Staff A, B, C have verification of completing CPR and First Aid training, however this is not documented in their quality and credentials account. Corrective Action: Submit high school diplomas for Staff B, and C to Northern Lights. Submit certificates for CPR and First Aid completion for Staff A, B and C. Since Staff A indicated her intentions are to continue to work on her high school diploma and compeltion of Fundamentals, please provide Licensor [name] with verification of enrollment with Vermont Adult Learning. Additionally, please provide Licensor [name] with confirmation from Vermont Adult Learning on what has been completed to date, and what still needs to be completed in order to obtain a high school diploma. Provide verification of enrollment in the one Fundamental course still needed for that certificate. If a course is not currently being offerred, please advise Licensor [name] of this.”

Correction date in the state record: Oct 2, 2019

Regulation 2.3.8.3: The FCCP shall ensure that the FCCP; all individuals residing in the home; staff; and any individuals who are left alone with children have met ongoing background check requirements by submitting at least once every five (5) years a Records Check Authorization form to the Division and as required shall submit to fingerprinting.

“Provider A, B, & C have not completed the fingerprinting process as required. Provider A confirmed this was not completed. Corrective Action: Fingerprinting must be completed by the due date. If you are missing the required paperwork to have this process completed, contact your licensing technician [name] for additional forms. Advise Licensor [name] of when the fingerprint process has been completed.”

Correction date in the state record: Sep 5, 2019