Ms. Deanna Southern

22.1-289.036-A

“Applicants are required to undergo a background check every 5 years. The 5-year update to the central registry search for Applicant 1 was overdue by 3 months.”

22.1-289.035-B-3

“The center must request a search of the central registry prior to the employee’s first day of employment. Caregiver 5, who has been employed for more than one month, did not have a central registry search requested.”

22.1-289.035-B-3

“The center must request a search of the central registry prior to the employee’s first day of employment. Caregiver 5, who has been employed for more than one month, did not have a central registry search requested.”

8VAC20-800-320-B

“Child-resistant protective covers shall be installed on all unused electrical outlets accessible to children under five years of age. There was an uncovered electrical outlet that was accessible to the children (ages 15 months-4 years) in the bathroom.”

8VAC20-800-320-B

“Child-resistant protective covers shall be installed on all unused electrical outlets accessible to children under five years of age. There was an uncovered electrical outlet that was accessible to the children (ages 15 months-4 years) in the bathroom.”

8VAC20-790-190-B-12

“A written care plan is required for each child with a diagnosed food allergy, to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction. Child 1, who has been enrolled for 2 weeks, has a diagnosed food allergy and did not have a written care plan in their file.”

8VAC20-800-180-A

“A tuberculosis screening/test is required every two years from the date of the last screening/test. An updated tuberculosis screening/test for Caregiver 2 was not completed and was overdue by 2 months. An updated tuberculosis screening/test for Household Member 1 was not completed and was overdue by 14 months.”

8VAC20-790-190-B-12

“A written care plan is required for each child with a diagnosed food allergy, to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction. Child 1, who has been enrolled for 2 weeks, has a diagnosed food allergy and did not have a written care plan in their file.”

8VAC20-800-180-A

“A tuberculosis screening/test is required every two years from the date of the last screening/test. An updated tuberculosis screening/test for Caregiver 2 was not completed and was overdue by 2 months. An updated tuberculosis screening/test for Household Member 1 was not completed and was overdue by 14 months.”

22.1-289.035-B-2

“Based on document review, the provider failed to ensure that no person shall be hired for compensated employment prior to the facility obtaining an employment eligibility letter upon the completion of a fingerprint background check as required by the Code of Virginia. Evidence: 1. The record for Caregiver 3 contained a documented hire date of 11/02/2023; the employment eligibility letter for Caregiver 3 was dated 11/09/2023. 2. The record for Caregiver 5 contained a documented hire date of 11/08/2023; the employment eligibility letter for Caregiver 5 was dated 11/09/2023.”

8VAC20-770-60-C-2

“Based on record review, the provider failed to obtain the findings from a search of the central registry within 30 days of employment. Evidence: 1. The record for Caregiver 3 contained a documented hire date of 11/02/2023. The search of the central registry for Caregiver 3 was dated 01/26/2024. 2. The record for Caregiver 5 contained a documented hire date of 11/08/2023. There was not a search of the central registry available for Caregiver 5.”

8VAC20-800-170-A

“Based on record review, the provider failed to obtain from each caregiver at the time of hire, a report documenting the absence of tuberculosis in a communicable form. Evidence: 1. The record for Caregiver 3 contained a documented hire date of 11/02/2023. The tuberculosis screening/test was dated 11/08/2023. 2. The record for Caregiver 5 contained a documented hire date of 11/08/2023. The tuberculosis screening/test was dated 11/09/2023.”

22.1-289.035-A

“REPEAT VIOLATION Based on record review, the provider failed to ensure that all caregivers shall undergo a background check in accordance with the Code of Virginia prior to employment and every five years thereafter. Evidence: The most recent search of the central registry for Caregiver 4 was dated 12/12/2018; there was not a follow-up search of the central registry obtained by 12/12/2023.”

8VAC20-770-60-B

“Based on record review, the provider failed to ensure that an employee must not be employed until the agency has the person’s completed sworn statement or affirmation. Evidence: The record for Caregiver 5 contained a documented hire date of 11/08/2023. The sworn statement in the record for Caregiver 5 was dated 11/09/2023.”

22.1-289.035-B-2

“Based on document review, the provider failed to ensure that no person shall be hired for compensated employment prior to the facility obtaining an employment eligibility letter upon the completion of a fingerprint background check as required by the Code of Virginia. Evidence: 1. The record for Caregiver 3 contained a documented hire date of 11/02/2023; the employment eligibility letter for Caregiver 3 was dated 11/09/2023. 2. The record for Caregiver 5 contained a documented hire date of 11/08/2023; the employment eligibility letter for Caregiver 5 was dated 11/09/2023.”

8VAC20-770-60-C-2

“Based on record review, the provider failed to obtain the findings from a search of the central registry within 30 days of employment. Evidence: 1. The record for Caregiver 3 contained a documented hire date of 11/02/2023. The search of the central registry for Caregiver 3 was dated 01/26/2024. 2. The record for Caregiver 5 contained a documented hire date of 11/08/2023. There was not a search of the central registry available for Caregiver 5.”

8VAC20-800-170-A

“Based on record review, the provider failed to obtain from each caregiver at the time of hire, a report documenting the absence of tuberculosis in a communicable form. Evidence: 1. The record for Caregiver 3 contained a documented hire date of 11/02/2023. The tuberculosis screening/test was dated 11/08/2023. 2. The record for Caregiver 5 contained a documented hire date of 11/08/2023. The tuberculosis screening/test was dated 11/09/2023.”

22.1-289.035-A

“REPEAT VIOLATION Based on record review, the provider failed to ensure that all caregivers shall undergo a background check in accordance with the Code of Virginia prior to employment and every five years thereafter. Evidence: The most recent search of the central registry for Caregiver 4 was dated 12/12/2018; there was not a follow-up search of the central registry obtained by 12/12/2023.”

8VAC20-770-60-B

“Based on record review, the provider failed to ensure that an employee must not be employed until the agency has the person’s completed sworn statement or affirmation. Evidence: The record for Caregiver 5 contained a documented hire date of 11/08/2023. The sworn statement in the record for Caregiver 5 was dated 11/09/2023.”

22.1-289.035-A

“Based on record review, the provider failed to ensure that all caregivers shall undergo a background check in accordance with the Code of Virginia prior to employment and every five years thereafter. Evidence: The most recent criminal history record check for Caregiver 3 was dated 08/06/2018; there was not a follow-up criminal history record check obtained by 08/06/2023.”

8VAC20-800-570-A

“Based on observations and record review, the provider failed to ensure that a caregiver does not exceed 16 points by using the required point system to determine if additional caregivers are needed. Evidence: There were 12 non-resident children and 1 resident child, totaling 34 points, and 2 caregivers present during the inspection; the allowed 32 points was exceeded.”