Potter's House School

Regulation 3.4.6.5: Staffing Schedule: A licensee shall maintain a written record of the daily schedule for at least 365 days of all staff including exact days and hours worked and the group of children to whom they are assigned.

“While there was a document showing the days, hours and rooms staff are assigned, there did not seem to be a system which clearly reflects when staff from one room may cover in another room, or other changes with staff and child room assignments that are stated to occur during opening and closing transition times. Due to this, the staff:child ratios at these times of day were unable to be fully assessed. Corrective Action: Immediately plan to develop a system which ensures documentation of a comprehensive timeline of when each staff member is in each classroom and/or assigned to each group of children during all hours of operation. This means that if Staff A opens in the transition room, then moves to their assigned classroom, the exact times they were with the infant room and in their assigned classroom are appropriately captured. See corrective action for rule 6.2.1.3 for further details of addressing a system.”

Correction date in the state record: Dec 4, 2025

Regulation 7.2.2: The licensee shall ensure that all new staff and auxiliary staff, prior to working with children in the CBCCPP; and any new individual designated as the representative of the licensee shall submit a Records Check Authorization form to the Division and shall submit to fingerprinting at a location designated by the Division after having received the Fingerprinting Authorization Certificate by the Division.

“A review of staff BFIS accounts reflected that Staff D had not yet submitted a Records Check Authorization Form to the Division to be added to the staff list for this program. Staff D was present at the program, counted in ratio and left alone with children during this visit. Staff D and the director confirmed that Staff D has been working in the program and with children since October of 2024. This is a repeat violation which was cited on 02/01/2024, 09/20/2024, and 01/23/2025. Corrective Action: As discussed, immediately submit a records check authorization form for Staff D to the Division and ensure that staff D is not left alone with a child or children until such a time when the program and the individual recieve a final clearance letter based on the fingerprint supported background check indicating that Staff D may be left alone with children. Develop a system which ensures all newly hired staff submit a records check to the Divsion for the program prior to working with children in the program. Include details of who will be responsible for ensuring new staff submit records check authorization forms to the Division prior to working with children, submit to fingerprinting within 30 days of having received the notification from the Division requiring fingerprinting, and that all staff are aware of who can and cannot be left alone with children at any given time moving forward.”

Correction date in the state record: Jul 17, 2025

Regulation 6.2.1.3: The program director shall ensure that the number of staff present meets requirements described in the chart below for ages of children, maximum group size, and staff/child ratios at any time of day.

“Staff statements reflect that the program has operated over ratio on numerous occassions over the months of April and May 2025. A review of staff and child attendance did not offer clear indications of compliance with staff:child ratio requirements, as the program did not have a detailed schedule to reflect when each staff member was assigned to each group of children. The Director stated that there was one morning in the last two weeks when there were six (6) infants and one (1) staff member and there were no extra staff to cover. The director also stated that there have been times at the end of the day when the opening teachers leave for the day and the program may be one or two children over ratio for a few minutes if parents are running late. Six (6) staff members, who are assigned to the infant, transition and toddler rooms, stated that the program has operated over ratio in at least two of the classrooms on multiple occasions. Two (2) staff stated that the transition room has frequently operated over ratio, sometimes with up to eight (8) children and one (1) staff member for up to thirty (30) minutes. Three (3) staff stated that the infant room has operated over ratio on several occasions with up to seven(7) infants with one (1) staff member for up to thirty (30) minutes. When staff have made the Director aware, the Director has stated that there were no extra staff to cover. Additionally, observations of the playground on 06/13/2025, reflected that the toddler and transition groups were present and there was no indication that they were operating as separate groups. Later seven (7) preschool students from Pottter's House Preschool and Childcare entered the playground with assigned staff. All groups of children intermingled. Staff occassionally engaged with children. There was one incident where a child from the toddler room became injured and was cared for by a staff member assigned to the Pre-K Room. A toddler staff eventually approached the injured child and asked a few questions. During this time, another child became injured and two children were observed to be tackling each other to the ground. No staff were observed to respond to these two children. As the groups did not appear to be operating separately and/or receiving proper supervision from their assigned staff, this would be considered one group of children. The combination of groups in this scenario meant group size of eighteen children, including children under the age of 24 months. The max group size for mixed age groups, including children under the age of twenty-four months is eight. This is a serious violation which requires notification letters to be sent to all families enrolled at the program at the time of the incidents. Corrective Action: Immediately plan to; 1. reduce enrollment or 2. the number of children who are dropped off prior to 8:30 AM and who stay past 4:30 PM to ensure proper ratios are maintained, 3. adjust staffing schedules to account for the number of children who are anticipated each morning and afternoon, and/or 4. develop a system to have staff request that parents remain with their children until additional staff arrive, and to ensure the proper number of staff are present for the number of children at the end of the day to ensure the staff to child ratios are met at all times moving forward. Additionally, plan to ensure that each group of children either clearly operates separately when utilizing the same space, or that the group size and ratios are consistently in compliance based on the youngest child in the group. As this is a serious violation which impacts the health and safety of children, a program improvement plan has been assigned. In the Program Improvement Plan, include details of: 1. How staffing schedules will be kept up-to-date in a manner which shows the exact times each staff member is with each group of children, 2. A system for staff to reach out for assistance immediately in the event of being over ratio, 3. A plan to respond immediately to remedy the issue, 4. A policy for expectations of staff to require parents to stay with their children once the staff: child ratio and/or group size has been reached the maximum allowed and until adequate staffing arrives to maintain proper staff to child ratios, 5. A system to handle times when staff are out unexpectedly and no other staff are available for some or all of the day, 6. How staffing schedules will be adjusted as needed to account for proper ratios at all times. 7. How groups will operate separately from other groups when sharing the same space or how a schedule will be made to ensure that groups are not sharing the same spaces moving forward. 8. How staff will be made aware of these requirements and/or schedules moving forward.”

Correction date in the state record: Dec 4, 2025

Regulation 6.2.7.3: Staff shall use positive methods of guidance and behavior management that encourage self-control, self-direction, self-esteem, and cooperation.

“Staff statements reflect that staff voices from the toddler room can frequently be heard in the infant and transition rooms. Staff B, E and F confirmed hearing staff voices rise to a level that made it possible to hear a frustrated tone and on occasion the exact words being used by staff in the toddler room from the infant and transition rooms. When the staff were able to hear what the toddler staff was saying, it has been things like, "Just stop that!" or "Sit down!" Staff B, who works in the transition room confirmed that the tone and volume described by other staff was accurate and that Staff C, who works in the toddler room, was the voice being heard. The director sent a revised policy for positive guidance and behavior management to the Division on 06/19/2025. The policy was approved. The Director stated that the policy has been reviewed with all staff. This visit occured after said policies were implemented. This is a repeat violation which was cited on 01/11/2018 and 05/09/2025. Corrective Action: Immediately plan to use positive methods of guidance and behavior management that encourage self-control, self-direction, self-esteem, and cooperation. Develop a system which ensures the toddler staff have regular and frequent oversight from leadership, receive feedback and suggestions based on those observations, and that documenation of those observations and feedback meetings are maintained onsite until such a time when it is assessed that all staff in the toddler room are using positive guidance and behavior management practices at all times.”

Correction date in the state record: Jul 17, 2025

Regulation 2.3.9.3: The licensee shall ensure that all staff 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.

“A review of staff BFIS credential accounts and staff files reflected that Staff A has not yet submitted to fingerprinting and/or has not yet received a final clearance letter baed on the fingerprint supported background check from the Division. Staff A holds a position title which allows them to be left alone with children. Staff A has been working with the program since 12/2024 and received notice of the need to be fingerprinted from the Division on 12/30/2024. This is a repeat violation which was cited on 01/11/2018, 11/20/2019, and 12/04/2024. Corrective Action: Immediately plan to have Staff A submit to fingerprinting at an approved fingerprinting station and deliver the letter from the Division to the individual who performs the fingerprinting process. Immediately ensure that Staff A is not left alone with a child or children until they receive a fingerprint supported final clearance letter from the Division.”

Correction date in the state record: Dec 4, 2025

Regulation 3.4.7.3: Within six (6) months of the initial date of employment; staff and auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations, and the program director 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 in sections 7.3 and 7.4 of these regulations shall be submitted to Northern Lights at CCV to be verified and maintained in BFIS.

“A review of staff BFIS credential accounts and staff files reflected that numerous documents for numerous staff had not been submitted to Norhern Lights at CCV to be added to staff BFIS accounts. These documents included staff qualification evidence and required training and certification documents. This is a repeat violation which was cited on 03/21/2022, 02/01/2024, 12/01/2024 and 01/23/2025. Corrective Action: Immediately submit all required documentation for all currently employed staff to Northern Lights at CCV with cover sheets and communicate to Licensor [name] when that has been completed. Develop a system which will track staff document submissions and uploads to BFIS. Include details of what system will be used, who will be responsible for maintaining the system, who will be responsible for informing staff of upcoming needs for professional development, recertifications, etcetera, and who will ensure documents are submitted within six months of any newly hired staff and then in a manner which ensures up-to-date credential accounts and that those documents are reflected in accounts as expected moving forward.”

Correction date in the state record: Dec 4, 2025

Regulation 6.2.7.3: Staff shall use positive methods of guidance and behavior management that encourage self-control, self-direction, self-esteem, and cooperation.

“Staff reports reflect that Staff B has been witnessed to slap children on their bottoms, lift children off the floor by the backs of their shirts, and lift children off of the floor by one arm, in response to age-appropriate behaviors. Staff C reported that Staff B slapped at least three children on their bottoms more than five times over the past 60 days, having seen Staff B lift at least three children off of the floor by the backs of their shirts or by their arms many times over the past 60 days. Staff D reported having seen Staff B lift a child off the floor by one arm on at least two occasions. It was reported that the children seemed surprised, then lay on the floor crying after these incidents. The Director and staff report that Staff B is no longer working for the program. Corrective Action: As discussed, immediately plan to review positive guidance and behavior management techniques with all staff. Develop a plan which will ensure ongoing positive guidance and behavior management from every staff member at all times. Include in the plan: 1. Program policies regarding positive guidance and behavior management policies, 2. How these policies have been strengthened and/or shared with all staff, 3. Signed documentation from each staff attesting to have read and understood the positive guidance and behavior management policies, 4. A plan for all staff to complete at least a two hour training on positive guidance and behavior management for young children, including the name and date of the training, 5. A plan for leadership to conduct regular and ongoing observations of all classrooms and share feedback about those observations to pertinent staff, 6. How staff will continue to receive training on positive behavior management from leadership, and 7. How the documentation of said observations and feedback will be stored and readily available for review moving forward.,”

Correction date in the state record: Jun 16, 2025

Regulation 3.2.4: Missing child: When it is determined that a child attending the CBCCPP is missing from the program, the licensee or staff must immediately notify the police, the child's parents and the Division. A written report shall be made to the Division within twenty-four (24) hours.

“Staff D reported to the Director that Child X had gone missing from the playground on 04/25/2025 for an undetermined amount of time. The Director confirmed that she was made aware of the incident and did not make a report about this incident to the Division. Corrective Action: As discussed, immediately update program policies to include information about required reports to the Division and the staff and director responsibilities to ensure required reports are made moving forward.”

Correction date in the state record: Jun 6, 2025

Regulation 6.2.6.1: Staff shall be able to hear all children of pre-kindergarten age and younger at all times, shall be able to see the children with a quick glance, and shall be able to physically respond immediately.

“Staff A and the Director confirmed that one year old Child X, had escaped the playground area without the knowledge of the supervising staff for an unknown amount of time on 04/25/2025. Staff reports reflect that Child X's location was unknown to staff for a minimum of one and a maximum of ten minutes and that Child X was found behind the building in an unfenced area including a small pool of water, and direct access to a wooded area and a parking lot approximately 25 yards away. Staff report that Child X is known to run from or hide from the group and did not appear upset when located. This is a serious violation. Corrective Action: As discussed, immediately plan to speak with all staff members regarding proper and safe supervision of children. Develop a plan which will ensure staff are properly supervising every child moving forward. Include in the plan: 1. Program policies around supervision of children, including headcounts, proper safety procedures for transitions into and out of the classroom, playground, etcetera, 2. how these policies have been strengthened and/or shared with all staff, 3. a signed statement from each staff member confirming having read and understood supervision policies, 4. How regular and ongoing observations of classroom transition times will be conducted and feedback will be shared with pertinent staff by leadership, 5. where observations and feedback notes will be stored and ready for review moving forward.”

Correction date in the state record: Jun 6, 2025

Regulation 3.3.2: The licensee, staff, auxiliary staff, and partner staff working with children are mandated reporters of child abuse and neglect pursuant to 33 V.S.A. S4913 and are required to report to the Child Abuse Hotline when they reasonably suspect abuse or neglect of a child. This report must be made within twenty-four (24) hours of the time information regarding the suspected abuse or neglect was first received or observed.

“During interviews with the Division, Staff C reported having witnessed Staff B slap children on their bottoms. Staff C reported that Staff B slapped at least three children on the bottom more than five times over the past 60 days, having seen Staff B lift at least three children off of the floor by the backs of their shirts or by their arms many times over the past 60 days. Staff D reported having seen Staff B lift a child off the floor by one arm on at least two occasions. It was reported that the children seemed surprised, then lay on the floor crying after these incidents. Staff D stated that they had reported the incidents to the Director. Staff Cand D reported that they had not made mandated reports after witnessing these events. The Director stated that she had been made aware of at least one of these incidents and had decided not to make a report. Corrective Action: As discussed, immediately update the program's mandated reporter policies to reflect proper reporting expectations, which do not include the requirement to inform anyone aside from the Child Abuse Hotline and to inform staff of these changes and requirements. Develop a plan which will ensure all staff have a strong knowledge of the mandated reporting process. Include in the plan: 1. Program policies regarding mandated reporting, 2. How these policies have been strengthened, corrected and shared with staff, 3. the date and time that each staff member will take or retake the approved mandated reporter training, Protecting Vermont's Children: Reporting Abuse and Neglect, 4. the requirement for each staff to take the training and put their understaanding of the training in writing with their signature and date, 4. How leadership will provide clear expectations of the mandated reporter requirements, clarifying that the only requirement is that the report be made to the Child Abuse Hotline within 24 hours moving forward.”

Correction date in the state record: Jun 6, 2025

Regulation 3.3.5: The licensee, staff, and auxiliary staff shall be trained in prevention, identification and mandatory reporting of child abuse and neglect.

“During the 12/4/24 compliance visit documentation was requested to confirm completion of this training by required staff. Documentation was not provided prior to the submission of that report, therefore the program was advised this would be assessed at a follow up focus compliance visit. As of 1/23/25 five (5) staff required to have completed this training have not provided documentation to confirm completion. Corrective Action: Ensure the five (5) staff who have not completed Protecting Vermont's Children: Reporting Abuse & Neglect training do so by 2/7/25. In the corrective action email provide confirmation of completion by attaching the training certificates.”

Correction date in the state record: Jun 6, 2025

Regulation 7.1.3: The licensee, in consultation with the program director, shall establish written program policies and procedures and provide these to staff and to auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations during an orientation training session approved by the Division prior to being left alone with children. Trainees under eighteen (18) years of age and other staff not left alone with children shall complete the orientation training within at least one (1) month of their first date of working with children. Complete written information and the orientation training session shall include: Basic knowledge of child growth and development; Routine and emergency health protection of children including health related exclusions; Safety and sanitation requirements including handling and storage of hazardous materials and disposal of bio contaminants; Positive behavior management; Supervision of children; Child accident and injury procedures including building and physical premises safety; Safe sleep practices; Administration of medication requirements; Emergency and evacuation requirements; Nutrition and food safety including prevention of and response to emergencies due to food and allergic reactions; Recordkeeping; Transportation and child passenger safety; Release of children; Respectful engagement of families; Preventing, recognizing, and reporting child abuse and neglect; including information about the signs and symptoms of sexual abuse, sexual violence, grooming processes, recognizing the dangers of child sexual abuse, and other predatory behaviors of sex offenders; Recognition of and response to the symptoms of common childhood illnesses; Preventing the spread of infectious disease; Providing developmentally appropriate activities and experiences for children; Inclusion of children with special needs; Guidelines for volunteers, partner staff, auxiliary staff, and business managers; Responsibility to comply with current applicable licensing regulations; Staffing requirements to include opening and closing; and Ensuring children have extra clothes and diapers available.

“A violation was cited to this rule on 12/4/24 and corrective action was required by 1/10/25. As of 1/23/25 four (4) staff required to have completed this training have not provided documentation to confirm completion. Corrective Action: Ensure the four (4) staff identified as not having completed Orientation do so by 2/14/25. In the corrective action email, attach the documentation for all four (4) staff to confirm completion.”

Correction date in the state record: Feb 5, 2025

Regulation 7.1.2.2: Staff who are counted in the staff/child ratios and auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations shall obtain training in pediatric first aid and in infant and child CPR within three (3) months of beginning work in the CBCCPP and remain currently certified.

“A violation was cited to this rule on 12/4/25 and corrective action was required by 1/10/25. As of 1/23/25 four (4) staff have not provided documentation of completing CPR and First Aid. Corrective Action: Ensure all four (4) staff have obtained CPR and First Aid certification by 2/7/25. In the corrective action email, attach the certifications to confirm completion of this required training.”

Correction date in the state record: Feb 7, 2025

Regulation 6.2.1.4: Staff who are qualified as defined in the rules in section 7.3 of these regulations, meet professional development requirements as defined in the rules in section 7.4 of these regulations, and are physically present and working with children may be counted in staff/child ratios.

“During the 12/4/24 compliance visit documentation was requested to confirm staff qualifications. Documentation was not provided prior to the submission of that report, therefore the program was advised this would be assessed at a follow up focus compliance visit. As of 1/23/25 documentation has not been provided to confirm two (2) staff identified as Trainees who have been employed over twelve (12) months, and one (1) staff documentation has not been provided to confirm they meet Teacher qualifications. Corrective Action: By 2/14/25 ensure education documents are submitted to Northern Lights at CCV and that Supervisor Sheldrick-Humphries is cc'd in those submissions. If the identified staff do not meet qualifications for the position they serve submit a plan that 1) identifies what each staff person will do to obtain qualifications to include meeting with a Resource Advisor thorugh Northern Lights at CCV and providing that plan to Supervisor Sheldrick-Humphries, and 2) identify how each of the staff will be used in the program until qualifications are met.”

Correction date in the state record: May 22, 2025

Regulation 3.4.7.3: Within six (6) months of the initial date of employment; staff and auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations, and the program director 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 in sections 7.3 and 7.4 of these regulations shall be submitted to Northern Lights at CCV to be verified and maintained in BFIS.

“A violation was cited to this rule on 12/4/24 with corrective action required by 1/20/25. Though some documents have been submitted for BFIS accounts, as of 1/23/25 required documentation to be reflected in staff BFIS Quality and Credential accounts is not reflected, nor has the program cc'd Supervisor Sheldrick-Humphries in the identified missing components when submitting to Northern Lights at CCV. Corrective Action: Schedule time to review staff BFIS Quality and Credential accounts to confirm what is outstanding and needs to be reflected. Connect with Northern Lights at CCV to inquire about their assistance allowing enough time for them to provide guidance prior to the due date of 2/14/25.”

Correction date in the state record: Feb 12, 2025

Regulation 5.1.2: General Health Examinations: Within forty-five (45) days of enrollment, the licensee 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 violation was cited to this rule on 12/4/24 requiring corrective action by 1/10/25. As of 1/23/25 the program has not confirmed that all children's files have been reviewed and all contain a health exam as required by this rule. Corrective Action: Schedule time to review all children's files to ensure each contains a required health exam. For those who do not have a required health exam please work with families to obtain this by the required due date of 2/14/25. In the corrective action email identify which children did not have an exam and the date that was obtained by the program.”

Correction date in the state record: Feb 7, 2025

Regulation 7.2.2: The licensee shall ensure that all new staff and auxiliary staff, prior to working with children in the CBCCPP; and any new individual designated as the representative of the licensee shall submit a Records Check Authorization form to the Division and shall submit to fingerprinting at a location designated by the Division after having received the Fingerprinting Authorization Certificate by the Division.

“A violation was cited to this rule on 12/4/24 requiring corrective action to be complete by 1/20/25. As of 1/23/25 two (2) staff identified/observed in the program have not submitted a record check to the Division, and Staff A has not provided confirmation of completing fingerprinting or being scheduled for this. Corrective Action: Ensure the two (2) staff who have not submitted a record check to the Division no longer work in the program until a record check has been submitted to the Division, and ensure that Staff A does not work in the program until scheduled to complete fingerprinting. In the corrective action email either 1) confirm the staff not reflected on the associated parties list are not employed, or 2) cc Supervisor Sheldrick-Humphries in the submission of their record check authorization forms to the Division, and 3) provide confirmation of Staff A's fingeprinting appointment and receipt to follow once completed.”

Correction date in the state record: Feb 12, 2025

Regulation 5.1.2: General Health Examinations: Within forty-five (45) days of enrollment, the licensee 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.

“Three (3) of the six (6) files reviewed were missing the general health exam. Corrective Action: Ensure a review is done of all children's files to confirm each one (1) contains a general health exam. For those missing the exam be sure one (1) is obtained by the due date. Inform Supervisor Sheldrick-Humphries of the system the program will use to maintain compliance with this rule.”

Correction date in the state record: Feb 7, 2025

Regulation 2.3.9.3: The licensee shall ensure that all staff 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.

“Staff A record check and fingerprinting expired on 7/26/24. As of 12/23/24 an updated record check has not been submitted to the Division nor has Staff A updated their fingerprinting. The program was notified in writing on 8/19/24 that Staff A was due for an updated record check and fingerprinting. This is a repeat violation. Corrective Action: Ensure Staff A submits a record check by 12/27/24, and submits to fingerprinting by 1/5/24. Inform Supervisor Sheldrick-Humphries of the system to track when staff are required to submit an updated record check to the Division and to complete fingerprinting.”

Correction date in the state record: Dec 16, 2024

Regulation 7.1.2.2: Staff who are counted in the staff/child ratios and auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations shall obtain training in pediatric first aid and in infant and child CPR within three (3) months of beginning work in the CBCCPP and remain currently certified.

“At the time of the visit four (4) staff were not current in CPR and First Aid certification. Since the visit two (2) of the staff completed the training, and two (2) of the staff were removed from the associated parties list/employed staff. Corrective Action: Ensure all staff employed three (3) months or longer have current CPR and First Aid certification. Inform Supervisor Sheldrick-Humphries of the system the program has in place to maintain compliance with this rule.”

Correction date in the state record: Feb 7, 2025

Regulation 3.4.1: The licensee shall keep all required records, schedules, materials, and equipment used to operate and maintain the CBCCPP in good order and in locations appropriate for day to day access.

“Several documents not observed on site 12/4/24 were requested post visit. As of 12/23/24 several documents were not received prior to submission of this report. Corrective Action: A virtual focus compliance visit will be conducted post corrective action due date to confirm all trainings, and education documents are reflected in staff BFIS quality and credential accounts to confirm compliance with rules cited in non-compliance as well as rules 3.3.5, 7.7.4, 6.2.4.3, and 6.2.1.4.”

Correction date in the state record: Feb 12, 2025

Regulation 3.4.7.3: Within six (6) months of the initial date of employment; staff and auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations, and the program director 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 in sections 7.3 and 7.4 of these regulations shall be submitted to Northern Lights at CCV to be verified and maintained in BFIS.

“Prior to the licensing visit a review of the programs associated parties list was done to ensure staff qualifications and professional development was reflected in staff accounts. Due to several documents not in staff accounts, on site files and post visit requests were made to confirm qualifications and completion of professional development despite not being able to fully complete the assessment. This is a repeat violation. Corrective Action: Ensure all staff have education and all professional development certificates submitted to Northern Lights at CCV. A virtual focused compliance visit will be conducted post corrective action due date in collaboration with Northern Lights at CCV to confirm missing documentation has been received by the program. Further non-compliance will result in additional violations, to include a full assesment of staff qualifications, completion of trainings, annual professional development and CPR/First Aid.”

Correction date in the state record: Feb 12, 2025

Regulation 7.2.2: The licensee shall ensure that all new staff and auxiliary staff, prior to working with children in the CBCCPP; and any new individual designated as the representative of the licensee shall submit a Records Check Authorization form to the Division and shall submit to fingerprinting at a location designated by the Division after having received the Fingerprinting Authorization Certificate by the Division.

“Staff J was working on site with children during the licensing visit, however Staff J was not reflected on the associated parties list. As of 12/23/24 Staff J is not reflected still which indicates a record check was not submitted to the Division for this staff person at this program. Staff B, Staff D, and Staff G have not completed the background clearance process. At the time of the licensing visit Staff C and Staff F had not completed the background clearance process, but have since been removed from the programs associated parties list/employed staff. Corrective Action: Ensure all staff who work at the program are reflected on the associated parties list; for those who are not reflected ensure a record check authorization form is submitted to the Division. For those staff who are required to complete out of state record check forms and/or submit to fingerprinting do so by the due date. Ensure as record checks, to include out of state record check forms are submitted to the Division Supervisor Sheldrick-Humphries is cc'd in those submissions. Ensure staff who submit to fingerprinting obtain a receipt documenting the location and date fingerprints were obtained; provide a copy of those receipts to Supervisor Sheldrick-Humphries. Lastly, inform Supervisor Sheldrick-Humphries of the system the program has in place to ensure compliance to this rule.”

Correction date in the state record: Feb 12, 2025

Regulation 7.1.3: The licensee, in consultation with the program director, shall establish written program policies and procedures and provide these to staff and to auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations during an orientation training session approved by the Division prior to being left alone with children. Trainees under eighteen (18) years of age and other staff not left alone with children shall complete the orientation training within at least one (1) month of their first date of working with children. Complete written information and the orientation training session shall include: Basic knowledge of child growth and development; Routine and emergency health protection of children including health related exclusions; Safety and sanitation requirements including handling and storage of hazardous materials and disposal of bio contaminants; Positive behavior management; Supervision of children; Child accident and injury procedures including building and physical premises safety; Safe sleep practices; Administration of medication requirements; Emergency and evacuation requirements; Nutrition and food safety including prevention of and response to emergencies due to food and allergic reactions; Recordkeeping; Transportation and child passenger safety; Release of children; Respectful engagement of families; Preventing, recognizing, and reporting child abuse and neglect; including information about the signs and symptoms of sexual abuse, sexual violence, grooming processes, recognizing the dangers of child sexual abuse, and other predatory behaviors of sex offenders; Recognition of and response to the symptoms of common childhood illnesses; Preventing the spread of infectious disease; Providing developmentally appropriate activities and experiences for children; Inclusion of children with special needs; Guidelines for volunteers, partner staff, auxiliary staff, and business managers; Responsibility to comply with current applicable licensing regulations; Staffing requirements to include opening and closing; and Ensuring children have extra clothes and diapers available.

“At the time of the licensing visit, six (6) staff had not completed Vermont Orientation. Corrective Action: Ensure all staff have completed Vermont Orientation and documentation is submitted to Northern Lights at CCV. Please cc Supervisor Sheldrick-Humphries in those submissions. Inform Supervior Sheldrick-Humphries how the program will ensure all staff required to complete this training do so to maintain compliance with this rule.”

Correction date in the state record: Feb 5, 2025

Regulation 7.2.2: The licensee shall ensure that all new staff and auxiliary staff, prior to working with children in the CBCCPP; and any new individual designated as the representative of the licensee shall submit a Records Check Authorization form to the Division and shall submit to fingerprinting at a location designated by the Division after having received the Fingerprinting Authorization Certificate by the Division.

“Review of BFIS account and follow up with the Division's Business Technician's revealed Staff A, Staff B, Staff C, and Staff D have not yet completed required Out of State paperwork to complete the fingerprinting process. Staff A was notified on 1/9/23, Staff B on 12/29/23, Staff C on 3/25/22, and Staff D on 11/28/23 of this requirement. It also revealed Staff E has not yet had their fingerprints completed. Staff E was notified of this requirement on 12/29/23. Program was advised of these outstanding fingerprints on 5/10/24 and was informed on 6/17/24 of how to obtain additional copies of missing Out of State paperwork. Corrective Action: By the corrective action due date given have all missing Out of State paperwork submitted to the Division. Ensure Staff E has scheduled an appointment for fingerprinting and advise of the appointment. Create a system for tracking Records Check Authorizations and fingerprinting to ensure they are completed in accordance with this regulation.”

Correction date in the state record: Jan 24, 2025

Regulation 7.2.2: The licensee shall ensure that all new staff and auxiliary staff, prior to working with children in the CBCCPP; and any new individual designated as the representative of the licensee shall submit a Records Check Authorization form to the Division and shall submit to fingerprinting at a location designated by the Division after having received the Fingerprinting Authorization Certificate by the Division.

“Staff A was observed on 1/24/24 as being present in the classroom working with children. It was determined based on review of BFIS, staff file on site and follow up with Program Director that as of the date of this Licensor's 1/24/24 visit Staff A had not yet had fingerprinting done. A letter advising Staff A of fingerprint requirement was printed and sent to Staff A on 1/9/23. Corrective Action: Ensure Staff A is fingerprinted by the corrective action date given.”

Correction date in the state record: May 10, 2024

Regulation 7.4.4: All staff shall complete fifteen (15) clock hours of annual professional development activities as required in the rule 7.4.2 of these regulations. Substitutes filling a staff position for less than thirty (30) consecutive days within a 365 day period shall be exempt.

“Review of Staff A's BIFS Quality and Credential account as well as review of staff files on site and email follow up correspondance with Program Director determined Staff A did not complete annual professional development hours are required by this rule. Corrective Action: Develop a plan for Staff A to complete required fifteen (15) hours of professional development that were missed for the past year in addition to the fifteen (15) professional development hours needed for this year. Create a system for tracking professional development hours for all staff to ensure hours are completed as required.”

Correction date in the state record: Mar 15, 2024

Regulation 3.4.7.3: Within six (6) months of the initial date of employment; staff and auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations, and the program director 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 in sections 7.3 and 7.4 of these regulations shall be submitted to Northern Lights at CCV to be verified and maintained in BFIS.

“Review of staff BFIS Quality and Credential acounts as well as staff files on site detmerined four (4) staff accounts in BFIS were not up to date to include all required documents, such as professional development completed, orientation certificates, and mandated reporter training certificates, found in on site files. All four (4) staff have been working at the program for longer than six (6) months. Corrective Action: Review staff BFIS accounts and compare them documentation in on site files. Submit any documents in on site files not currently reflected in BFIS to Northern Lights at CCV using the cover sheet. Create a system for submitting documentation to Northern Lights as CCV and tracking its submission to ensure it is completed.”

Correction date in the state record: Mar 15, 2024

Regulation 7.1.2.2: Staff who are counted in the staff/child ratios and auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations shall obtain training in pediatric first aid and in infant and child CPR within three (3) months of beginning work in the CBCCPP and remain currently certified.

“Review of BFIS Credential Account for Staff B as well as on site file review and post site visit follow up with Program Director determined CPR/First Aid certification for Staff B had lapsed. Corrective Action: Ensure Staff B completes both CPR and First Aid training by corrective action due date provided. Develop a system for tracking staff CPR/First Aid certification expiration dates to ensure trainings are renewed and there is no lapse in certification.”

Correction date in the state record: Feb 12, 2024

Regulation 5.10.4.5.6: Exterior stairs, walks, ramps, and porches shall be cleared of ice and snow or other environmental hazards that may block exits.

“Set of four (4) stairs leading from the Toddler classroom directly outside were found to have piles of a couple inches of snow on each step. The snow also appeared to have a layer of ice on top. It was confirmed through conversation with Staff A that this exit and these stairs are used as a secondary exit in the event of an emergency. Corrective Action: Immediately clean steps outside the Toddler classroom. Create a system to ensure each exit is cleared and checked for clearance after adverse weather.”

Correction date in the state record: Feb 8, 2023

Regulation 7.1.2.2: Staff who are counted in the staff/child ratios and auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations shall obtain training in pediatric first aid and in infant and child CPR within three (3) months of beginning work in the CBCCPP and remain currently certified.

“Six staff members had CPR/First Aid certifications that expired in September of 2021. Those six staff members completed CPR/First Aid training in March, after this compliance visit. Corrective Action: Ensure that staff CPR/First Aid certifications are valid. If the program is unable to locate trainings they should contact their Northern Lights resource advisor for support.”

Correction date in the state record: Apr 21, 2022

Regulation 3.4.7.3: Within six (6) months of the initial date of employment; staff and auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations, and the program director 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 in sections 7.3 and 7.4 of these regulations shall be submitted to Northern Lights at CCV to be verified and maintained in BFIS.

“Review of staff quality and credential accounts revealed that seven staff members are missing required documentation. This documentation includes valid CPR/FA certificates, educational transcripts, completion of Vermont Orientation and Mandated Reporter trainings. Corrective Action: By 04/21/2022 please submit the missing documentation that was discussed during the 03/31/2022 meeting to Northern Lights @CCV. Ensure that within 6 months of hire all staff have complete and up to date BFIS quality and credential account.”

Correction date in the state record: Apr 21, 2022