VIRGINIA DEPARTMENT OF SOCIAL SERVICES

YMCA-SACC and Summer Camp at Lewis & Clark
18101 Clark & York Boulevard
Ruther glen, VA 22546
(804) 448-9622

Current Inspector: Florence Martus (804) 389-0157

Inspection Date: May 16, 2019 , May 24, 2019 and June 21, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-185 ADMINISTRATION. 22VAC40-185 STAFF QUALIFICATIONS AND TRAINING. 22VAC40-185 STAFFING AND SUPERVISION. 22VAC40-185 SPECIAL SERVICES. 22VAC40-191 Background Checks (22VAC40-191) 63.2(17) License & Registration Procedures

Technical Assistance:

n/a

Comments:

The licensing inspector conducted an unannounced complaint inspection in response to a complaint that was received by the department on 04/16/2019 regarding concerns of the center's staffing and supervision; special care provisions and emergencies; and special services. The investigation was initiated on 05/16/2019 and completed on 07/08/2019. On 05/16/2019, the inspector was on site on from 3:57pm to 4:50pm. Interviews with staff were completed, observations were made at the center, and documentation reviewed. On 05/24/2019, the inspector was on site conducting additional interviews and reviewing documentation from 1:50pm to 3:15pm. Additional interviews were conducted on 06/21/2019. The preponderance of the evidence gathered during the investigation supports the allegation, therefore the complaint is determined to be valid. See the violation notice for more details. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return it to me within 5 business days from the date of receipt. Please specify how the deficient practice will be or has been corrected. Your plan of correction should contain: 1) steps to correct the noncompliance with the standards, 2) measures to prevent the noncompliance from occurring again, and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). If you have any questions about this inspection, please contact the licensing inspector, Florence Martus, at (804) 662-9772.

Violations:

Standard #:	22VAC40-185-240-D-4
Complaint related:	Yes
Description:	Based on a review of documentation, observation, and interviews, the center did not ensure that for any child for whom emergency medications (such as but not limited to albuterol, glucagon, and epipen) have been prescribed shall always be in the care of a staff member or independent contractor who meets the requirements for medication administration training (MAT). Evidence: 1) During interview on 05/16/2019, Staff #2 reported that two children, who have emergency medications on site, were in attendance on 05/16/2019. The licensing inspector observed Staff #1 and Staff #2 were the only staff present at the center on 05/16/2019. 2) A review of training documentation at the facility indicated that neither Staff #1 or Staff #2 were MAT certified, and therefore could not administer the emergency medications. 3) During interview, Staff #4 reported there are no current staff at this site with current MAT certification.
Plan of Correction:	Per the Center: "MAT training has been conducted on June 10, 2019. Another MAT training will be scheduled for remaining staff in Aug 2019."
Standard #:	22VAC40-185-340-C
Complaint related:	Yes
Description:	Based on a review of documentation, observation, and interview, the center did not ensure that during the stated hours of operation, there always shall be on the premises and on field trips when one or more children are present, one staff member who meets the qualifications of a program leader or program director and an immediately available staff member, volunteer or other employee who is at least 16 years of age, with direct means for communication between the two of them. Evidence: During the inspection conducted on May 16, 2019, the licensing inspector was on site to investigate a complaint regarding staffing. During the inspection, staff were interviewed, observations were made and documentation was reviewed. The following was determined: 1) On May 16, 2019, the licensing inspector arrived at the facility at approximately 3:55pm. Staff #1 was observed parking the facility?s bus with a group of children at approximately 3:55pm. The licensing inspector entered the center at approximately 3:57pm. Staff #2 was observed alone in the cafeteria, supervising 14 children. The licensing inspector asked Staff #2 if any additional staff or volunteers were in the building. Staff #2 stated ?Yes, [Staff #1] just returned from the bus run.? At approximately 3:58pm, Staff #1 was observed entering the cafeteria with four children. There were no other staff present prior to Staff #1?s arrival at 3:58pm. The first group of children arrive at the center at approximately 3:45pm. It is estimated that Staff #2 was alone with more than one child present for approximately 13 minutes. 2) Staff interviewed reported that in the month of April 2019, on several occasions, Staff #3 was the only staff present at the center from approximately 3:30pm until approximately 4:00pm. The first group of children begins arriving at the center at 3:45pm. Staff interviewed reported that Staff #1 would arrive at the center after picking up all other enrolled children from area schools between 3:55pm and 4:00pm. There must always be at least one staff member who meets the qualifications of a program leader or program director and an immediately available staff member, volunteer or other employee who is at least 16 years of age, when one or more children are present.
Plan of Correction:	Per the Center: "Appropriately trained staff have been engaged for all programs. Staff #1 has been terminated and is no longer employed by the YMCA. All staff have been briefed on proper ratios and been counseled on arriving for work in a timely manner. Staff understand that failure to adhere to rules may mean discipline and possible termination."
Standard #:	22VAC40-185-340-D
Complaint related:	Yes
Description:	Based on a review of documentation and interview, the center did not ensure that in each grouping of children at least one staff member who meets the qualifications of a program leader or program director shall be regularly present. Evidence: 1) Staff interviewed reported that in the month of April 2019, on several occasions, Staff #3 was the only staff present at the center from approximately 3:30pm until approximately 4:00pm. The first group of children begins arriving at the center at 3:45pm. Staff interviewed reported that Staff #1 would arrive at the center after picking up all other enrolled children from area schools between 3:55pm and 4:00pm. A review of Staff #3?s record revealed that Staff #3 was not a qualified program leader.
Plan of Correction:	Per the Center: "Staff #1 has been terminated from employment. Additional staff with appropriate levels of training have been hired."
Standard #:	22VAC40-185-580-C
Complaint related:	Yes
Description:	Based on interview on 05/16/2019, the center did not ensure to have the required documentation during transportation of children. Evidence: 1) During interview, Staff #2 reported that three school age children were transported from the center to school on 04/08/2019, but a list of the names of the children being transported was not in the vehicle used for transportation.
Plan of Correction:	Per the Center: "Staff has been trained on proper procedures for transporting children."