VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Caroline Family YMCA
17422 Library Boulevard
Ruther glen, VA 22546
(804) 448-9622

Current Inspector: Florence Martus (804) 389-0157

Inspection Date: Oct. 16, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-185 ADMINISTRATION. 22VAC40-185 STAFF QUALIFICATIONS AND TRAINING. 22VAC40-185 PHYSICAL PLANT. 22VAC40-185 STAFFING AND SUPERVISION. 22VAC40-185 PROGRAMS. 22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES. 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 monitoring inspection on Wednesday, October 16, 2019 to determine the center?s compliance with licensing standards. The inspection was initiated at 10:00am and concluded at approximately 1:00pm. The center?s director was present and assisted the inspector throughout the inspection. The census for today?s inspection consisted of seven children in the direct care of two staff members. Upon the inspector?s arrival, the children were observed at two separate tables playing with puzzles and letters. The children later transitioned into an art activity related to the theme of the week. This week?s theme is the letter G and the color brown. The children were also observed taking bathroom breaks, washing hands, eating their morning snack, and later separated into two different groups. The younger children stayed in the classroom, while the older group completed a swimming activity. Staff were observed having positive interactions with the children. The classroom is decorated with the children?s artwork and is equipped with age and stage appropriate materials. The required posting were observed. The first-aid kit and non-emergency supplies were inspected and found complete. Per the director, transportation is not provided at this time and there are no children on medications. The center has CPR, First Aid, Daily Health Observation, and MAT trained staff on site. Five children?s records and three staff records were reviewed today. 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 #:	22VAC40-185-130-A
Description:	Based on a review of five children's records and interview on 10/16/2019, the center did not have documentation that four children had received the immunizations required by the State Board of Health before the child can attend the center. Evidence: 1) The record for Child #1, enrolled on 08/12/2019, did not contain immunization documentation. 2) The record for Child #2, enrolled on 08/12/2019, did not contain immunization documentation. 3) The record for Child #3, enrolled on 08/12/2019, did not contain immunization documentation. 4) The record for Child #4, enrolled on 08/12/2019, did not contain immunization documentation. 5) During interview, a member of management reported the immunization documentation for Child #1, Child #2, Child #3, and Child #4 was obtained, but the documentation could not be located at the time of the inspection.
Plan of Correction:	Per the Center: "Documents were located and secured"
Standard #:	22VAC40-185-140-A
Description:	Based on a review of five children's records and interview on 10/16/2019, the center did not have documentation that five children had a physical examination by or under the direction of a physician before the child's attendance; or within one month after attendance. Evidence: 1) The record for Child #1, enrolled on 08/12/2019, did not contain a physical examination 2) The record for Child #2, enrolled on 08/12/2019, did not contain a physical examination. 3) The record for Child #3, enrolled on 08/12/2019, did not contain a physical examination. 4) The record for Child #4, enrolled on 08/12/2019, did not contain a physical examination. 5) The record for Child #5, enrolled on 08/12/2019, did not contain a physical examination. 6) During interview, a member of management reported the physical examinations for Child #1, Child #2, Child #3, Child #4, and Child #5 were obtained, but the documentation could not be located at the time of the inspection.
Plan of Correction:	Per the Center: "Documents were located and secured"
Standard #:	22VAC40-185-160-A
Description:	Based on a review of three staff records on 10/16/2019, the center did not ensure that two staff members shall submit documentation of a negative tuberculosis screening. Evidence: 1) The record for Staff #1, hired on 08/11/2019, did not contain documentation of a negative tuberculosis screening. 2) The record for Staff #2, hired on 03/22/2019, did not contain documentation of a negative tuberculosis screening. Documentation of the screening shall be submitted no later than 21 days after employment or volunteering and shall have been completed within 12 months prior to or 21 days after employing or volunteering.
Plan of Correction:	Per the Center: "Staff is completing a TB test"
Standard #:	22VAC40-185-60-A
Description:	Based on a review of five children's records and interview on 10/16/2019, the center did not ensure four children's records contained the required information. Evidence: 1) The record for Child #1, enrolled on 08/12/2019, did not contain written agreements between the parent and the center as required by 22 VAC40-185-90 or documentation of viewing proof of the child's identity and age. 2) The record for Child #2, enrolled on 08/12/2019, did not contain written agreements between the parent and the center as required by 22 VAC40-185-90 or documentation of viewing proof of the child's identity and age. 3) The record for Child #3, enrolled on 08/12/2019, did not contain written agreements between the parent and the center as required by 22 VAC40-185-90, documentation of viewing proof of the child's identity and age. 4) The record for Child #4, enrolled on 08/12/2019, did not contain the name and phone number of child's physician. 5) During interview, a member of management confirmed the written agreements and documentation of viewing proof of identify and age were not on file for Child #1, Child #2, or Child #3.
Plan of Correction:	Per the Center: "Documents were located and secured"
Standard #:	22VAC40-185-70-A
Description:	Based on a review of three staff records on 10/16/2019, the center did not ensure that two staff records contained the required information. Evidence: 1) The record for Staff #1, hired on 08/11/2019, did not contain the following information: address and telephone number of a person to be notified in an emergency which shall be kept at the center; documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering; or information, to be kept at the center, about any health problems which may interfere with fulfilling the job responsibilities. 2) The record for Staff #2, hired on 03/22/2019, did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering.
Plan of Correction:	Per the Center: "Staff are re-completing hire paperwork"
Standard #:	22VAC40-185-480-B
Description:	Based on a review of records and observation on 10/16/2019, the center did not maintain written permission from the parent of one child who participates in swimming or wading and a statement from the parent advising of the child's swimming skills before the child is allowed in water above the child's shoulder height. Evidence: 1) The record for Child #2, enrolled on 08/12/2019, did not have written permission from the parent or a statement advising of the child's swimming skills. 2) During the inspection, Child #2 was observed participating in a swimming activity.
Plan of Correction:	Per the Center: "Documentation was located and secured"
Standard #:	22VAC40-185-550-E
Description:	Based on a review of documentation and interview on 10/16/2019, the center did not maintain a record of the dates of all practice drills for one year. Evidence: 1) The licensing inspector reviewed the center's practice drill log. The last documented evacuation drill was listed as 01/24/2019. 2) During interview, a member of management reported monthly evacuation drills and two shelter-in-place drills have been practiced, but the documentation could not be located at the time of the inspection.
Plan of Correction:	Per the Center: "Emergency drills were obtained, and regular drills will be performed"
Standard #:	22VAC40-191-60-B
Description:	Based on a review of three staff records and interview on 10/16/2019, the center did not ensure that one staff had a completed sworn statement or affirmation prior to the beginning of employment. Evidence: 1) The record for Staff #1, hired on 08/11/2019,did not contain a sworn statement or affirmation. 2) During interview, a member of management reported Staff #1 completed a sworn statement, but it could not be located at the time of the inspection.
Plan of Correction:	Per the Center: "Staff are completing sworn statement again."
Standard #:	22VAC40-191-60-C-2
Description:	Based on a review of three staff records and interview on 10/16/2019, the center did not obtain a central registry clearance for two staff members within 30 days of employment. Evidence: 1) The record for Staff #1, hired on 08/11/2019, did not contain the results of a central registry finding. 2) The record for Staff #2, hired on 03/22/2019, did not contain the results of a central registry finding. 3) During interview, a member of management stated the central registry findings for Staff #1 and Staff #2 were obtained, but could not be located at the time of the inspection.
Plan of Correction:	Per the Center: "Staff are re-completing central registry findings"
Standard #:	63.2(17)-1720.1-B-2
Description:	Based on a review of three staff records and interview on 10/16/2019, the center did ensure that one staff obtained a fingerprint-based background check determination from the Office of Background Investigation prior to employment. Evidence: 1) The record for Staff #1, hired on 08/11/2019, did not contain the results of a fingerprint-based background check. 2) During interview, a member of management reported the fingerprint-based background check for Staff #1 was completed, but it could not be located at the time of the inspection.
Plan of Correction:	Per the Center: "Staff #1 is being re-fingerprinted"