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: Oct. 28, 2019 and Oct. 31, 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 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 announced inspection on October 31, 2019 at the administrative office to review five staff records from 9:00am to approximately 11:40am. The licensing inspector conducted an unannounced renewal inspection on October 28, 2019 from 4:15pm to approximately 5:55pm. There were a total of 19 children present at the center with 2 staff supervising the children. During the inspection, children were observed completing homework, playing in the cafeteria, eating an afternoon snack and having a dancing class. Later, the children were observed in the playground interacting with their peers and the staff. The afternoon snack consisted of mini wheat bagels, cream cheese, dried fruit, and water. All areas of the center including the cafeteria, gym, hallways, bathrooms, and playground were inspected. The center was equipped with toys and supplies and items were available to the children. The following information was reviewed: emergency supplies, injury reports, fire and shelter-in-place drills, daily attendance, menu, required postings and parent agreements. Medication is administered, and medication and medication authorization forms were reviewed. During the inspection, five children?s records were reviewed. Staff information required to be present at the center for staff members were reviewed. If you have any questions about this inspection, please contact the licensing inspector, Florence Martus, at (804) 662-9772.

Violations:

Standard #:	22VAC40-185-160-A
Description:	Based on a review of five staff records on 10/31/2019, the center did not ensure three staff submitted documentation of a negative tuberculosis (TB) screening within the required time frame. Evidence: 1) The record for Staff #2, hired on 10/07/2019, did not contain documentation of a negative tuberculosis screening. 2) The record for Staff #3, hired on 08/30/2019, did not contain documentation of a negative tuberculosis screening. 3) The record for Staff #4, hired on 05/31/2019, did not contain documentation of a negative tuberculosis screening. Each staff member and individual from an independent contractor shall submit 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 were contacted on 10/31/2019 to complete TB tests, they were given until 11/21/2019 to turn them in. In the future, staff will have 21 days to complete or they will be unable to work."
Standard #:	22VAC40-185-60-A
Description:	Based on a review of five children's records on 10/28/2019, the center did not ensure two children's records contained the required information. Evidence: 1) The record for Child #1, enrolled on 08/13/2018, did not contain the address for the two emergency contacts listed. 2) The record for Child #2, enrolled on 08/13/2018, did not contain the address for the two emergency contacts listed. 3) The record for Child #2 did not contain written agreements between the parent and the center as required by 22 VAC40-185-90. 4) The record for Child #1, Child #2, Child #3, Child #4, and Child #5 did not contain each child's first date of attendance.
Plan of Correction:	Per the Center: "Parents will be contacted on file completion and director will document the date of enrollment on each child's file."
Standard #:	22VAC40-185-70-A
Description:	Based on a review of documentation and observation, the center did not ensure four staff records contained the required information. Evidence: 1) The record for Staff #1, hired on 10/24/2019, did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment. 2) The record for Staff #2, hired on 10/07/2019, did not contain documentation of a second reference. 3) The record for Staff #3, hired on 08/30/2019, did not contain documentation of a second reference. 4) The record for Staff #4, hired on 05/31/2019, did not contain documentation of a second reference. 5) On 10/28/2019, the licensing inspector observed Staff #3 and Staff #4 at the center. A review of documentation revealed that the center did not maintain information for Staff #3 and Staff #4, to be kept at the center, about any health problems which may interfere with fulfilling their job responsibilities.
Plan of Correction:	Per the Center: "Director will contact references to complete staff files by 11/8/2019. In the future, references will be completed prior to hire. Director will update emergency contact form to include question about the employees physical ability to work by 11/14/2019"
Standard #:	22VAC40-185-210-A
Description:	Based on observation, record review and interview, the center did not ensure one staff member that is a program leader met program leader qualifications. Evidence: 1) During the inspection on 10/28/2019, Staff #3 was observed supervising children on her own. 2) During interview on 10/31/2019, a member of management reported Staff #3 is a program leader. 3) The record for Staff #3, hired on 08/30/2019, did not have documentation that she was qualified as a program leader.
Plan of Correction:	Per the Center: "Director will request a copy of education and diploma for Staff #3 on 10/31/2019. In the future, all staff will be required to show proof of qualifications."
Standard #:	22VAC40-185-240-D-5
Description:	Based on a review of records, observation, and interview, the center did not ensure there shall always be at least one staff member on duty who has obtained within the last three years instruction in performing the daily health observation of children. Evidence: 1) On 10/28/2019, the licensing inspector observed Staff #3 and Staff #4 were the two staff on duty during the inspection. 2) The record for Staff #3, hired on 08/30/2019, does not contain documentation that the staff has current daily health observation training. 3) The record for Staff #4, hired on 05/31/2019, does not contain documentation that the staff has current daily health observation training. 4) During interview on 10/31/2019, a member of management reported Staff #3 and Staff #4 do not have current daily health observation training.
Plan of Correction:	Per the Center: "Director will contact the trainer on 10/31/2019 to schedule a training for SACC staff and it will be corrected when the trainer is available."
Standard #:	22VAC40-185-550-D
Description:	Based on a review of documentation and interview on 10/28/2019, the center did not implement a monthly practice evacuation drill for the most likely to occur scenarios. Evidence: 1) The licensing inspector reviewed the center's emergency practice drills for 2018 and 2019 and observed there were no evacuation drills documented for March 2019, April 2019, and May 2019. 2) During interview, staff reported they were not sure the drills prior to August 2019 were conducted.
Plan of Correction:	Per the Center: "Moving forward, monthly evacuation drills will be conducted and documented. The director will monitor the drills to make sure they are completed."
Standard #:	22VAC40-191-60-B
Description:	Based on a review of five staff records on 10/31/2019, the center did not ensure that two staff had a completed sworn statement or affirmation prior to hire. Evidence: 1) The sworn statement in the file for Staff #1, hired on 10/24/2019, was dated 10/31/2019. 2) The sworn statement in the file for Staff #4, hired on 05/31/2019, was dated 10/25/2019. An employee or volunteer of a licensed or registered child welfare agency or of a family day home approved by a family day system must not be employed or provide volunteer service until the agency or home has the person's completed sworn statement or affirmation.
Plan of Correction:	Per the Center: "Already corrected. In the future, staff will complete the sworn statement prior to working."
Standard #:	22VAC40-191-60-C-2
Description:	Based on a review of documentation, observation, and interview, the center did not discontinue employment of two employees when the central registry findings for two of five staff were not obtained within 30 days of employment. Evidence: 1) The record for Staff #3, hired on 08/30/2019, did not contain the results of a central registry finding. 2) The record of Staff #4, hired on 05/31/2019, did not contain the results of a central registry finding. 3) Staff #3 and Staff #4 were still employed on the date of inspection on 10/28/2019. 4) During interview on 10/31/2019, a member of management reported the central registry findings for Staff #3 and Staff #4 could not be located.
Plan of Correction:	Per the Center: "Director contacted Staff #4 and requested completion of the missing background check by 11/08/2019. Director will contact the central registry office to follow up on the results for Staff #3."
Standard #:	63.2(17)-1720.1-B-2
Description:	Based on a review of five staff records and interview on 10/31/2019, the center did not 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 #4, hired on 05/31/2019, did not contain the results of a fingerprint based background check. 2) During interview, a member of management reported the determination letter for Staff #4 could not be located.
Plan of Correction:	Per the Center: "Director contacted Staff #4 on 10/31/2019 to follow up on fingerprints and requested they are completed by 11/08/2019. In the future, staff will not be hired prior to the receipt of fingerprint results."