VIRGINIA DEPARTMENT OF SOCIAL SERVICES

YMCA SACC at Lee Hill Elementary School
3600 Lee Hill School Drive
Fredericksburg, VA 22408
(540) 735-9622

Current Inspector: Donna Liberman (540) 359-5244

Inspection Date: Sept. 8, 2022

Complaint Related: No

Areas Reviewed:

8VAC20-780 Administration. 8VAC20-780 Staff Qualifications and Training. 8VAC20-780 Physical Plant. 8VAC20-780 Staffing and Supervision. 8VAC20-780 Programs. 8VAC20-780 Special Care Provisions and Emergencies. 8VAC20-780 Special Services. 8VAC20-770 Background Checks 22.1 Background Checks Code

Comments:

An unannounced monitoring inspection was conducted on 9/8/22 from 6:45am to 7:15am with program staff. There were seven children in care, ranging in age from six-years- to 10-years-old, supervised by two staff. The children were observed having free play with legos and other toys, resting, and playing ?Uno? with a staff member. Three child records and two staff records were requested to be scanned as they were not available on-site. Both staff have current certification in CPR and First Aid. Two medications and their authorization forms were reviewed. The attendance and emergency drill log were reviewed. If you have questions regarding this inspection, please contact the Licensing Inspector, Laura Brindle, at laura.brindle@doe.virginia.gov or 540-905-2062. Please complete the "Plan of Correction" and "Date to be Corrected" areas on the Violation Notice for each violation cited and return to me by close of business on 9/15/22. Plans of correction should include steps to correct the noncompliance with the standard, and measures to prevent the noncompliance from occurring again.

Violations:

Standard #:	8VAC20-770-60-B
Description:	Based on review of two staff records, the center did not obtain a completed sworn disclosure statement for each staff prior to date of hire. Evidence: The sworn statement submitted for Staff B, with a start date of 4/27/22, was dated 5/10/22.
Plan of Correction:	Ensure sworn statement is done prior to hiring.
Standard #:	8VAC20-780-40-L
Description:	Based on interview, the center did not ensure that all staff who work with children were informed of children?s allergies, sensitivities, and dietary restrictions. Evidence: The Licensing Inspector asked both staff on-site on 9/8/22 if any of the children had food allergies. Staff B stated that they were new to the site and did not know if any of the children had allergies. Staff A stated that two children had epi-pens for food allergies, but they were not sure if any other children had allergies.
Plan of Correction:	Provide staff with allergy list.
Standard #:	8VAC20-780-40-M
Description:	Based on interview, the center did not maintain, in a way that was accessible to all staff who worked with children, a current written list of all children's allergies, sensitivities, and dietary restrictions. Evidence: The Licensing Inspector requested the allergy list during the inspection on 9/8/22. Staff reported that allergy information was kept in the program?s tablet, but the tablet did not work at the site due to a poor internet connection. There were two emergency medications for food allergies observed on-site for two children.
Plan of Correction:	A physical copy will be accessible in three areas where YMCA SACC is located.
Standard #:	8VAC20-780-60-A
Description:	Based on interview, the center failed to maintain and keep at the center a separate record for each child enrolled which contained required documentation and information. Evidence: On 9/8/22 the Licensing Inspector (LI) requested child records for review. Program staff reported that the information was kept in the program?s tablet, but the tablet did not work at the site due to a poor internet connection.
Plan of Correction:	Staff will have a physical copy on site regarding children documentation.
Standard #:	8VAC20-780-70
Description:	Based on review of documentation, the center did not ensure that the address, verification of age requirement, job title, and date of employment or volunteering; and name, address, and telephone number of a person to be notified in an emergency were kept at the center for staff. Evidence: Required on-site documentation was requested by the Licensing Inspector (LI) on 9/8/22. Staff presented a binder containing documentation for YMCA staff, but the two staff present did not have any documentation in the binder.
Plan of Correction:	Staff files will be present at site.
Standard #:	8VAC20-780-240-A
Description:	Based on review of two staff records, the center did not ensure that the Virginia Department of Education-sponsored orientation course was completed within 90 calendar days of employment by one staff member. Evidence: The Licensing Inspector requested that documentation of completion of the orientation course be scanned as it was not available on-site. There was no documentation of completion of the course submitted for Staff B, with a date of employment of 4/27/22.
Plan of Correction:	This training will be completed within 90 days of employment moving forward.
Standard #:	8VAC20-780-245-J
Description:	Based on a review of medication and documentation, the program had agreed to administer a prescribed, emergency medication to two children without a staff member on-site who had satisfactorily completed a training program that qualified them to administer medication. Evidence: Two emergency medications for two children were observed on-site on 9/8/22. The Licensing Inspector requested Medication Administration Training ( MAT) documentation be scanned for on-site staff as the documentation was not available on-site. There was no MAT certification documentation submitted for Staff A or Staff B.
Plan of Correction:	Staff will be getting MAT trained.
Standard #:	8VAC20-780-245-L
Description:	Based on review of two staff records, the center did not ensure that there was always at least one staff member on duty who had obtained within the last three years instruction in performing the daily health observation of children. Evidence: The Licensing Inspector requested Daily Health Observation (DHO) training documentation be scanned for on-site staff as the documentation was not available on-site. There was no DHO training documentation submitted for Staff A or Staff B.
Plan of Correction:	Staff will have daily health observation training. Staff trainings will be on site.