VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Young Men's Christian Association of Greater Richmond - Tuckahoe
9211 Patterson Avenue
Henrico, VA 23229
(804) 350-0647

Current Inspector: Susan Ellington-Sconiers (804) 588-2368

Inspection Date: Oct. 27, 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. 8VAC20-820 THE LICENSE. 8VAC20-820 THE LICENSING PROCESS. 8VAC20-820 HEARINGS PROCEDURES. 8VAC20-770 Background Checks (8VAC20-770) 20 Access to minor?s records 22.1 Background Checks Code, Carbon Monoxide 63.2 Child Abuse & Neglect

Comments:

A renewal inspection was initiated on 10/27/2022 from approximately 1:55 p.m. ? 5:00 p.m. and concluded with staff and child record review off-site. There were 54 children and 5 staff supervising. The inspector reviewed compliance in the areas of administration, qualifications and training, physical plant, staffing and supervision, programming, medication, special care and emergencies, and nutrition. Eight child records and eight staff records were reviewed. The information gathered during the inspection determined violations with applicable standards or law. A violation notice was issued. 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 today, 11/01/2022. 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 standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations:

Standard #:	22.1-289.058
Description:	Based on observation, provider failed to ensure the center was equipped with at least one carbon monoxide detector. Evidence: No carbon monoxide was located in the area used by the licensed program.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-770-60-B
Description:	Based on staff record review, the provider failed to ensure that one of eight staff records contained a Sworn Statement completed prior to the first day of employment. Evidence: The record for S8, employed 10/01/2021 contained a Sworn Statement signed 10/18/2021.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-770-60-C-2
Description:	Based on staff record review, the provider failed to ensure that four of eight staff records contained central registry findings within 30 days of employment. Evidence: The record for staff, S2, employed 6/2/2022 did not contain documentation of a central registry finding. S2 has been employed more than 30 days. The center did not have any documentation of contact to follow up on the status of the central registry finding. The record for S3, employed 06/03/2022 contained results of a central registry finding dated 07/31/2022, exceeding 30 days from the date of employment. The record for S4, employed 12/07/2021 contained results of a central registry finding dated 01/24/2022, exceeding 30 days from the date of employment. The record for S8, employed 10/01/2021 contained results of a central registry finding dated 12/06/2022, exceeding 30 days from the date of employment.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-60-A
Description:	Based on child record review, the provider failed to ensure that seven of eight records contained all the required information. Evidence: 1. C1 enrolled 08/30/2022 did not have a record to review containing the requirements of 8VAC20-780-60-A. 2. The record for C3 enrolled 08/30/2022 did not contain: parent name, address, and phone number; parent work phone numbers; name of child?s physician and phone number; emergency contacts; child day care and schools previously attended; proof of identity; immunizations; and physical. 3. The record for C4 enrolled 08/30/2022 did not contain: parent work phone numbers; one of two emergency contacts; and allergies and health problems. 4. The record for C5 enrolled 08/30/2022 did not contain documentation of allergies and health problems. 5. The record for C6 enrolled 08/30/2022 did not contain emergency contacts for the child if the child?s parent could not be located. 6. The record for C7 enrolled 08/30/2022 did not contain documentation of allergies and health problems. 7. The record for C8 enrolled 08/30/2022 did not contain a second emergency contact for the child if the child?s parent could not be located.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-70
Description:	Based on staff record review, the provider failed to ensure that 6 of 8 records contained required information. Evidence: Record for S1, employed 08/26/2019 did not contain health information required by 8VAC20-780-160.C and documentation 16 hours of annual trainings for 08/26/2021-08/26/2022. Record for S2, employed 06/2/2022 did not contain First Aid and CPR training orientation and completion of the 10-hour Pre-Service training. Record for S3, employed 06/03/2022 did not contain: health information required by 8VAC20-780-160.A; orientation and training required by 8VAC20-780-240; and completion of the 10-hour Pre-Service training. Record for S5, employed 10/6/2022 did not contain documentation of First Aid and CPR training orientation. Record for S6, employed 09/13/2021 did not contain information about any health problems that may interfere with filling the job responsibilities or emergency contacts and documentation of the annual 3 hour refresher training after completion of the 10 hour pre-service training. Record for S7 employed 06/07/2022 did not contain: documentation demonstrating the individual possessing an educational degree; orientation and training required by 8VAC20-780-240; and completion of the 10-hour Pre-Service training.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-540-B
Description:	Based on observation, the provider failed to ensure that each first aid kit was not accessible to children. Evidence: The wall mounted first aid kit located in the Clubhouse was not locked to prevent access by children.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-540-E
Description:	Based on observation, the provider failed to ensure that nonmedical emergency supplies (battery-operated flashlight and radio) were available in each building that is used by children. Evidence: The Clubhouse used by children did not have a battery-operated flashlight and radio.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-550-I
Description:	Based on observation, the provider failed to ensure that 911, fire, and emergency medical services and the number of the regional poison control center were posted in a visible place at each telephone. Evidence: Emergency numbers were not posted in a visible place at the Program Office telephone.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-550-K
Description:	Based on interview, the provider failed to ensure the document kept in a vehicle used to transport children contained routes frequently driven by center staff. Evidence: During the inspection of Bus #2, Program Director reported that the document kept in the vehicle used to pick up and drop off children to schools was missing three of six routes to school sites.
Plan of Correction:	Not available online. Contact Inspector for more information.