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: April 12, 2023

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 20 Access to minor's records 22.1 Early Childhood Care and Education 32.1 Report by person other than physician 63.2 Child Abuse & Neglect

Technical Assistance:

n/a

Comments:

An unannounced monitoring inspection was conducted on Wednesday, April 12, 2023 to determine the center's compliance with licensing standards. The inspector was on site from4:20pm to approximately 5:40pm. There were a total of 27 children in care in the direct care of five staff members. During the inspection, the children and staff were observed participating in a variety of activities. Staff were observed having positive interactions with the children. All areas of the facility used by the children were inspected. The center is equipped with toys and supplies and items were available to the children. The required postings were reviewed and found to be in compliance. Medication is administered, but there are no medications on-site at this time. During the inspection, five children's records were reviewed and applicable staff information required to be at the center was reviewed. On Tuesday, April 25, 2023, the inspector conducted an unannounced inspection at the administrative office to review four staff records. Information gathered during the inspections determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program.

Violations:

Standard #:	22.1-289.035-B-2
Description:	Based on a review of four staff records and interview, the center did not ensure two staff had the satisfactory results of the fingerprint-based national criminal background check prior to employment. Evidence: 1) The fingerprint-based national criminal background check in the record of Staff #1, employed on 11/12/22, was dated 01/04/23. 2) The record of Staff #3, employed on 02/01/23, did not contain the results of the fingerprint-based national criminal background check requested by the current employer. 3) During interview, a member of management confirmed the fingerprint-based national criminal background check for Staff #1 and Staff #3 were not obtained at the time of employment.
Plan of Correction:	Staff with missing fingerprints will obtain no later than 5/12/23.
Standard #:	22.1-289.035-B-4
Description:	Based on a review of four staff records and interview, the center did not obtain the results of a sex offender registry check and a search of the child abuse and neglect registry or equivalent registry from any state in which one staff member had resided in the preceding five years within the required timeframe. Evidence: 1) The record of Staff #3, employed on 02/01/23, indicated the staff had resided in another state outside of Virginia within the last five years. The record did not contain a sex offender registry check or a search of the child abuse and neglect registry. The out-of-state sex offender registry check is required to be obtained prior to employment. The out-of-state search for founded complaints of child abuse or neglect is required to be requested within the first 30 days of employment. An out-of-state criminal history record information check was not required because the state participates in the National Fingerprint File (NFF) program through the FBI. 2) During interview, a member of management confirmed the required out-of-state checks were not obtained for Staff #3 within the required timeframe.
Plan of Correction:	The center will initiate the searches and follow up with the LI.
Standard #:	8VAC20-770-60-B
Description:	Based on a review of four staff records and interview, the center did not ensure one staff had a completed sworn statement or affirmation prior to employment. Evidence: 1) The sworn statement in the record of Staff #1, employed on 11/12/22, was not signed. 2) During interview, a member of management confirmed the sworn statement for Staff #1 was not complete at the time of employment.
Plan of Correction:	Corrected. Staff will complete sworn statement at the time of employment.
Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of four staff records and interview on 04/25/23, the center did not ensure two staff members had a central registry finding within 30 days of employment. Evidence: 1) The central registry finding in the record of Staff #1, employed on 11/12/22, was dated 01/07/23. 2) During interview, a member of management confirmed the results of the central registry for Staff #1 were received more than 30 days after employment. The record did not contain documentation of any further contact with the Office of Background Investigations, and the staff member had been continuously employed. 3) The record of Staff #4, employed on 03/13/23, did not have a central registry finding. 4) During interview, a member of management confirmed the results of the central registry for Staff #4 had not been received to date. The record did not contain documentation of any further contact with the Office of Background Investigations, and the staff member had been continuously employed.
Plan of Correction:	In the future, documentation will be maintained if the center contacts OBI about a late central registry finding. A follow up email was sent to OBI on 4/28/23 to request additional information about the missing central registry.
Standard #:	8VAC20-780-130-A
Description:	Based on a review of five children's records and interview, the center did not obtain documentation that one child had received the immunizations required by the State Board of Health before the child attended the center. Evidence: 1) The immunization documentation in the record of Child #2, date of attendance 02/27/23, was dated 02/28/23. 2) During interview, a member of management confirmed the center did not obtain documentation of the child's immunizations before the child attended the center.
Plan of Correction:	Moving forward, all immunizations will be obtained prior to a child's attendance.
Standard #:	8VAC20-780-160-A
Description:	Based on a review of four staff records and interview, the center did not ensure four staff members submitted documentation of a negative tuberculosis screening within the required timeframe. Evidence: 1) The most recent tuberculosis (TB) screening in the record of Staff #1, employed on 11/12/22, was dated 02/19/21 and expired on 02/19/23. 2) The most recent TB screening in the record of Staff #2, employed on 12/17/22, was dated 08/31/21. 3) The record of Staff #3, employed on 02/01/23, did not contain documentation of a negative tuberculosis screening. 4) The TB screening in the record of Staff #4, employed on 03/13/23, was dated 03/22/23. 5) During interview, a member of management confirmed Staff #1, Staff #2, Staff #3, and Staff #4 did not submit documentation of a negative tuberculosis screening within the required timeframe. Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children; and the documentation shall have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician's designee, or an official of the local health department.
Plan of Correction:	The missing TBs will be obtained no later than 5/12/23. In the future, TBs will not be accepted if they were completed 30 days prior to employment and will be required at the time of employment.
Standard #:	8VAC20-780-60-A
Description:	Based on a review of five children's records and interview, the center did not ensure one child's record contained the required information. Evidence: 1) The record of Child #2, enrolled on 02/27/23, did not contain documentation of two emergency contacts. 2) During interview, a member of management confirmed the center did not have documentation of two emergency contacts for Child #2. Each child record shall contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.
Plan of Correction:	The missing information was requested and filed on 04/28/23.
Standard #:	8VAC20-780-70
Description:	Based on staff interview and observations on 04/12/23, the center did not ensure that the required information for each staff was kept at the center. Evidence: 1) Staff #1, Staff #2, Staff #4, Staff #5, and Staff #6 were observed at the center on 04/12/23. 2) Staff interviewed stated that an emergency contact and information about any health problems staff have were not available for review at the center. The center should maintain at the center the name, address, and telephone number of a person to be notified in an emergency and information about any health problems that may interfere with fulfilling the job responsibilities for each staff member.
Plan of Correction:	The binder was removed and were found at the YMCA. It will be updated and returned to the school to include all staff as of 4/28.
Standard #:	8VAC20-780-530-A
Description:	Based on a review of records, observation, and interview, the center did not ensure that there shall be at least one staff member with current certification in cardiopulmonary resuscitation (CPR) and current certification in first aid where children are present. Evidence: 1) On 4/12/23, Staff #5 was observed providing transportation to four children that attend the program from another school. Staff #5 was the only staff member present during transportation. 2) The First Aid and CPR certificate in the record of Staff #5 expired on 11/14/22. 3) During interview, a member of management confirmed the CPR and First Aid certification of Staff #5 was expired.
Plan of Correction:	The staff attended an in-person training to renew their CPR/First Aid certification.
Standard #:	8VAC20-780-550-D
Description:	Based on a review of documentation and interview, the center did not implement a monthly practice evacuation drill. Evidence: 1) The licensing inspector observed the emergency drill log for the year 2022. An evacuation drill was not conducted for January, March, or May 2022. 2) During interview, management reported the documentation of the drills could not be located and was not able to determine if the drills were conducted. The center shall implement a monthly practice evacuation drill.
Plan of Correction:	The center is searching for the missing documentation. In the future, evacuation drills will be practiced monthly.
Standard #:	8VAC20-780-550-E
Description:	Based on a review of documentation and interview, the center did not practice shelter-in-place procedures a minimum of twice per year. Evidence: 1) The licensing inspector observed the emergency drill log for the year 2022. There was no documentation that shelter-in-place drills were practiced. 2) During interview, management reported the documentation of the drills could not be located and was not able to determine if the drills were conducted. Shelter-in-place procedures shall be practiced a minimum of twice per year.
Plan of Correction:	Two shelter in place drills will be conducted moving forward.
Standard #:	8VAC20-780-550-F
Description:	Based on a review of documentation and interview, the center did not practice lockdown procedures at least annually. Evidence: 1) The licensing inspector observed the emergency drill log for the year 2022. There was no documentation that a lockdown drill was practiced. 2) During interview, management reported the documentation of the drills could not be located and was not able to determine if a lockdown drill was conducted. Lockdown procedures shall be practiced at least annually.
Plan of Correction:	A lockdown drill will be practiced annually.
Standard #:	8VAC20-780-550-P
Description:	Based on a review of documentation on 04/12/2023, the center did not ensure that written injury records contained the required information. Evidence: Three out of three written injury records reviewed did not contain the date and time parents were notified of the injuries. The center shall maintain a written record of children's serious and minor injuries in which entries are made the day of occurrence. The record shall include the following: date and time of injury; name of injured child; type and circumstance of the injury; staff present and treatment; date and time when parents were notified; any future action to prevent reoccurrence of the injury; staff and parent signatures or two staff signatures; and documentation on how parent was notified.
Plan of Correction:	A meeting was conducted on 4/26/23 and these items were addressed moving forward. All reports will ensure that each line item is filled out and that the date and time a parent was notified will be listed.