VIRGINIA DEPARTMENT OF SOCIAL SERVICES

YMCA - Midlothian
737 Coalfield Road
Midlothian, VA 23114
(804) 474-4405

Current Inspector: Lynn Powers (804) 840-8260

Inspection Date: May 30, 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 initiated on Tuesday, May 30, 2023, to determine the center's compliance with licensing standards. The inspection was concluded on Friday, June 2, 2023. On May 30, the inspector was on site from 4:00pm to approximately 5:20pm. There was a total of 39 children in care in the direct care of five staff members. Upon the inspector's arrival, a group of children was observed in their designated classroom and later transitioning to the gym. Additional children were later observed arriving at the center. Sign-in and pick-up procedures were observed. The children and staff were engaged in various activities. The children were observed during transitions, free-play, and teacher-led activities. The center is equipped with age-appropriate materials and equipment for the children's use. Staff were engaged with the children and offered guidance when needed. The areas where children receive care were inspected and found in compliance. The required postings were observed. Medication is administered and medications were reviewed. The center provides transportation and the vehicles used for transportation were inspected. During the inspection, six children's records and five staff records were reviewed. Additional documentation was submitted electronically on June 1 and June 2, 2023. 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-A
Description:	Based on a review of five staff records and interview, the center did not ensure one staff completed three required background checks every five years. Evidence: 1) The most recent results of the fingerprint-based national criminal background check in the record of Staff #3 (DOE: 11/23/10) was completed on 04/17/23. The previous fingerprint-based national criminal background check was completed on 04/02/18. The new results should have been obtained no later than 04/02/23. 2) The most recent central registry check in the record of Staff #3 was completed on 05/09/22. The previous central registry check in the record was completed on 04/17/17. A new search of the central registry should have been obtained no later than 04/17/22. 3) The most recent sworn statements in the record of Staff #3 were completed on 08/30/22 and 11/11/22. The previous sworn statement in the record was completed on 08/01/17. A new sworn statement should have been completed no later than 08/01/22. 4) During interview, a member of management acknowledged the background checks for Staff #3 were not completed every five years as required.
Plan of Correction:	Per the Center: "We are working on process for all background checks to ensure all are done timely."
Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of five staff records and interview, the center did not ensure one staff member had a central registry finding within 30 days of employment. Evidence: 1) The central registry finding in the record of Staff #2 (DOE: 06/15/22) was completed on 10/03/22. 2) During interview, a member of management confirmed the central registry finding for Staff #2 was not received within 30 days of 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.
Plan of Correction:	Per the Center: "We have fixed this process moving forward"
Standard #:	8VAC20-780-160-A
Description:	Based on a review of five staff records and interview, the center did not ensure one staff member submitted documentation of a negative tuberculosis (TB) screening within the required timeframe. Evidence: The TB screening in the record of Staff #5 (DOE: 05/23/22) was completed on 12/19/22. There was no documentation a TB screening was completed prior to this date. Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children.
Plan of Correction:	Per the Center: "We have fixed this process moving forward"
Standard #:	8VAC20-780-160-C
Description:	Based on a review of five staff records, the center did not ensure one staff obtained and submitted the results of a follow-up tuberculosis (TB) screening at least every two years. Evidence: The most recent TB screening in the record of Staff #1 (DOE: 01/06/21) was completed on 02/18/23. The previous TB screening was completed on 12/31/20. A new TB screening should have been obtained no later than 12/31/22.
Plan of Correction:	Per the Center: "We are working on this process for all staff to ensure compliance."
Standard #:	8VAC20-780-240-A
Description:	Based on a review of five staff records and interview, the center did not ensure one staff complete within 90 calendar days of employment the Virginia Department of Education-sponsored orientation course. Evidence: 1) The record of Staff #5 (DOE:05/23/22) did not contain the Virginia Department of Education-sponsored orientation course. 2) During interview, a member of management reported the staff member has not completed the orientation to date.
Plan of Correction:	Per the Center: "We have told staff about this training to complete asap."
Standard #:	8VAC20-780-550-P
Description:	Based on a review of documentation, the center did not ensure that written injury records contained the required information. Evidence: Six written injury records were reviewed. The following documentation was missing: 1) Injury record #1 did not contain documentation of the date and time when parents were notified; documentation of how parent was notified; and any future action to prevent reoccurrence of the injury. 2) Injury record #2 did not contain documentation of the date and time when parents were notified; documentation of how parent was notified; and any future action to prevent reoccurrence of the injury. 3) Injury record #3 did not contain documentation of the type and circumstance of the injury; staff present and treatment; future action to prevent reoccurrence of the injury; the date and time when parents were notified; and documentation of how parent was notified. 4) Injury record #4 did not contain documentation of the date and time when parents were notified; documentation of how parent was notified; staff present; and future action to prevent reoccurrence of the injury. 5) Injury record #5 did not contain documentation of the type and circumstance of the injury; staff present and treatment; future action to prevent reoccurrence of the injury; the date and time when parents were notified; and documentation of how parent was notified. 6) Injury record #6 did not contain documentation of the staff present; the date and time when parents were notified; documentation of how parent was notified; and future action to prevent reoccurrence. 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:	Per the Center: "We are working on retraining all staff over required information."