VIRGINIA DEPARTMENT OF SOCIAL SERVICES

YMCA of the Virginia Peninsulas - Mackey Thompson
13027 History Land Hwy
Warsaw, VA 22572
(804) 333-4117

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

Inspection Date: July 26, 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. 8VAC20-820 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 monitoring inspection was conducted on 07/26/2023 from approximately 11:20 a.m. to 1:45 p.m. There were 24 school age children present and 2 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. Five child records and four 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, 08/3/2023. 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). If you have any questions related to this inspection, please contact Inspector Susan Ellington-Sconiers, at 804-588-2368 or susan.ellington-sconiers@doe.virginia.gov.

Violations:

Standard #:	8VAC20-770-60-C-2
Description:	Based on staff record review, the provider failed to have central registry findings within 30 days of employment. Evidence: The record for S3, employed 05/26/2023 did not contain findings of a central registry search.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-140-A
Description:	Based on child record review, the provider failed to ensure that each child shall have a physical examination by or under the direction of a physician. Evidence: The record for C5, enrolled 06/05/2023 did not contain a physical examination.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-150-B
Description:	Based on record review, the provider did not keep the required records for two of four staff. Evidence: The record for S2, did not contain documentation to demonstrate orientation and training required by 8VAC20-780-240-C and 8VAC20-780-240-D. The record did not contain a completed orientation and training log. The record for S1 did not contain documentation to demonstrate that the individual possesses the experience required by the job position. The record for S1 did not document six months supervised experience required to serve as a program leader (8VAC20-780-210).
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-160-A
Description:	Based on staff record review, the provider failed to ensure that three of four staff submit documentation of a negative tuberculosis screening at the time of employment or documentation completed within the last 30 calendar days of the date of employment. Evidence: The record for S2, employed 05/26/2023, contained a screening completed 06/06/2023. The record for S3, employed 05/16/2023, contained a screening completed 08/12/2022. The record for S4, employed 04/26/2023, contained a screening completed 08/19/2022.
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 two of five records contained required information. Evidence: The records for C2 and C3 enrolled 05/30/2023 did not document the date of viewing proof of the child?s identity and age.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-70
Description:	Based on record review, the provider did not keep the required records for two of four staff. Evidence: The record for S2, did not contain documentation to demonstrate orientation and training required by 8VAC20-780-240-C and 8VAC20-780-240-D. The record did not contain a completed orientation and training log. The record for S1 did not contain documentation to demonstrate that the individual possesses the experience required by the job position. The record for S1 did not document six months supervised experience required to serve as a program leader (8VAC20-780-210).
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-240-B
Description:	Based on staff record review, the provider failed to ensure that two of four staff shall complete orientation training prior to working alone with children and no later than seven days of the date of assuming job responsibilities. Evidence: The record for S3, employed 05/16/2023 documented the orientation training being completed 06/01/2023. The record for S4, employed 04/26/2023 documented the orientation training being completed 05/11/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.