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Henrico Police Athletic League - Harvie
3401 Harvie Road
Henrico, VA 23223
(804) 690-1588

Current Inspector: Florence Martus (804) 662-9772

Inspection Date: Nov. 7, 2019

Complaint Related: No

Areas Reviewed:
22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-191 Background Checks (22VAC40-191)
63.2(17) License & Registration Procedures

Technical Assistance:
n/a

Comments:
The licensing inspector conducted an announced monitoring inspection at the administrative building on Thursday, November 7, 2019 to review staff records from 9:00am to approximately 4:15pm. A total of twelve staff records were reviewed for this facility.

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 the day of receipt. You should 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, please contact the licensing inspector, Florence Martus, at (804) 662-9772.

Violations:
Standard #: 22VAC40-185-160-A
Description: Based on a review of twelve staff records on 11/07/2019, the center did not ensure that one staff member submitted documentation of a negative tuberculosis screening within the required time frame.

Evidence: 1) The TB screening in the record for Staff #1, hired on 11/09/2018, was dated 12/07/2018. Documentation of the screening shall be submitted no later than 21 days after employment or volunteering and shall have been completed within 12 months prior to or 21 days after employing or volunteering.

Plan of Correction: Per the Center: "1) Henrico PAL Administrative office will provide notification of TB requirement to staff #1.

2) Henrico PAL Administrative office will ensure that each potential employee have a TB screen prior to hire date and contact with children.

3) Henrico PAL office manager will be responsible for implementing each step and preventative measure. Implementation began on 11/8/19."

Standard #: 22VAC40-185-160-C
Description: Based on a review of twelve staff records and interview on 11/07/2019, the center did not ensure that two staff resubmit TB test results at least every two years from the date of the first initial screening or testing, or more frequently as if recommended by a licensed physician or the local health department.

Evidence: During the review of staff records the licensing inspector observed the following:

1) The most recent negative TB screenings in the record for Staff #8 are dated 9/28/2017 and 10/30/2019.

2) The most recent negative TB screenings in the record for Staff #10 are dated 9/28/2017 and 10/30/2019.

3) During interview, a member of management acknowledged the subsequent TB screenings/tests for Staff #8 and Staff #10 were not completed within the required two year time frame.

Plan of Correction: Per the Center: "1) Henrico PAL Administrative office will provide notification of TB expiration and requirements to staff #1 and #8.

2) Henrico PAL Administrative office will provide TB screen expiration notification to all staff 30 days before expiration and also provide TB screening to all staff members by registered nurse prior to
expiration date.

3) Henrico PAL office manager will be responsible for implementing each step and preventative
measure. Implementation began on 11/8/19"

Standard #: 22VAC40-185-70-A
Description: Based on a review of twelve staff records on 11/07/2019, the center did not ensure that two staff records contained the required information.

Evidence: 1) The record for Staff #1, hired on 11/09/2018, did not contain written information that the individual completed orientation training. Each staff record shall contain written information to demonstrate that the individual possesses the education, orientation training, staff development, certification, and experience required by the job position.

2) The record for Staff #9, hired on 3/16/2018, contained two references that were obtained on 3/20/2018. Each staff record shall include documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering.

Plan of Correction: Per the Center: "1) Henrico PAL Administrative office will ensure that staff #1 employee file contains written information about orientation training completion and that staff #9 contains two references for employee file.

2) Henrico PAL Administrative office will request that each staff complete the staff orientation checklist to verify completion of the orientation training. Henrico PAL Administrative office will ensure that each potential employee has two references contacted before date of hire.

3) Henrico PAL office manager will be responsible for implementing each step and preventative
measure. Implementation began on 11/8/19."

Standard #: 22VAC40-185-240-C
Description: Based on a review of twelve staff records on 11/07/2019, the center did not ensure seven staff received the required 16 hours of annual training.

Evidence: During the review of staff records, the licensing inspector observed the following:

1) Staff #2 completed 10 hours of annual training in the last annual training cycle from 11/2018-10/2019.

2) Staff #3 completed 8 hours of annual training in the last annual training cycle from 7/2018-6/2019.

3) Staff #4 completed 10 hours of annual training in the last annual training cycle from 9/2018-8/2019.

4) Staff #6 completed 10 hours of annual training in the last annual training cycle from 10/2018-9/2019.

5) Staff #8 completed 10 hours of annual training in the last annual training cycle from 10/2018-9/2019.

6) Staff #10 completed 10 hours of annual training in the last annual training cycle from 10/2018-9/2019.

7) Staff #11 completed 12 hours of annual training in the last annual training cycle from 10/2018-9/2019.

Plan of Correction: Per the Center: "1) Henrico PAL administrative office will notify staff members #4, #6, #8, #10 and #11 of incomplete training hours and the requirement of needing 16 hours of training per year from their date of hire.

2) Henrico PAL will create training calendar and preschedule training opportunities for staff members. Henrico PAL will also keep a detailed spreadsheet record of all types of staff trainings, training hours completed for each staff and training hours needed for completion of licensing requirement for each
staff.

3) Henrico PAL office manager will be responsible for implementing each step and preventative measure. Implementation began on 11/8/19"

Standard #: 22VAC40-191-60-C-2
Description: Based on a review of twelve staff records on 11/07/2019, the center did not obtain a central registry finding for three staff members within 30 days of employment.

Evidence: 1) The record for Staff #1, hired on 11/09/2018, did not contain the results of a central registry finding. Staff #1 was still employed at the time of the inspection on 11/07/2019.

2) The record for Staff #3, hired on 6/01/2018, contained the results of a central registry finding dated 9/25/2018.

3) The record for Staff #9, hired on 3/16/2018, did not contain the results of a central registry finding. Staff #9 was still employed at the time of the inspection on 11/07/2019.

Plan of Correction: Per the Center: "1) Henrico PAL Administrative office will and have obtained central registry findings for staff #1, #3 and have submitted central registry request for staff #9 and will follow up with Central Registry Unity by 12/20/2019.

2) Henrico PAL Administrative office will keep detailed records in spreadsheets about timeframes for future central registry follow ups before the 4-day grace period is over from 30 days after date of
mailing.

3) Henrico PAL office manager will be responsible for implementing each step and preventative measure. Implementation began on 11/8/19."

Standard #: 63.2(17)-1720.1-B-2
Description: Based on a review of twelve staff records on 11/07/2019, the center did not ensure that one staff, hired prior to January 22, 2018, by September 30, 2018.

Evidence: 1) The record for Staff #2, hired on 10/11/2017, did not contain the results of a fingerprint based background check.

Plan of Correction: Per the Center: "1) Henrico PAL Administrative office will and have obtained fingerprint results for staff #2.

2) Henrico PAL Administrative office will send each potential employee to submit fingerprints and hire once results have been received and employee is found eligible for hire.

3) Henrico PAL office manager will be responsible for implementing each step and preventative measure. Implementation began on 11/8/19."

Disclaimer:
A compliance history is in no way a rating for a facility.

The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.

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