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Boys & Girls Clubs of Harrisonburg/Rockingham County-Simms Unit
620 Simms Avenue
Harrisonburg, VA 22802
(540) 434-6060

Current Inspector: Beth Orebaugh (540) 847-9173

Inspection Date: May 7, 2015 and May 12, 2015

Complaint Related: No

Areas Reviewed:
22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 PHYSICAL PLANT.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 PROGRAMS.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-185 SPECIAL SERVICES.
22VAC40-80 THE LICENSE.
22VAC40-80 THE LICENSING PROCESS.
32.1 Report by person other than physician
63.2 General Provisions.
63.2 Child Abuse and Neglect
63.2 Licensure and Registration Procedures
63.2 Facilities and Programs..
22VAC40-191 Background Checks (22VAC40-191)

Technical Assistance:
We discussed the requirements for staff records, children's records, posting weekly menus, asbestos surveillance, background checks, authorized pick-up, and the care, protection and guidance of children. The risk assessment for violations were provided. As a reminder, the health inspection and fire inspection reports are due by twelve months from the date of the last inspection by each agency. We discussed the use of tracking systems for records and reminder systems for due dates. Also, we talked about the use of volunteers and interns.

Comments:
Thank you for your assistance during the unannounced renewal inspection conducted on May 7, 2015 from 2:00 PM to 7:10 PM. Announced follow-up inspections were conducted on May 12, 2015 from 10:50 AM to 12:20 PM and from 4:05 PM to 4:35 PM. I viewed program activities, staffing, supervision, snack and dinner, equipment, daily routines, posted information, emergency supplies and drill records, injury records, asbestos management, agency inspections, written information, six records for children, five staff records, staff qualifications, staff training, indoor and outdoor areas. On May 7, fifty-nine children received care after school with five to six staff. There was oversight by staff as children arrived after school and were directed to snack or an activity. Frequent reminders regarding hand washing were given to children during snack time. Staff have provided regular assistance with homework. Also, children had opportunities for active play in the gym and outside. We talked about the need to provide consistent close supervision, and assurance that children adhere to rules and expectations so that children do not leave their group, make inappropriate play choices such as ball use in the cafeteria, or enter the entrance counter area. Also, it was suggested that you plan ahead for the use and staffing of areas such as the upstairs game activity room. As a reminder, the maintenance of compliance with minimum standards for health and safety is the responsibility of the licensee. The renewed license will be recommended after receipt of all required background checks for administrative staff and representatives of the licensee. Call if you need further assistance. 540/430-9259

Violations:
Standard #: 22VAC40-185-140-A
Description: Based on a review of six records for children, and an interview with the provider, the physical examination records for child 2 and 4 were not obtained within thirty days of enrollment. Evidence: There were only copies of the immunization reports in the records. Child 2 began attending on March 31, 2015 and child 4 started on March 30, 2015.

Plan of Correction: The unit director will request and obtain copies of the physical examination reports, such as the ones on file with the elementary schools, from the parents. The unit director is reviewing all records to make sure they contain all required information. In the future, a tracking and reminder system will be used when physical examination records are not included with the immunization reports at the time of enrollment so that the information is obtained within the first month of attendance.

Standard #: 22VAC40-185-160-A
Description: Based on a review of five staff records, and an interview with administrative staff, the initial TB screenings and statements were not obtained within twenty-days of initial employment for the positions held by staff members 4 and 5. Evidence: Staff member 4 transferred to begin work as a program leader on April 7, 2015 and there was not a TB statement in the staff files. The files did not include a signed TB statement for staff member 5 who began employment on June 10. 2013 and has held various positions with the agency.

Plan of Correction: The administrative staff will arrange to obtain the required TB statements from staff members 4 and 5. The administrative staff will use a tracking and recording system for staff record dates and make sure arrangements are made for obtaining the initial TB statements before twenty-one days of initial work with children.

Standard #: 22VAC40-185-60-A
Description: Based on observation of the pick up of child 6, interviews with staff, and a review of the child's file, there was not written authorization from the parent for the person who sometimes has conducted the pick up today. Evidence: A young woman was seen leaving with child 6 and a staff person indicated her role with the child. L.I. asked a staff person if she had written authorization from the parent and was told the person's name was not in the compeputer with the list of authorized names. The registration form did not include this person's name under authorized pick up of the child and there were not any written notes from the parent in the file. Administrative staff indicated they had verbal authorization from the parent and he thought something written on a sticky note was discarded.

Plan of Correction: The unit director will contact the parent and have the parent provide written authorization for the pick up of child 6 by the person who will conduct pick up on designated days. The unit director will review all records to make sure the authorized pick ups of children by persons other than a parent or guardian has been provided in writing. The staff who oversee check-out will always make sure a person is on the authorized list before they let a child leave with someone other than a parent or guardian. Administrative staff will instruct all staff to never accept verbal authorization in place of written authorization.

Standard #: 22VAC40-185-70-A
Description: Based on a review of five records for staff, and interviews with administrative staff, there was required information missing from the staff records for staff members 2, 3, 4, and 5. Evidence: There were not any reference checks documented in the files for staff member 3 who began work October 20, 2014, staff member 4 who started with a transfer on April 7, 2015, and staff member 5 who was employed with the agency on June 10, 2013. The start dates or transfer dates were not documented in the staff records for staff members 3 and 4. No documentation of orientation training in the records of staff members 3 and 5. No documentation of the annual training completed by staff member 2 between October 2013 and October 2014. Incomplete documentation of training for the records of staff members 1 and 5.

Plan of Correction: The unit director or administrative staff will obtain at least two reference checks for each staff member and place documentation in the staff files. The assigned administrative staff person will ensure that reference checks are completed by the time a staff person begins working in the program. The start dates or transfer dates will be added to the staff files and always documented in a consistent manner by the assigned administrative staff member at the time a staff member is assigned a position with the program. The unit director will use the orientation training form and checklist to document the orientation training that was conducted with staff members 3 and 5. Orientation training will be documented at the time it is conducted with new employees. The unit director will request and obtain pertinent college transcripts and training certificates from staff member 2 for placement with staff training records. All completed training will be recorded in the files of staff members 1 and 5. The unit director or assigned staff will make sure the documented training in topics related to the position held is placed in the staff files at the time of completion. The unit director and staff will keep track of the hours of annual staff development participated in by the anniversary date of hire.

Standard #: 22VAC40-185-260-C
Description: Based upon a review of the asbestos management at the center on May 7, 2015, and interviews with administrative staff, the terms of the asbestos management plan have not been complied with by maintaining a surveillance schedule and documenting findings at least every six months. (Repeat Violation.) Evidence: The last surveillance of the asbestos containing materials and documentation that the materials were in good condition was October 31, 2015.

Plan of Correction: An administrative staff person immediately conducted the required asbestos surveillance and documented the information in the file on May 7, 2015. The trained administrative staff who conducts the six month surveillance of asbestos containing materials will use a reminder system for completing this task on time.

Standard #: 22VAC40-185-340-A
Description: Based on observation of the program activities on May 7, 2015, and interviews with staff and children, there were two supervising staff in the cafeteria who did not ensure the care, protection and guidance of two children who left the cafeteria were in the entrance foyer. Evidence: AT approximately 4:50 PM, there were two staff standing near the kitchen wall to supervise the cafeteria area. The inspector entered the front foyer from the cafeteria and saw two boys behind the check-in counter and no staff in the front foyer. Parents were arriving in the foyer for pick up of children. When the licensing inspector asked the boys if they were supposed to be behind the counter, one boy immediately left. After the inspector addressed the two children, a staff person entered the foyer and went to the boy standing by the computer and instructed him to return to the cafeteria. Later, the inspector confirmed that the two boys were eight years old and had not been given permission by staff to leave the cafeteria. Staff indicated that children are not allowed behind the counter.

Plan of Correction: The administrative staff met with the supervising staff members of the program on May 12, 2015 to review the requirements for supervising each area of the building and enforcement of the expectation that children stay in the activity area with their group so that children are supervised and receiving protection at all times. The staff will make sure they keep a count of all children and provide active supervision of the doorway leading to the entrance foyer. The staff will use the program's behavior management policy for providing the necessary guidance and consequences when children do not adhere to the limits established by the program leaders and program procedures.

Standard #: 22VAC40-185-560-F
Description: Based on a review of the posted information, and interviews with staff, there was not a written menu either posted or given to parents for this week's daily dinners served to children. Evidence: Only the snack menu was posted on a wall near the kitchen door. Staff indicated that the menus do not stay on the wall when using tape and the dinner menu has not been posted this week. The staff person who was preparing the food for dinner was observed seeking administrative staff to discuss today's plans for dinner. Dinner was served during two shifts at 6:00 PM and 6:30 PM. No written dinner menu of food served was available.

Plan of Correction: The unit director will make sure a written dinner menu is printed from the computer and posted in a place where it is visible to parents and staff. Substitute food plans will be posted in an updated menu or marked on the posted menu.

Standard #: 22VAC40-191-40-D-1-B
Description: Based on a review of five staff records, and an interview with the administrative staff, there were not any central registry searches completed at the time of initial employment for staffs 3 and 5. Evidence: Staff member 3 began work on October 20, 2014 and there was only a sworn statement and criminal history record check in the staff files. Initial employment for staff member 5 was June 10, 2013 and administrative staff indicated that staff member 5 has held various positions at different units. The record of staff member 5 only included sworn statements and a criminal history record check.

Plan of Correction: The administrative staff will make sure staff members 3 and 5 complete a request for the central registry checks. The missing records will be obtained, viewed and placed in the staff files. The unit director or assigned administrative staff member will make sure all required background checks are requested and obtained for staff members within the first month of employment. A tracking and reminder system will be used to make sure all required records are included in staff records.

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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