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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: Oct. 13, 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.
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 qualifications, staff records, children's records, background checks, injury records and TB statements. The risk assessments for violations were provided. As a reminder, the asbestos surveillance is due this month.

Comments:
Thank you for your assistance during today's unannounced monitoring inspection conducted from 2:58 PM to 6:05 PM. Today, there were eighty-five children with five to eight staff. Also, there were student volunteers participating with groups in the gym, cafeteria and upstairs. I viewed program activities, daily routines, staffing, supervision, interactions with children, emergency supplies and drill records, injury records, five staff records, staff qualifications, five records for children, menu, posted information, indoor and outdoor areas. The children enjoyed active games in the gym. Hand washing routines were monitored before and after children's snack time. Upstairs, children were offered homework assistance and had opportunities to read books and hear stories. There were a number of activity choices in the game room. Children were escorted in the halls and stairways during parent pick-up. Let me know if you need any assistance. 540/430-9259

Violations:
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 2 and 4 (Repeat violation.). Evidence: The files did not include a signed TB statement for staff member 2 who began work with the agency on April 12, 2013. Staff member 4 began work on June 25, 2013 and there was not a TB statement in the staff files.

Plan of Correction: Staff member 4 immediately contacted the office of the health care provider where a TB screening was completed and arranged to obtain the statement by Friday, October 16. The unit director will contact staff member 2 and obtain the TB statement that was repeatedly requested for the record. A system for filing the records will be used when they are received. The unit director or assigned administrative staff will use a checklist to track the records contained in each staff file. All records will be reviewed to make sure they contain required information. The unit director will make sure the TB statements are obtained from new employees within twenty-one days of initial employment.

Standard #: 22VAC40-185-60-A
Description: Based on a review of five records for children, and an interview with administrative staff, there was emergency contact information missing from the record of child 1. Evidence: There was only one emergency contact provided in the registration forms. The section for a required second name, address and phone number was left blank.

Plan of Correction: The unit director immediately called the parent an obtained the name, address and phone number for a second emergency contact. The unit director or assigned staff will review all new children's records and make sure they contain all required information. In the future, the administrative staff who accept the registration forms and sign the agreements with parents will review the information provided to make sure the record is complete.

Standard #: 22VAC40-185-70-A
Description: Based on a review of three records for staff, and interviews with administrative staff, there was required information missing from the staff records for staff members 1, 2, 4 and 5 (Repeat violation.). Evidence: There were not any reference checks in the file for staff member 1 who started with a transfer on April 7, 2015, staff member 2 who was employed with the agency on April 12, 2013, staff member 4 who began on June 25, 2015. A second reference check was not obtained for staff member 5 who was hired August 27, 2015.

Plan of Correction: The unit director will request and obtain reference checks either by phone, email or by requesting written letters from the references provided by each staff member in the application form. The unit director will use a checklist in each staff file to make sure all required information has been obtained for staff. All staff records will be checked to make sure they contain required information. The unit director or assigned administrative staff member will obtain two references at the time of hire for new staff.

Standard #: 22VAC40-185-210-A
Description: Based on a review of five records for staff, and interviews with staff, staff members 3 and 5 do not have the minimum programmatic experience and/or education and training to meet the qualification requirements for the position of program leader. Evidence: Staff member 2, hired as a Y.D.P.L., completed a college degree in an area of study that was not child related. Although a child development course was completed, a minimum of twenty-four hours of training was not completed within the first month of hire on September 10, 2015 in the areas of playground safety, child abuse/neglect and health and safety topics. In addition, the the required six months of programmatic experience with children was not demonstrated in the record. Staff member 3, hired on August 27, 2015 as a Y.D.P.L. did not have a minimum of six months (1000 hours) of experience and completed twenty-fours hours of training in all required topics within the first month of hire. Child development training was the only documented required topic toward the qualification training requirements.

Plan of Correction: The unit director will make sure the programmatic experience for each staff member is clearly demonstrated in each staff record. Administrative staff will arrange for the staff who need to complete training in required topics for meeting the qualifications participate in the training within thirty days of hire or promotion. Until staff members 3 and 5 have the required qualifications, they will be paired with Y.D.P.L. staff who do meet the minimum qualifications. In the future, the unit director and administrative staff involved in hiring will review the options for education/training and minimum experience in the licensing standards to determine eligibility for staff positions. The qualifications of staff members will be documented in staff records.

Standard #: 22VAC40-185-550-M
Description: Based on a review of recent injury reports, and an interview with administrative staff, there were injury records that lacked some of the required information regarding parent notification. Evidence: Injury reports for July 22, 2015 and July 23, 2015 had phone calls documented as the method of parent notification and did not include the dates and times for the phone calls. An injury report from August 14, 2015 lacked documentation of the method, date and time of parent notification for a minor injury that was treated.

Plan of Correction: The unit director will make sure the most up-to-date injury report form is used by staff so that the time and date of parent notification has an assigned space on the form for documenting all required information. The unit director will review the requirements for documenting injuries with the staff. The unit director will make sure that the requirements for documenting injuries that are treated by staff with current first aid certification are taught during initial orientation training for new and temporary staff. All injury records will be reviewed by the director to determine the accuracy of the report before they are filed in the binder.

Standard #: 22VAC40-191-40-D-1-B
Description: Based on a review of five staff records, and an interview with the administrative staff, there was not a central registry search completed at the time of initial employment for staffs 2 (Repeat violation.). The background checks for staff member 4 were obtained late and not within the first thirty days of employment. Evidence: Staff member 2 began work in 2013 and there was only a sworn statement and criminal history record check in the staff files. Staff member 4 began work with children on June 25, 2015 and the criminal history record was obtained August 7, 2015. The central registry clearance for staff member 4 was obtained late on August 12, 2015. Both request forms were not received in Richmond until July 25, 2015 and July 28, 2015.

Plan of Correction: The administrative staff will arrange to mail the initial requests for the background checks within the first seven days of employment. The unit director started documenting the date the request forms are mailed to the agencies in Richmond. The request for the central registry clearance for staff member 2 was mailed in September. An administrative staff member will call the agency in Richmond to check on the processing of the background checks that have been requested and make sure they are obtained for the staff file. The unit director will use a checklist to track the records obtained for files and make sure all required information has been viewed and filed.

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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