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Boys & Girls Clubs of Harrisonburg & Rockingham Co.-Spotswood
400 Mountain View Drive
Harrisonburg, VA 22801
(540) 434-6060

Current Inspector: Maureen Gallagher-McLeod (540) 430-9259

Inspection Date: April 5, 2017

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, staff qualifications, children's records, posted emergency procedures, storage of hazardous substances, and sight supervision. The risk assessments for violations were provided. We reviewed the requirements for injury records.

Comments:
Thank you for your assistance during the unannounced renewal inspection conducted from 1:15 PM to 2:50 PM at the main office for the staff record review and from 3:20 PM to 6:15 PM at the school site. Today, there were thirty-three school age children with three to four staff. One student intern was assisting staff. I viewed program activities, staffing, supervision, interactions with children, posted information, five records for staff, staff qualifications, staff training, five records for children, agency inspections, insurance, procedures, snack/menu, daily routines, injury records, emergency supplies and drill records, indoor and outdoor areas. The children enjoyed active play in the gym and outside on the playground. Computer time and homework assistance have been regularly offered. Art and table activities have been available in the cafeteria. Staff were observed providing communication with parents regarding children's experiences and time in the program. The recommendation for issuance of the license will be determined after receipt of the required background checks for one new board officer. Let me know if you need any assistance. 540/430-9259

Violations:
Standard #: 22VAC40-185-140-A
Description: Based on a review of five records for children, and an interview with administrative staff, there were not any physical examination records obtained for the files. (Repeat violation.) Evidence: There were only copies of school computer records listing immunization dates. The administrative staff at the unit indicated that the reports were not requested.

Plan of Correction: The unit director or administrative staff will request and obtain copies of the physical examination records from the parents. The unit director will make sure all current enrolled children have copies of physical examination reports in the files. The administrative staff will make sure all new children's parents provide copies of physical examination reports no later than the first month of attendance. A periodic review of records will be conducted to check that all records are complete.

Standard #: 22VAC40-185-150-B
Description: Based on a review of five records for children, and an interview with administrative staff, the immunization records in the files did not include signatures by a physician or designee. (Repeat violation.) Evidence: There were only copies of the the school's computer record of individual immunization dates in the four records viewed. The records did not include signatures by the health care providers and dates for the reports. The administrative staff indicated that these were the records obtained for every enrolled child.

Plan of Correction: The unit director or administrative staff will request and obtain copies of immunization reports that include signatures by the health care provider. The copy of the school's maintained computer record of dates will not be accepted for children's records. The staff who enroll new children will check to make sure the signed immunization report has been received before children begin attending after school.

Standard #: 22VAC40-185-60-A
Description: Based on a review of five records for children, and an interview with administrative staff, there was not information for two emergency contacts, other than the parents, in the record of child 4. Evidence: The section of the registration form for the names, addresses and phone numbers of emergency contacts were not completed. The staff indicated that the emergency contact information was not located in other forms.

Plan of Correction: The unit director or assigned staff will obtain the required information for two emergency contacts for child 4. The unit director will review the children's records to make sure they contain all required information. The administrative staff who enroll new children will make sure the forms are completed to include all required information by the first date of attendance.

Standard #: 22VAC40-185-70-A
Description: Based on a review of five staff records, and interviews with administrative staff, there was required information missing from the records of staff member 1, 3 and 4. Evidence: The start date and change of position was not documented for staff member 1. The start date and position was not in the record for staff member 4. There were no documented reference checks for staff member 3 and 4. There was not a copy of the most recent college transcripts or degree to show the highest level of education for staff member 1. The records of staff member 3 and 4 did not have background information regarding experience (no application, resume or documented programmatic experience) and education/training (no college transcripts/training). Incomplete orientation training in the file for staff member 4.

Plan of Correction: The unit director or assigned administrative staff will obtain the missing information and place it in each record. A minimum of two references will be obtained for staff member 3 and 4. Staff position titles and effective dates will be recorded in the records. Staff members 1, 3 and 4 will provide college transcripts. Dates and positions for all applicable experience will be written for the records. The unit director will complete the orientation training form with staff member 4.

Standard #: 22VAC40-185-210-A
Description: Based on a review of five records for staff, and interviews with administrative staff, staff member 3 was hired in October 2016 as a program leader without meeting the qualification requirements for the position. Evidence: The transcripts for completed college courses were not in the record and the staff member indicated she has studied a child related field. There was no verification of the minimum programmatic experience required (six months) and no completion of training in required topics.

Plan of Correction: The unit director will make sure the transcripts and documented hours/months of programmatic experience are added to the file of staff member 3. Also, the minimum twenty-four hours of training in required topics will be completed to supplement the college courses. The administrative staff who hire program leaders will make sure the program leaders meet one of the options in the licensing standards for education/training and experience. The qualifications will be documented in each staff record.

Standard #: 22VAC40-185-280-B
Description: Based on observation of the activity areas used by children, and an interview with staff, there were hazardous substances that were not kept in a locked storage area and were accessible on a table in the gym and a computer room cabinet during afternoon check-in and activities. Evidence: The table at the south side wall of the gym had Clorox Clean-up wipes, Expo White Board Cleaner labeled "Combustible" and a pump container container of hand sanitizer labeled "Keep Out of Reach of Children" and with a content of sixty-two percent ethyl alcohol. The cabinet in the computer lab had Lysol wipes and a locking mechanism was not used on the cabinet doors.

Plan of Correction: The unit director will speak with school staff to arrange for the hazardous items used for school-related use moved out of the gym by the end of each school day. The director will speak with the computer teacher regarding moving the cleaning wipes or a lock will be installed on the cabinet door. The director will remind the program leaders to check areas and make sure hazardous substances are locked or removed. All staff who supervise children will check the areas prior to use each day and make sure all hazardous substances have been kept in locked storage areas and are not accessible to children in the program.

Standard #: 22VAC40-185-340-F
Description: Based on observation of the transition of a group of fifteen children, ages six to eight years, the majority of the children leaving the gym bathroom hallway were briefly without sight supervision in the stairway. Evidence: The inspector was entering the stairway from the hall and walking down stairs on the left side as children were coming through double doors from the gym bathroom hallway. There were up to eleven children seen walking upstairs, some stopped on the stairs or at the hall door, and no staff were within view. As the final four children came to the stairway door, they were with two staff.

Plan of Correction: The unit director will instruct the staff to transition children using procedures that keep children within sight of a staff person at all times. The unit director or administrative staff who conduct orientation training will provide consistent information about meeting all applicable licensing standards, including sight and sound supervision of the children. As needed, the administrative staff will provide additional training regarding the requirements for sight and sound supervision of children. The director and/or administrative staff will conduct periodic observations of the transitions of groups of children to make sure all required procedures for adherence to sight and sound supervision of children are followed as expected.

Standard #: 22VAC40-185-550-C
Description: Based on a review of the posted information, including the posted emergency procedures/maps, the procedures for all emergency evacuation routes and shelter-in-place routes were not posted in view to staff and children on each floor of the building. (Repeat Violation.) Evidence: The only posted emergency procedure/maps were seen in the computer lab and homework room and showed the primary evacuation routes from those activity rooms. There were no secondary routes for evacuation or procedures for shelter-in-place. There were not any posted procedures for the cafeteria area and the lower floor gym.

Plan of Correction: The assigned administrative staff and director will make sure the emergency procedures/maps for the primary and secondary evacuation routes and tornado warning shelter-in-place locations are posted in conspicuous locations for the staff and children to view on each floor of the building. The information will be applicable to the areas used during after school hours. The administrative staff will no longer assume that the school's posted emergency maps will show all required procedures for the after school program.

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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