VIRGINIA DEPARTMENT OF SOCIAL SERVICES

YMCA Alexandria
420 E. Monroe Ave
Alexandria, VA 22301
(703) 838-8085

Current Inspector: Jenifer Nalli (703) 309-9153

Inspection Date: Feb. 19, 2020 and Feb. 27, 2020

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 SPECIAL SERVICES. 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 SANCTIONS. 22VAC40-80 HEARINGS PROCEDURES. 22VAC40-191 Background Checks (22VAC40-191) 32.1 Report by person other than physician 63.2 Child Abuse & Neglect 63.2 Facilities & Programs.

Comments:

An unannounced investigation was conducted 02/19/2020 and 02/27/2020 in response to a self- reported incident regarding sight and sound supervision of a child under 10 years old. During the investigation, staff were interviewed, staff and children's files were reviewed, the entrance of the school was observed and the distance between the playground and the facility was measured. The preponderance of evidence supports the allegation; therefore, violations were cited related to the self-reported incident. A violation not related to the reported incident was also cited. Please see violation notice for details. The exit interview was conducted with the executive director via email. If you have any questions pertaining to this investigation, please contact Kimberly.Sawyer@dss.virginia.gov.

Violations:

Standard #:	22VAC40-185-40-E
Description:	Based on interviews and record review, the center did not comply with operational responsibilities of the license to include the center's own policies and procedures that are required by these standards Evidence: 1. The center's "Supervision Policy" states "Staff shall always be in sight and sound supervision of children". 2. According to the "Transition Procedures", before leaving the playground staff shall "Line kids along the fence; Take a head count and a face count; and Take attendance by calling out individual names". 3. Staff A confirmed training in the "Supervision Policy" on 05/2019. 4. Staff B confirmed training in the "Supervision Policy" on 10/01/2018. 5. Staff C confirmed training in the "Supervision Policy" on 06/2014, 04/06/2018, 04/16/2018, 06/08/2018,and 06/09/2018. 6. Staff D confirmed training in the "Supervision Policy" on 04/24/2019. 7. On 01/29/2020, Child A, 5 years old, was out of sight and sound supervision of staff for an undetermined amount of time.
Plan of Correction:	1. The incident was reported by Staff E, YMCA Program Director, to: a. Direct Supervisor, Staff F, Associate Executive Director b. Staff G, Executive Director 2. Staff E met with all of the staff involved to record their knowledge of the incident, and each of them put their reports in writing. 3. Staff E submitted an internal incident report with the staff reports attached. 4. Staff E and Staff F contacted the parent and informed her of the incident. 5. Staff E contacted Child Protective Services 6. Staff G, Executive Director, reported it to: a. YMCA of Metropolitan Washington Youth Development department b. Association Director of Licensing c. Director of Corporate Services d. Direct Supervisor, Vice President of Operations 7. We received a response from CPS deeming the incident an accident requiring no further action. 8. YMCA Association Director of Licensing interviewed all of the staff involved to question them on the incident and have them to review with her their understanding of appropriate protocols. 9. After meeting with staff, the Association Director of Licensing met with Staff E, Staff F, and Staff G to review her findings and make recommendations. 10. Staff E updated and reviewed with each staff the transition procedures and had each one sign off on them.
Standard #:	22VAC40-185-60-A
Description:	Based on record review, the record of each child did not include all required information. Evidence: The file of Child A was missing the mother's employer phone number.
Plan of Correction:	Parents will update record.
Standard #:	22VAC40-185-70-A
Description:	Based on record review, staff records did not include required information. Evidence: Staff A, B, C and D did not have an address for their emergency contact.
Plan of Correction:	Forms will be updated and staff will complete forms.
Standard #:	22VAC40-185-240-A
Description:	Based on record review and interview, documentation of orientation was not maintained for each staff. Evidence: There was no documentation of initial orientation for Staff D.
Plan of Correction:	Staff was retrained.
Standard #:	22VAC40-185-240-C
Description:	Based on record review and interview, staff who work directly with children did not annually attend 16 hours of staff development activities. Evidence: 1. Staff B, C, and D did not have 16 hours of training for 2019. There were no training hours available to be viewed. 2. Staff E stated she could not locate the training documents for Staff B, C and D.
Plan of Correction:	Staff will maintain training for 2020.
Standard #:	22VAC40-185-340-A
Description:	Based on interviews, when supervising children staff did not always ensure their care and protection. Evidence: 1. On 01/29/2020, Staff left Child A( 5 years old), alone on the playground without supervision of staff for an undetermined amount of time. 2. Staff B stated all children and staff were outside for a special visit from the local fire department where children were observing the truck. After the visit, all children and staff went to the playground. When it was time to go inside, staff called for the children to line up and children and staff walked into the building. About 10-15 minutes later, a neighborhood adult brought Child A into the school and explained to Staff A that the child was found outside on the playground. 3. Staff A stated Child A was in line on the way into the school and believes Child A was out sight and sound supervision for approximately 3-5 minutes. 4. Staff A and B confirm they were unaware that Child A was left outside on the playground until Child A was brought back to the school age room.
Plan of Correction:	1. The incident was reported by Staff E, YMCA Program Director, to: a. Direct Supervisor, Staff F, Associate Executive Director b. Staff G, Executive Director 2. Staff E met with all of the staff involved to record their knowledge of the incident, and each of them put their reports in writing. 3. Staff E submitted an internal incident report with the staff reports attached. 4. Staff E and Staff F contacted the parent and informed her of the incident. 5. Staff E contacted Child Protective Services 6. Staff G, Executive Director, reported it to: a. YMCA of Metropolitan Washington Youth Development department b. Association Director of Licensing c. Director of Corporate Services d. Direct Supervisor, Vice President of Operations 7. We received a response from CPS deeming the incident an accident requiring no further action. 8. YMCA Association Director of Licensing interviewed all of the staff involved to question them on the incident and have them to review with her their understanding of appropriate protocols. 9. After meeting with staff, the Association Director of Licensing met with Staff E, Staff F, and Staff G to review her findings and make recommendations. 10. Staff E updated and reviewed with each staff the transition procedures and had each one sign off on them.
Standard #:	22VAC40-185-340-F
Description:	Based on interviews, children under 10 years of age were not always within sight and sound supervision of staff. Evidence: On 01/29/2020, Child A (5 years old) was alone on the playground, out of sight and sound supervision of staff for an undetermined amount of time. 2. Staff B stated she noticed a child was left behind when a the neighborhood parent brought him back into the center. 3. Staff A stated Child A was in line on the way into the school and believes Child A was out sight and sound supervision for approximately 3-5 minutes.
Plan of Correction:	1. The incident was reported by Staff E, YMCA Program Director, to: a. Direct Supervisor, Staff F, Associate Executive Director b. Staff G, Executive Director 2. Staff E met with all of the staff involved to record their knowledge of the incident, and each of them put their reports in writing. 3. Staff E submitted an internal incident report with the staff reports attached. 4. Staff E and Staff F contacted the parent and informed her of the incident. 5. Staff E contacted Child Protective Services 6. Staff G, Executive Director, reported it to: a. YMCA of Metropolitan Washington Youth Development department b. Association Director of Licensing c. Director of Corporate Services d. Direct Supervisor, Vice President of Operations 7. We received a response from CPS deeming the incident an accident requiring no further action. 8. YMCA Association Director of Licensing interviewed all of the staff involved to question them on the incident and have them to review with her their understanding of appropriate protocols. 9. After meeting with staff, the Association Director of Licensing met with Staff E, Staff F, and Staff G to review her findings and make recommendations. 10. Staff E updated and reviewed with each staff the transition procedures and had each one sign off on them.
Standard #:	22VAC40-191-60-C-2
Description:	Based on record review, staff did not have complete central registry results within 30 days of being hired. Evidence: Staff A was hired 09/12/2019 and a central registry search had not been completed.
Plan of Correction:	The director said she will redo the search.