VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Young Men's Christian Association of Greater Richmond-Spring Run
13901 N. Spring Run Road
Midlothian, VA 23112
(804) 549-6578

Current Inspector: Molly Muscat (804) 588-2367

Inspection Date: April 19, 2022

Complaint Related: No

Areas Reviewed:

8VAC20-780 Administration. 8VAC20-780 Staff Qualifications and Training. 8VAC20-780 Physical Plant. 8VAC20-780 Staffing and Supervision. 8VAC20-780 Programs. 8VAC20-780 Special Care Provisions and Emergencies. 8VAC20-780 Special Services. 8VAC20-820 THE LICENSE. 8VAC20-820 THE LICENSING PROCESS. 8VAC20-770 Background Checks (8VAC20-770) 22.1 Background Checks Code, Carbon Monoxide

Comments:

An unannounced monitoring inspection was conducted on-site on April 19, 2022 and concluded remotely on April 21, 2022. The director was available during the inspection. There were 19 children present, ranging in ages from 6 years to 10 years, with 3 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of 5 child records and 5 staff records were reviewed. Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program. 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 today. Please 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 preventative measures. Please do not use staff names; list staff by positions only.

Violations:

Standard #:	22.1-289.035-B-2
Description:	Based on a review of records and interview, the center did not ensure to obtain a fingerprint based national criminal record check prior to the first day of employment for each staff. Evidence: The record of staff #5 (hired on 10/7/21) contained documentation of fingerprints dated 9/3/22. Administration confirmed they were late.
Plan of Correction:	We are sending staff #5 to get fingerprints again. If this is not corrected staff #5 will be taken off the schedule.
Standard #:	22.1-289.035-B-4
Description:	Based on a review of records and interview, the center did not ensure to obtain a copy of the results of a criminal history record check prior to the first day of employment from any state in which the applicant has resided in the preceding five years. Evidence: The record of staff #2 (hired on 2/25/22) did not contain documentation of an out-of-state criminal name search. Staff #2 indicated living out of the state in the previous five years on the staff's sworn disclosure statement. Administration acknowledged the out of state check was not complete.
Plan of Correction:	We are working with our HR team to complete this criminal name search and have produced a plan.
Standard #:	8VAC20-770-60-B
Description:	Based on a review of staff records, the center did not ensure to obtain a Sworn Statement from each staff prior to employment. Evidence: The record of staff #1 (hired on 5/25/21) contained documentation of a sworn statement dated 10/18/22.
Plan of Correction:	Moving forward we will make sure all sworn statements are signed before hire date with administration.
Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of staff records and interview, the center did not ensure that each staff record reviewed contained a central registry finding within 30 days of employment. Evidence: 1. The record of staff #2 (hired on 2/25/22) contained documentation of central registry results dated 4/5/22. 2. The record of staff #3 (hired on 11/22/21) contained documentation of central registry results dated 4/18/22. 3. The record of staff #5 (hired on 10/7/21) contained documentation of central registry results dated 4/18/22. 4. Administration acknowledged the central registry checks were late.
Plan of Correction:	Administration will be keeping closer records of our 30 day follow up with all CRS.
Standard #:	8VAC20-780-150-B
Description:	Based on a review of children's records, the center did not ensure that physicals and immunizations received shall be signed by a physician, his designee, or an official of the local health department. Evidence: 1.. The record of child #3 (DOE 8/23/21) and child #5 (DOE 10/15/21) contained documentation of immunizations that were not signed by a physician, physician's designee or an official of the local health department. 2.. The record of child #5 (DOE 10/15/21) contained documentation of a physical that was not signed by a physician, physician's designee or an official of the local health department.
Plan of Correction:	We will fix all child files with proper records.
Standard #:	8VAC20-780-60-A
Description:	Based on observation and interview on April 19, 2022, the center did not maintain and keep at the center a separate record for each child enrolled which contains the required information. Evidence: 1. During a discussion with administration it was stated that children's records are kept electronically. Administration indicated the children's records were unable to be accessed on-site through the center's electronic system due to poor internet connection. The children's records had to be requested to be sent remotely. 2. The record of child #1 (DOE 12/16/21) and child #4 (DOE 8/23/21) did not contain documentation of a name, address, and phone number for two individuals to contact in an emergency. 3. The record of child #5 (DOE 10/15/21) did not contain documentation of the name, address, and phone number of a second person to contact in an emergency.
Plan of Correction:	Moving forward we will make sure to always have access to child files and will fix all child file violations.
Standard #:	8VAC20-780-540-B
Description:	Based on observation and interview on April 19, 2022, the center did not maintain the required first aid kit supplies. Evidence: There was no first aid manual in the kit. Administration acknowledged there was no manual.
Plan of Correction:	We have already purchased and replaced first aid kit items.
Standard #:	8VAC20-780-540-D
Description:	Based on observation and interview on April 19, 2022, the center did not maintain the required emergency supplies at the center. Evidence: There was no ice pack available. Administration acknowledged the center didn't have an ice pack.
Plan of Correction:	We have already purchased and replaced all emergency kit items.
Standard #:	8VAC20-780-540-E
Description:	Based on observation and interview on April 19, 2022, the center did not maintain the required nonmedical emergency supplies. Evidence: There was no flashlight available at the center. Administration acknowledged the center didn't have a flashlight.
Plan of Correction:	We have already purchased and replaced all emergency kit items.