VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Young Men's Christian Association of Greater Richmond - Munford
211 Westmoreland Street
Richmond, VA 23226
(804) 780-6267

Current Inspector: Jennifer Moore (540) 430-0384

Inspection Date: Oct. 13, 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) 20 Access to minors records 22.1 Background Checks Code, Carbon Monoxide 22.1 Early Childhood Care and Education

Comments:

An unannounced monitoring inspection was initiated on 10/13/2022 and concluded on 10/17/2022. The inspector was on site on 10/13/2022 from approximately 2:45 pm-3:55 pm. There were 49 children present, ranging in ages from five (5) to 10 years, with five (5) staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies, nutrition and background checks. A total of five (5) child records and four (4) staff records were reviewed. Staff records were reviewed remotely on 10/14/2022 and 10/17/2022. 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. You will need to specify how the deficient practice will be or has been corrected. Just writing the word corrected is not acceptable. Your plan of correction must 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 #:	8VAC20-770-60-B
Description:	Based on a review of four (4) staff records and interview, the center did not ensure that one (1) staff had a completed sworn statement prior to the first date of employment as required. Evidence: 1. The record of staff #4 (date of employment: 10/8/2022) did not contain a completed sworn statement. 2. Administration acknowledged that the sworn statement was missing from the record.
Plan of Correction:	We already had the staff redo this background check
Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of four (4) staff records and interview, the center did not ensure to obtain a central registry finding for one (1) staff within 30 days of employment as required. Evidence: 1. The record of staff #1 (date of employment: 09/08/2021) contained a central registry finding dated 05/04/2022. 2. Administration acknowledged that the findings were not obtained within the required time frame.
Plan of Correction:	we have been focusing on better systems of follow up for our CRS-we will make sure paper records are kept.
Standard #:	8VAC20-780-140-A
Description:	Based on a review of five (5) children?s records and interview, the center did not ensure that one (1) child had a physical examination by or under the direction of a physician: 1. Before the child's attendance; or 2. Within 30 days after the first day of attendance. Evidence: 1. The record of child #4 (date of attendance: 08/29/2022) did not contain a physical report. 2. Administration acknowledged that the report had not been obtained.
Plan of Correction:	We will make sure all child files are completed and corrected.
Standard #:	8VAC20-780-40-E
Description:	Based on review of documentation, observation, and interview, the center did not ensure that the center's services were maintained in compliance with the center's own policies and procedures that are required by the standards. Evidence: 1. The record of child #1 (date of enrollment: 8/29/2022) contained a current medication authorization. The medication in the center?s lock box expired in July of 2022. The center?s procedure for methods to prevent use of outdated medication stated that ?If medication is found to be out-of-date, the medication must be immediately returned to the locked location?when the child is picked up that same day, the medication must be handed in person to the parent/legal guardian for their disposal?Staff are responsible for completing a medication checklist once a month in order to stay on top of expiring medications and authorization forms.? 2. Administration acknowledged that the medication was expired and had not been returned to the parent.
Plan of Correction:	we will reach out to the families to make sure we receive all required documents. We will make sure all medication is checked and returned to parents.