Sign in
Back
The YMCA of South Hampton Roads- Ghent Elementary

Inspection · 2024-08-26

Date
2024-08-26
Complaint Related
No
Licensing Inspector
Trisha Brown
(757) 404-2601
SHSIA monitoring inspection of an approved subsidy vendor to determine compliance with current subsidy requirements regarding the health and safety of children and to promote quality standards for the children in their care.
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.
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect

Inspector Notes

An unannounced, on-site renewal inspection was initiated on August 26 and completed on August 27, 2024 as a part of the licensure period. The on-site inspection began at 7am and ended at 8:15am. The inspector reviewed compliance in the areas listed above. There were 14 children present and four staff. The inspector reviewed six children?s records on site and four staff records electronically on August 27, 2024. This inspection included document review, tour of the facility, interviews, and observations.

Information gathered during the inspection determined non-compliance with applicable standards or law, and violations are documented on the violation notice issued to the program.

Please complete the plan of correction (POC) and date to be corrected sections for each violation cited on the violation notice. Specify how the deficient practice will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on September 4, 2024 . A POC submitted after this date will not appear on the public website

Violations

11
Standard 22.1-289.035-A
Based on record review the center failed to ensure that background checks are updated within required time frames.
Evidence:
1 - The record for Staff #1 contains a fingerprint background check dated July 2, 2018. Therefore, the fingerprint is past due for update.
2 - The record for Staff #1 contains a Virginia central registry background check dated July 28, 2017. Therefore, the background check is past due for update.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.035-B-1
Based on record review the center failed to ensure that staff provide a sworn statement or affirmation prior to employment.
Evidence:
1 - The sworn statement or affirmation on file for Staff #3 is dated August 19, 2024. However, the documented date of hire is August 13, 2024. Therefore the sworn statement or affirmation was not obtained prior to employment.
2 - There is not documentation of sworn statement or affirmation on file for Staff #2. While there is not a documented date of hire the fingerprint on file for Staff #2 is dated May 30, 2023.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.035-B-3
Based on record review the center failed to obtain required background checks within required time frames.
Evidence;
1 - The record for Staff #2 does not contain any documentation of Virginia central registry background check. There is no documented date of hire on file. However, the fingerprint results were dated May 30, 2023.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-130-A
Based on record review and interview the center failed to ensure that immunizations are obtained with the required time frame.
Evidence:
1 - The record for Child #1 did not contain any documentation of immunization documentation.
2 - Staff #1 confirmed that the immunization documentation was not available at the center.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-140-A
Based on record review the center failed to obtain a physical examination for each child.
Evidence:
T1 - he record for Child #1 did not have any documentation that a physical examination was obtained before the child's first day of attendance or within 30 days after the first date of attendance.
2 - Staff #1 confirmed that the physical examination for Child #1 was not available for review during the inspection.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-160-A
Based on record review the center failed to ensure that tuberculosis (TB) screenings are obtained within required time frames.
Evidence:
1 - The record for Staff #4 did not contain any documentation of TB screening with documented date of hire of December 15, 2023.
2 - The record for Staff #3 contains TB screening dated January 17, 2024. However, the documented date of hire is August 13, 2024. Therefore the documented TB screening was obtained within the required 30 days of employment.
3 - The record for Staff #2 contains a TB screening dated May 6, 2024. While there is not a documented date of hire, the fingerprint on file is dated May 30, 2023. Therefore, the screening was not obtained within the required 30 days of employment.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-160-C
Based on record review the center failed to ensure that tuberculosis (TB) screening is obtained at least every two years.
Evidence:
The record for Staff #1 contains a TB screening dated June 18, 2019. The screening is past due for update.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-40-H
Based documentation review the center failed to provide documentation of liability insurance.
Evidence:
The documentation of liability insurance available during the inspection expired on January 1, 2024.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-550-A
Based on documentation review the center failed to maintain a written emergency preparedness plan.
Evidence:
The emergency preparedness available at the center during the inspection was for another licensed center and the Ghent Elementary center.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-550-H
Based on record review the center failed to maintain a record of the dates of the emergency practice drills for one year.
There was not any documentation of any emergency evacuation drills available for review during the inspection.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-70
Based on record review the center failed to ensure that staff records are maintained as required.
Evidence:
1 - The record for Staff #2 did not contain documentation of age verification, date of hire, or reference checks.
2 - The record for Staff #3 and #4 did not contain documentation of age verification.
3 - The record for Staff #4 contains one complete reference where two are required. The incomplete reference did not include a signature or the date.
Plan of Correction: Not available online. Contact Inspector for more information.