Inspection · 2021-04-01
Date
2021-04-01
Complaint Related
No
Licensing Inspector
Adrianna Walden
(757) 404-2487
(757) 404-2487
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
22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 SPECIAL SERVICES.
22VAC40-191 Background Checks (22VAC40-191)
63.2(17) License & Registration Procedures
Inspector Notes
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 4/1/21 and concluded on 4/22/21. A self-reported incident was received by the department on 3/31/21 regarding an unattended and unsupervised child. The director was contacted by telephone to conduct the investigation. The inspector did a virtual tour of the center and conducted interviews of staff. The evidence gathered during the investigation resulted in violations of the standards that are listed on the violation report.
Violations
8Standard 22VAC40-185-340-A
Based on interviews, a virtual tour of the facility, including the outdoor areas and parking lots, and a review of documentation, it was determined that the licensee did not ensure that when staff are supervising children, they shall always ensure their care, protection, and guidance.
Evidence:
1. On March 31, 2021, at approximately 8:20 AM, child #1 (seven years old) was left unattended and unsupervised on the facility's bus for approximately two to three minutes.
2. When child #1 realized he was on the bus alone, he exited the bus. He then walked through the parking lot through the front doors into the facility and was found by staff #3 (front desk receptionist). Staff # 3 made sure child #1 was okay and then informed staff #2 (Program Director) about the incident.
3. The bus was not parked curbside to the facility. It was located in the parking lot which is shared by multiple businesses and that is adjacent to a heavily traveled road (45 MPH speed limit).
4. Staff #1 said he was unaware that child #1 had gotten on the bus when it originally left the center to transport children to the local public schools.
5 According to Weather Underground, the temperature was between 44-45 degrees from 7:51am-8:51am on 3/31/2021.
6. Staff #1 confirmed that was supposed to walk to the back of the bus to disengage the passenger alarm after each trip to insure all passengers have exited the bus and that he did not do that.
Evidence:
1. On March 31, 2021, at approximately 8:20 AM, child #1 (seven years old) was left unattended and unsupervised on the facility's bus for approximately two to three minutes.
2. When child #1 realized he was on the bus alone, he exited the bus. He then walked through the parking lot through the front doors into the facility and was found by staff #3 (front desk receptionist). Staff # 3 made sure child #1 was okay and then informed staff #2 (Program Director) about the incident.
3. The bus was not parked curbside to the facility. It was located in the parking lot which is shared by multiple businesses and that is adjacent to a heavily traveled road (45 MPH speed limit).
4. Staff #1 said he was unaware that child #1 had gotten on the bus when it originally left the center to transport children to the local public schools.
5 According to Weather Underground, the temperature was between 44-45 degrees from 7:51am-8:51am on 3/31/2021.
6. Staff #1 confirmed that was supposed to walk to the back of the bus to disengage the passenger alarm after each trip to insure all passengers have exited the bus and that he did not do that.
Plan of Correction: The facility responded: As of 4/22/2021 Buses will only board and offload against the curb. They are not to have any children walk across the parking lot at any time. All staff will ensure that they walk the bus to make sure no children are left unattended on the bus.
Standard 22VAC40-185-340-F
Based on interviews and a review of documentation, it was determined that the licensee did not ensure that children under 10 years of age always shall be within actual sight and sound supervision of staff.
Evidence:
1. On March 31, 2021, at 8:20 AM, child #1 (seven years old) was left alone and unsupervised by staff #1 for approximately two to three minutes when he was left on the bus at the conclusion of the morning bus run to drop off children at the local public schools.
2. Staff #1 and staff #2 (Program Director) confirmed that child #1 was not within actual sight and sound supervision of any staff as he was left on the bus which was parked in the parking lot in front of the facility upon returning from the local public school.
Evidence:
1. On March 31, 2021, at 8:20 AM, child #1 (seven years old) was left alone and unsupervised by staff #1 for approximately two to three minutes when he was left on the bus at the conclusion of the morning bus run to drop off children at the local public schools.
2. Staff #1 and staff #2 (Program Director) confirmed that child #1 was not within actual sight and sound supervision of any staff as he was left on the bus which was parked in the parking lot in front of the facility upon returning from the local public school.
Plan of Correction: The facility responded: As of 4/1/2021 - In relation to ensuring no children are left on the bus: All staff have been retrained on the procedures as of April 2nd, 2021. When arriving at the YMCA the accurate count of children will be told to the counselor checking in the children on the roster. This will be done prior to the children entering the building and before the bus parks, as to ensure all children are accounted for. Program staff who are riding the bus will check the bus to ensure no children are remaining before they get off the bus and enter the YMCA. They will do a head/face count along with checking the roster to ensure all children are accounted for. All bus drivers will ensure they walk to the back of the bus to disengage the alarm on the back door and to ensure no children are left on the bus prior to parking and exiting the bus. If a child did not get off the bus at the right location, the driver will notify their supervisor immediately and ensure the child gets transported safely to their destination.
Standard 22VAC40-185-40-E
Based on a review of the facility's policies and interviews, it was determined that the licensee did not ensure that the facility follows its own policies and procedures for supervision and transportation.
Evidence:
1. The facility's policy states that "The bus driver will adhere to the YMCA of South Hampton Roads' standard practices with regards to ensuring that no child has been left on the bus." One of the requirements for bus drivers states that the driver will "disengage passenger alarm after each trip to insure all passengers have exited the bus".
2. Staff #1 confirmed that after he parked the bus upon returning from the local public schools he did not walk the inside of the bus and check all the seats on the bus to ensure no child was unattended and unsupervised, or disengage the passenger alarm at the rear of the bus. As a result of staff #1 not following the facility's policy, child #1 was left on the bus.
Evidence:
1. The facility's policy states that "The bus driver will adhere to the YMCA of South Hampton Roads' standard practices with regards to ensuring that no child has been left on the bus." One of the requirements for bus drivers states that the driver will "disengage passenger alarm after each trip to insure all passengers have exited the bus".
2. Staff #1 confirmed that after he parked the bus upon returning from the local public schools he did not walk the inside of the bus and check all the seats on the bus to ensure no child was unattended and unsupervised, or disengage the passenger alarm at the rear of the bus. As a result of staff #1 not following the facility's policy, child #1 was left on the bus.
Plan of Correction: The facility responded: As of April 2nd the bus drive has been retrained on our policies for bus procedures prior to exiting the bus.
Standard 22VAC40-185-580-D
Based on interviews, it was determined that the facility did not ensure that children shall enter and leave the vehicle from the curb side of the vehicle or in a protected parking area or driveway.
Evidence:
1. Staff #1 returned from dropping off children at the local public schools and parked the facility's van in a public parking lot with moving traffic that is shared by several business. The bus was located in a parking space that was not curbside to the center.
2. When child #1 exited the bus, he had to cross the parking lot alone and unsupervised to enter the facility.
Evidence:
1. Staff #1 returned from dropping off children at the local public schools and parked the facility's van in a public parking lot with moving traffic that is shared by several business. The bus was located in a parking space that was not curbside to the center.
2. When child #1 exited the bus, he had to cross the parking lot alone and unsupervised to enter the facility.
Plan of Correction: The facility responded: As of 4/22/2021 Buses will only board and offload against the curb. They are not to have any children walk across the parking lot at any time. All staff will ensure that they walk the bus to make sure no children are left unattended on the bus prior to the bus parking.
Standard 22VAC40-185-580-K
Based on interviews and a review of documentation, it was determined that the licensee did not ensure that staff shall verify that all children have been removed from the vehicle at the conclusion of any trip.
Evidence:
1. On March 31, 2021, staff #1 completed his bus run after dropping children off at the local public schools by parking the bus and entering the facility at approximately 8:20am. However, staff #1 did not verify to see if all children had been removed from the bus because child #1 was still on the bus.
2. When staff #1 was asked if he had checked the bus to make sure all the children were off at the conclusion of his bus run, staff #1 stated that he did not walk to the back of the bus to ensure all children had exited the vehicle.
Evidence:
1. On March 31, 2021, staff #1 completed his bus run after dropping children off at the local public schools by parking the bus and entering the facility at approximately 8:20am. However, staff #1 did not verify to see if all children had been removed from the bus because child #1 was still on the bus.
2. When staff #1 was asked if he had checked the bus to make sure all the children were off at the conclusion of his bus run, staff #1 stated that he did not walk to the back of the bus to ensure all children had exited the vehicle.
Plan of Correction: The facility responded: As of April 2nd the bus drive has been retrained on our policies for bus procedures prior to exiting the bus.
When arriving at the YMCA the accurate count of children will be told to the counselor checking in the children on the roster. This will be done prior to the children entering the building and before the bus parks, as to ensure all children are accounted for. Program staff who are riding the bus will check the bus to ensure no children are remaining before they get off the bus and enter the YMCA. They will do a head/face count along with checking the roster to ensure all children are accounted for. All bus drivers will ensure they walk to the back of the bus to disengage the alarm on the back door and to ensure no children are left on the bus prior to parking and exiting the bus. If a child did not get off the bus at the right location, the driver will notify their supervisor immediately and ensure the child gets transported safely to their destination.
When arriving at the YMCA the accurate count of children will be told to the counselor checking in the children on the roster. This will be done prior to the children entering the building and before the bus parks, as to ensure all children are accounted for. Program staff who are riding the bus will check the bus to ensure no children are remaining before they get off the bus and enter the YMCA. They will do a head/face count along with checking the roster to ensure all children are accounted for. All bus drivers will ensure they walk to the back of the bus to disengage the alarm on the back door and to ensure no children are left on the bus prior to parking and exiting the bus. If a child did not get off the bus at the right location, the driver will notify their supervisor immediately and ensure the child gets transported safely to their destination.
Standard 22VAC40-191-60-B
Based on a review of one staff record, it was determined that the facility did not ensure that the facility did not ensure that an employee must not be employed until a sworn statement or affirmation has been completed.
Evidence:
1. The record for staff #1 (date of hire 8/30/19) did not contained a completed sworn statement or affirmation.
2. Staff #2 (Program Director) confirmed that there was not a complete sworn statement or affirmation for staff #1 available for viewing during the inspection.
Evidence:
1. The record for staff #1 (date of hire 8/30/19) did not contained a completed sworn statement or affirmation.
2. Staff #2 (Program Director) confirmed that there was not a complete sworn statement or affirmation for staff #1 available for viewing during the inspection.
Plan of Correction: The facility responded: The necessary Sworn Statement of Affirmation was completed on April 2nd, 2021
Standard 22VAC40-191-60-C-2
Based on a review of one staff record, it was determined that the facility did not deny continued employment of a staff who did not have a search of the central registry finding within 30 days of employment.
Evidence:
1. The record for staff #1 (date of hire 8/30/19) did not contain documentation of a completed search of the central registry finding.
2. Staff #2 (Program Director) reviewed the record for the staff #1, and confirmed that the search of the central registry finding has not been received.
Evidence:
1. The record for staff #1 (date of hire 8/30/19) did not contain documentation of a completed search of the central registry finding.
2. Staff #2 (Program Director) reviewed the record for the staff #1, and confirmed that the search of the central registry finding has not been received.
Plan of Correction: The facility responded: A CPS check was completed and mailed out on April 6th. Results from this were returned back on April 14th, 2021 and returned no result.
Standard 63.2(17)-1720.1-B-2
Based on a review of one staff record, it was determined that the facility did not ensure that an employee is allowed to begin employment without a completed national criminal history record check (finger printing).
Evidence:
1. The record for staff #1 (date of hire 8/30/19) did not contain documentation of a completed national criminal history record check (finger printing).
2. Staff #2 (Program Director) reviewed the record for the staff #1 and confirmed that the results of the finger print background check (finger printing) were not available for viewing during the inspection.
Evidence:
1. The record for staff #1 (date of hire 8/30/19) did not contain documentation of a completed national criminal history record check (finger printing).
2. Staff #2 (Program Director) reviewed the record for the staff #1 and confirmed that the results of the finger print background check (finger printing) were not available for viewing during the inspection.
Plan of Correction: The facility responded: A fIngerprint appointment was made for April 10th. Results from this were returned back on April 15th, 2021 as eligible.