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Young Men's Christian Association of Greater Richmond-Walnut Hil

Inspection · 2022-03-24

Date
2022-03-24
Complaint Related
No
Licensing Inspector
Molly Muscat
(804) 588-2367
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.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Early Childhood Care and Education
32.1 Report by person other than physician
63.2 Child Abuse & Neglect

Inspector Notes

This inspection was conducted by licensing staff using an alternate remote protocol, including telephone contacts, documents review, and a virtual tour of the program.

A monitoring inspection was initiated on 3/24/2022 and concluded on 03/28/2022. The director was contacted by telephone and a virtual inspection was conducted. There were 33 children present, ranging in ages from 5 to 12 years, with 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 3 child records and 3 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. 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

5
Standard 8VAC20-770-60-C-2
Based on record review and interview, the center did not ensure to obtain the results of a central registry background check within 30 days of employment for 2 staff as required.

Evidence:
1. The record of staff #2 (DOH: 11/22/2021) contained a central registry check dated 1/24/2022. The record of staff #3 (DOH: 1/19/2022) did not contain the results of a central registry background check.
2. Administration acknowledged that the background checks were not received within the required time frame.
Plan of Correction: create a better system for CRS checks
Standard 8VAC20-780-160-A-1
Based on record review and interview, the center did not ensure that documentation of a tuberculosis (TB) screening was submitted for each staff at the time of employment and prior to coming into contact with children.

Evidence:
1. The record of staff #2 (DOH: 11/22/2021) contained a TB screening dated 12/2/2021. The record of staff # 3 (DOH: 1/19/2022) did not contain a TB screening.
2. Administration acknowledged that the screenings ere not received within the required time frame.
Plan of Correction: have staff go and get TB
Standard 8VAC20-780-240-A
Based on record review and interview, the center did not ensure that each staff completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment as required.

Evidence:
1. The record of staff #2 (DOH: 11/22/2021) did not contain documentation to show the department sponsored course had been completed within 90 days of employment.
2. Administration acknowledged that the training had not been completed.
Plan of Correction: add to onboarding process
Standard 8VAC20-780-60-A
Based on record review and interview, the center did not ensure that each enrolled child had a record that contained all of the required information.

Evidence:
1. The records of child #1 (DOE:9/20/2021), child #2 (DOE:9/20/2021) and child #3 (DOE: 10/18/2021) did not contain complete information to include the name, address, and phone number of two designated people to call in an emergency if a parent could not be reached.
2. Administration acknowledged that each of the reviewed records were missing components of the emergency contact information.
Plan of Correction: work with the families to correct their accounts
Standard 8VAC20-780-70
Based on record review and interview, the center did not ensure that each staff's record contained all of the required information.

Evidence:
1. The record of staff #2 (DOH: 11/22/2021) did not contain record of the staff's orientation training.
2. The record of staff # 3 (DOH: 1/19/2022) did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment.
3. Administration acknowledged that the records were not complete.
Plan of Correction: create a more consistent onboarding process
View original record on Virginia Department of Social Services