Inspection · 2022-01-24
Date
2022-01-24
Complaint Related
No
Licensing Inspector
Rene Old
(757) 404-1784
(757) 404-1784
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.
8VAC20-770 Background Checks (8VAC20-770)
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced monitoring inspection was conducted on 05/29/2024 from 3:30 pm - 5:20 pm with an onsite inspection.
At the time of entrance there were a total of 40 children, ages 5 - 11 years, in care with 2 staff. Children were observed engaged in large motor games in the gym. Table games were observed in the cafeteria. Records were reviewed for seven children in care.
The inspection was concluded on 05/31/2024, from 10:30 am - 11:08 am, with a review of two staff records at the Greenbrier North Family YMCA.
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.
Violations
17Standard 22.1-289.011-F
Based on observation and interview the center failed to ensure that the findings of the most recent inspection shall be posted in a conspicuous place on the licensed premises.
Evidence:
1. The findings from the most recent monitoring inspection were not posted when the inspector arrived for the onsite inspection on 05/29/2024.
2. Staff 1 confirmed that the most recent licensing inspection documents were not posted.
Evidence:
1. The findings from the most recent monitoring inspection were not posted when the inspector arrived for the onsite inspection on 05/29/2024.
2. Staff 1 confirmed that the most recent licensing inspection documents were not posted.
Plan of Correction: The most recent inspection findings will be posted on the parent board.
Standard 8VAC20-770-60-C-2
Based on record review and interview the center failed to ensure that staff have a central registry finding within 30 days of employment.
Evidence:
1. Staff 2, hire date 09/07/2023, lacks the results of a central registry check.
2. Administrative staff stated there was not a central registry check on file for staff 2.
Evidence:
1. Staff 2, hire date 09/07/2023, lacks the results of a central registry check.
2. Administrative staff stated there was not a central registry check on file for staff 2.
Plan of Correction: A central registry check will be completed for staff #2 and added to the staff file.
Standard 8VAC20-780-130-A
Based on record review and staff interview, the center failed to obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center.
Evidence:
1. Documentation of current immunization information was not available for child 1.
a. Child 1 was in care during the inspection.
2. Staff 1 confirmed that immunization information was not on file for child 1.
Evidence:
1. Documentation of current immunization information was not available for child 1.
a. Child 1 was in care during the inspection.
2. Staff 1 confirmed that immunization information was not on file for child 1.
Plan of Correction: Immunization records for child 1 will be obtained and added to the child's file.
Standard 8VAC20-780-160-A
Based on record review, the center failed to ensure that the TB screening shall have been completed within the last 30 calendar days of the date of employment.
Evidence:
1. The TB screening for staff 2 was completed on 01/24/2022 which is more than 30 days prior to her hire date of 09/07/2023.
Evidence:
1. The TB screening for staff 2 was completed on 01/24/2022 which is more than 30 days prior to her hire date of 09/07/2023.
Plan of Correction: Administrative staff have instructed staff 2 to obtain an updated TB skin test. The results will be added to the staff file.
Standard 8VAC20-780-160-C
Based on record review and staff interview, the center failed to ensure that at least every two years from the date of the first initial screening or testing, staff members shall obtain and submit the results of a follow-up tuberculosis screening.
Evidence:
1. The most recent TB screening on file for staff 1 was completed on 08/27/2021.
2. Administrative staff stated this was the only TB screening on file for staff 1.
Evidence:
1. The most recent TB screening on file for staff 1 was completed on 08/27/2021.
2. Administrative staff stated this was the only TB screening on file for staff 1.
Plan of Correction: Administrative staff have instructed staff 1 to obtain an updated TB skin test. The results will be added to the staff file.
Standard 8VAC20-780-245-A
Based on record review and staff interview, the center failed to ensure that staff shall complete annually a minimum of 16 hours of training appropriate to the age of children in care.
Evidence:
1. There was no written documentation to confirm that staff 2 had completed 16 hours of required training in 2023.
a. Only 2 hours of annual training was listed on the training log for 2023.
2. Administrative staff stated no additional training logs were available for staff 2.
Evidence:
1. There was no written documentation to confirm that staff 2 had completed 16 hours of required training in 2023.
a. Only 2 hours of annual training was listed on the training log for 2023.
2. Administrative staff stated no additional training logs were available for staff 2.
Plan of Correction: Administrative staff will ensure that all training hours are logged in staff files to reflect training requirements are being met.
Standard 8VAC20-780-340-A
Repeat Violation
Based on observation, record review and staff interview, the center failed to ensure that when staff are supervising children, they shall always ensure their care and protection.
Evidence:
1. When the inspector arrived on 05/29/2024 for the onsite inspection, child 3 age 5 years, was observed sitting on the window ledge while twirling the cord from the window shade.
a. Staff 2, who was responsible for the supervision of child 3, was not aware that child 3 had climbed onto the window ledge until the inspector brought this to her attention.
2. On 03/01/2024, child 2, age 9 years, fell from the top of the outdoor slide when she ran up the slide to avoid being tagged by another child.
a. Staff 1 stated she was aware that another child had climbed up to the top of the slide to tag child 2 however, she did not provide any redirection or intervention to prevent the children from engaging in this activity.
b. Staff 1 stated that staff 2, who was sitting on the bench, did not provide any redirection to the children running up the slide to tag child 2.
c. This fall resulted in an injury to child 2 that required outside medical attention.
3. Staff 1 stated she did not have access to any written records or emergency contact information for child 2 to provide notification, to the parent, that their child had fallen from the top of slide slide on 03/01/2024.
a. Staff 1 stated she had to reach out to multiple administrative staff to obtain parental contact information for child 2 and that it took her approximately 15 minutes to receive emergency contact information.
Based on observation, record review and staff interview, the center failed to ensure that when staff are supervising children, they shall always ensure their care and protection.
Evidence:
1. When the inspector arrived on 05/29/2024 for the onsite inspection, child 3 age 5 years, was observed sitting on the window ledge while twirling the cord from the window shade.
a. Staff 2, who was responsible for the supervision of child 3, was not aware that child 3 had climbed onto the window ledge until the inspector brought this to her attention.
2. On 03/01/2024, child 2, age 9 years, fell from the top of the outdoor slide when she ran up the slide to avoid being tagged by another child.
a. Staff 1 stated she was aware that another child had climbed up to the top of the slide to tag child 2 however, she did not provide any redirection or intervention to prevent the children from engaging in this activity.
b. Staff 1 stated that staff 2, who was sitting on the bench, did not provide any redirection to the children running up the slide to tag child 2.
c. This fall resulted in an injury to child 2 that required outside medical attention.
3. Staff 1 stated she did not have access to any written records or emergency contact information for child 2 to provide notification, to the parent, that their child had fallen from the top of slide slide on 03/01/2024.
a. Staff 1 stated she had to reach out to multiple administrative staff to obtain parental contact information for child 2 and that it took her approximately 15 minutes to receive emergency contact information.
Plan of Correction: The Director of Childcare Health and Safety conducted a licensing training on 6/8/24 that included room sweeps to ensure that harmful materials including cords, chemicals etc. are removed before children enter the area.
Administrative staff have also provided training and direction on staff being in zones while supervising children to ensure that all areas are observable.
The Director of Childcare Health and Safety conducted a licensing training on 6/8/24 that included appropriate documentation and procedures for child injuries.
Administrative staff have also provided training and direction on staff being in zones while supervising children to ensure that all areas are observable.
The Director of Childcare Health and Safety conducted a licensing training on 6/8/24 that included appropriate documentation and procedures for child injuries.
Standard 8VAC20-780-340-F
Based on observation and interview, the center failed to ensure that children under 10 years of age always shall be within actual sight and sound supervision of staff.
Evidence:
1. Staff 1 left a group of approximately 16 children alone in the gym, with no adult supervision, for approximately one minute while she switched places with staff 2 who was in the cafeteria.
a. Staff 2 left a group of approximately 24 children alone in the cafeteria, with no adult supervision for approximately one minute, while she switched places with staff 1 who was in the cafeteria.
b. Staff 1 stated that she switched places with staff 2 at the request of staff 2.
c. The children in care ranged in age from 5 years - 11 years in both the gym and cafeteria.
2. The inspector observed, throughout the inspection, children being tasked by both staff 1 and staff 2, with walking from the cafeteria to the gym to notify of arrival of parent for pick-up.
a. No adult or staff supervision was provided to ensure sight and sound supervision of children walking to and from the cafeteria / gym.
3. The location of the gym does not allow for sight or sound supervision from the cafeteria.
Evidence:
1. Staff 1 left a group of approximately 16 children alone in the gym, with no adult supervision, for approximately one minute while she switched places with staff 2 who was in the cafeteria.
a. Staff 2 left a group of approximately 24 children alone in the cafeteria, with no adult supervision for approximately one minute, while she switched places with staff 1 who was in the cafeteria.
b. Staff 1 stated that she switched places with staff 2 at the request of staff 2.
c. The children in care ranged in age from 5 years - 11 years in both the gym and cafeteria.
2. The inspector observed, throughout the inspection, children being tasked by both staff 1 and staff 2, with walking from the cafeteria to the gym to notify of arrival of parent for pick-up.
a. No adult or staff supervision was provided to ensure sight and sound supervision of children walking to and from the cafeteria / gym.
3. The location of the gym does not allow for sight or sound supervision from the cafeteria.
Plan of Correction: Staff have been debriefed on appropriate sight and sound supervision as well as procedures for having children move from one area to another.
When staff ratios do not meet the appropriate procedures for children transitioning from one area to another without compromise, all children and staff will remain together.
When staff ratios do not meet the appropriate procedures for children transitioning from one area to another without compromise, all children and staff will remain together.
Standard 8VAC20-780-350-B-5
Based on observation and interview, the center failed to ensure the staff-to-children ratio of 1:18 (staff: children) shall be required whenever children are in care.
Evidence:
1. When the inspector arrived at 3:30 pm on 05/29/2024 staff 2 was observed caring for 24 children ages 5 years - 11 years in the cafeteria. 2 staff were needed to meet the required ratio of 1:18.
a. Staff 2 stated she was alone with this group of children.
b. Staff 1, who was in the gym with a group of 16 children, confirmed that staff 2 was alone with 24 children in the cafeteria.
2. A review of written attendance records for 05/29/2024 indicated there were 45 children in care , ages 5 - 11 years, when the program opened at 2:45 pm. Only 2 staff were available however, 3 staff were needed to meet the required staff-to-child ratio of 1:18.
a. Staff 1 confirmed the accuracy of the attendance record and that only 2 staff were present .
Evidence:
1. When the inspector arrived at 3:30 pm on 05/29/2024 staff 2 was observed caring for 24 children ages 5 years - 11 years in the cafeteria. 2 staff were needed to meet the required ratio of 1:18.
a. Staff 2 stated she was alone with this group of children.
b. Staff 1, who was in the gym with a group of 16 children, confirmed that staff 2 was alone with 24 children in the cafeteria.
2. A review of written attendance records for 05/29/2024 indicated there were 45 children in care , ages 5 - 11 years, when the program opened at 2:45 pm. Only 2 staff were available however, 3 staff were needed to meet the required staff-to-child ratio of 1:18.
a. Staff 1 confirmed the accuracy of the attendance record and that only 2 staff were present .
Plan of Correction: Staffing needs are being addressed through continuous employment of staff working for both the Summer programs and for school programs in the Fall. There will be another hiring event in July to build staff numbers for after school programs.
Administrative staff have also discussed alternative means of dividing children into groups to ensure that ratios are maintained.
Administrative staff have also discussed alternative means of dividing children into groups to ensure that ratios are maintained.
Standard 8VAC20-780-540-E
Based on review and staff interview, the center failed to ensure that the following nonmedical emergency supplies shall be required:
a. One-working battery -operated flashlight in each building used by children; and
b. One working, battery-operated radio in each building used by children.
Evidence:
1. The inspector was not able to get the radio or flashlight to turn on.
2. Staff 1 stated she was not able to get the radio or flashlight to turn on.
a. One-working battery -operated flashlight in each building used by children; and
b. One working, battery-operated radio in each building used by children.
Evidence:
1. The inspector was not able to get the radio or flashlight to turn on.
2. Staff 1 stated she was not able to get the radio or flashlight to turn on.
Plan of Correction: The required supplies will be present and in working order alone with staff competencies on how to use them.
Standard 8VAC20-780-550-G
Based on record review and staff interview, the center failed to ensure that documentation shall be maintained of emergency evacuation drills.
Evidence:
1.The emergency record for the facility indicated that no fire drill had been conducted in November and December of 2023 and in January, February and April of 2024.
2. Staff 1 stated she did not know if a fire drill had been completed for these months.
Evidence:
1.The emergency record for the facility indicated that no fire drill had been conducted in November and December of 2023 and in January, February and April of 2024.
2. Staff 1 stated she did not know if a fire drill had been completed for these months.
Plan of Correction: Administrative staff have retrained and modeled how to conduct and document monthly evacuation drills.
Drills will be conducted and documented moving forward.
Drills will be conducted and documented moving forward.
Standard 8VAC20-780-550-I
Based on observation, the center failed to ensure that a 911 or local dial number for police, fire and emergency medical services and the number of the regional poison control center shall be posted in a visible place at each telephone.
Evidence:
1. Emergency phone numbers for 991 or local police/ fire and poison control were not posted in any visible place when the inspector arrived for the onsite inspection on 05/29/2024.
2. Staff 1, who was in charge of the program, confirmed that emergency phone numbers were not posted.
Evidence:
1. Emergency phone numbers for 991 or local police/ fire and poison control were not posted in any visible place when the inspector arrived for the onsite inspection on 05/29/2024.
2. Staff 1, who was in charge of the program, confirmed that emergency phone numbers were not posted.
Plan of Correction: Emergency numbers will be posted on the parent board.
Standard 8VAC20-780-550-P
Based on record review, the center failed to ensure that the written record of children's serious and minor injuries include all of the required elements.
Evidence:
1. 6 of 7 injury reports reviewed lacked written documentation of the time that the parent was notified of the injury.
Evidence:
1. 6 of 7 injury reports reviewed lacked written documentation of the time that the parent was notified of the injury.
Plan of Correction: The Director of Childcare Health and Safety conducted a licensing training on 6/8/24 that included appropriate documentation and procedures for child injuries.
Standard 8VAC20-780-560-F
Based on observation and interview, the center failed to ensure that when centers choose to provide snacks, the menu listing foods to be served during the current one-week period shall be posted in a location conspicuous to parents.
Evidence:
1. The snack menu was not posted when the inspection arrived for the onsite inspection on 05/29/2024.
2. Staff 1 confirmed that the snack menu for the week was not posted.
Evidence:
1. The snack menu was not posted when the inspection arrived for the onsite inspection on 05/29/2024.
2. Staff 1 confirmed that the snack menu for the week was not posted.
Plan of Correction: Monthly snack menus will be posted on the parent board to reflect snack options.
Standard 8VAC20-780-60-A
Based on record review and staff interview, the center failed to maintain at the center a separate record for each child enrolled with all of the required elements.
Evidence:
1. There was no enrollment record on hand for child 1 who was in care during the on-site inspection on 05/29/2024.
a. Staff 1, who was in charge of the program during the inspection, confirmed she did not have an enrollment record for child 1.
b. Staff 1 stated that child 1 had been in care "since before Christmas."
2. An investigation of a serious injury that occurred on 03/01/2024 found that no enrollment record was available for child 2.
a. Staff 1 stated there was no written enrollment record on hand for child 2 who was injured while in care on 03/01/2024.
Evidence:
1. There was no enrollment record on hand for child 1 who was in care during the on-site inspection on 05/29/2024.
a. Staff 1, who was in charge of the program during the inspection, confirmed she did not have an enrollment record for child 1.
b. Staff 1 stated that child 1 had been in care "since before Christmas."
2. An investigation of a serious injury that occurred on 03/01/2024 found that no enrollment record was available for child 2.
a. Staff 1 stated there was no written enrollment record on hand for child 2 who was injured while in care on 03/01/2024.
Plan of Correction: Staff will ensure that enrollment records are maintained for all children in the programs. Enrollment records for child 1 and child 2 will be obtained before the child returns to the program.
Standard 8VAC20-780-70
Based on record review and interview, the center failed to ensure that staff records contain all of the required elements.
Evidence:
1. The staff record for staff 2 lacked documentation of the following required information:
a. Documentation that two or more references as to character and reputation as well as competency were checked before employment;
b. Documentation that orientation training had been completed prior to working alone with children and within seven days of the first day of employment.
2. Administrative staff confirmed this information was not available.
Evidence:
1. The staff record for staff 2 lacked documentation of the following required information:
a. Documentation that two or more references as to character and reputation as well as competency were checked before employment;
b. Documentation that orientation training had been completed prior to working alone with children and within seven days of the first day of employment.
2. Administrative staff confirmed this information was not available.
Plan of Correction: Reference checks will be obtained and added to the staff file for staff 2. Documentation of orientation will also be added to the staff file.
Standard 8VAC20-780-80-B-2
Based on record review and staff interview, the center failed to inform the department's representative as soon as practicable, but not to exceed two business days, of any injury to a child that occurs while the child is under the supervision of the center and requires outside medical attention.
Evidence:
1. The center notified the inspector on 03/12/2024 of a serious injury requiring outside medication attention that occurred on 03/01/2024.
2. Staff 1 stated that notification was received on 03/04/2024 that the child had been taken for medical care for the injury received on the afternoon of 03/01/2024.
3. Administrative staff confirmed that the incident was reported to the department's representative outside of the two business day time frame.
Evidence:
1. The center notified the inspector on 03/12/2024 of a serious injury requiring outside medication attention that occurred on 03/01/2024.
2. Staff 1 stated that notification was received on 03/04/2024 that the child had been taken for medical care for the injury received on the afternoon of 03/01/2024.
3. Administrative staff confirmed that the incident was reported to the department's representative outside of the two business day time frame.
Plan of Correction: The Director of Childcare Health and Safety conducted a licensing training on 6/8/24 that included appropriate documentation and procedures for child injuries.