Inspection · 2022-10-04
Date
2022-10-04
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)
20 Access to minor?s records
22 Checks Code, Carbon Monoxide.1 Background
Inspector Notes
An unannounced renewal inspection was conducted on 10/04/2022 with an on-sight inspection and concluded on 10/05/2022 with a review of staff records at the Greenbrier North YMCA.
47 School age children were observed in care with 4 staff during the inspection on 10/04/2022 which began at 3:36 pm and concluded at 6:00 pm.
Children were observed engaged in large motor activities in the gym and playing table games in the cafeteria. Records were reviewed for 4 staff and 6 children.
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
9Standard 22.1-289.035-B-4
Based on record review and interview, the center failed to obtain a copy of the results of a criminal history record information check from any state in which the individual has resided in the preceding five years.
1. The results of a criminal record check had not been obtained from a state that staff 1 indicated she had resided in within the past 5 years.
a. Administrative staff confirmed that a criminal record check had not been requested from the state for staff 1.
1. The results of a criminal record check had not been obtained from a state that staff 1 indicated she had resided in within the past 5 years.
a. Administrative staff confirmed that a criminal record check had not been requested from the state for staff 1.
Plan of Correction: Administrative staff stated that a CPS check had been requested and it was thought this included a criminal record check. A CRC will be requested immediately.
Standard 8VAC20-780-160-A
Based on record review and interview, the center failed to ensure that each staff member shall submit documentation of a negative tuberculosis screening at the time of employment, and prior to coming into contact with children.
Evidence:
1. Staff 3, hire date 09/28/2022, lacks documentation of a TB screening.
a. Staff 3 was observed working in the after school program on 10/04/2022.
2. Administrative staff confirmed that a TB screening had not been obtained for staff 3.
Evidence:
1. Staff 3, hire date 09/28/2022, lacks documentation of a TB screening.
a. Staff 3 was observed working in the after school program on 10/04/2022.
2. Administrative staff confirmed that a TB screening had not been obtained for staff 3.
Plan of Correction: Administrative staff stated that staff 3 will obtain a TB screening.
Standard 8VAC20-780-240-A
Based on record review and interview, the center failed to ensure that all staff complete the Virginia Department of Education-sponsored orientation course shall be completed within 90 calendar days of employment.
Evidence:
1. Staff 1, hire date 04/06/2022, lacks documentation of completion of Virginia Preservice Training.
a. Administrative staff confirmed that staff 1 had not completed this training.
Evidence:
1. Staff 1, hire date 04/06/2022, lacks documentation of completion of Virginia Preservice Training.
a. Administrative staff confirmed that staff 1 had not completed this training.
Plan of Correction: Administrative staff stated that staff 1 is working on this training.
Standard 8VAC20-780-340-A
Based on observation, record review and interview the center failed to ensure that when staff are supervising children, they shall always ensure their care and protection.
Evidence:
1. Staff lacked the ability to determine children in care during the inspection as demonstrated by the following:
a. None of the staff present were able to pull up the electronic attendance sheet to confirm and verify current attendance during the inspection.
b. Multiple staff made several attempts during the inspection to provide attendance documentation however, the electronic attendance was not available.
c. All staff stated that the school wi-fi was sporadic resulting in attendance not always being available.
d. All staff sated no written attendance documentation was maintained.
2. Written documentation was not maintained of glucose checks for a child in care with a diagnosed medical disease.
a. Child 1 was in care on 09/09/2022 and 10/04/2022 however, his medication log indicates no check of his glucose on either day.
b. Administrative staff 2 stated she had not checked child 1's glucose on 10/04/2022 because he had refused snack however, his medical plan indicates glucose should also be checked prior to exercise.
c. The lack of written documentation of glucose checks places child 1 at risk should a medical emergency or question arise.
Evidence:
1. Staff lacked the ability to determine children in care during the inspection as demonstrated by the following:
a. None of the staff present were able to pull up the electronic attendance sheet to confirm and verify current attendance during the inspection.
b. Multiple staff made several attempts during the inspection to provide attendance documentation however, the electronic attendance was not available.
c. All staff stated that the school wi-fi was sporadic resulting in attendance not always being available.
d. All staff sated no written attendance documentation was maintained.
2. Written documentation was not maintained of glucose checks for a child in care with a diagnosed medical disease.
a. Child 1 was in care on 09/09/2022 and 10/04/2022 however, his medication log indicates no check of his glucose on either day.
b. Administrative staff 2 stated she had not checked child 1's glucose on 10/04/2022 because he had refused snack however, his medical plan indicates glucose should also be checked prior to exercise.
c. The lack of written documentation of glucose checks places child 1 at risk should a medical emergency or question arise.
Plan of Correction: Administrative staff stated that medication logs will be monitored closely to ensure all relevant information is maintained for child 1.
Written attendance records will be implemented as a back up to the electronic method.
Written attendance records will be implemented as a back up to the electronic method.
Standard 8VAC20-780-340-F
Based on observation, 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. At approximately 3:50 pm, child 4 - age 5 years, was observed walking from the gym into the cafeteria for departure. The staff in the gym were not positioned to be able to see child 4 once he left the gym. There were no staff in the hallway or at the cafeteria door way to provide sight and sound supervision of this child.
2. At approximately 3:53 pm, child 5 - age 5 years, was observed leaving the gym to fill her water bottle at the fountain located in the hallway. The staff in the gym were not positioned to be able to see child 5 once she left the gym. There were no staff in the hallway or at the cafeteria door way to provide sight and sound supervision of this child while she filled up her water bottle.
Evidence:
1. At approximately 3:50 pm, child 4 - age 5 years, was observed walking from the gym into the cafeteria for departure. The staff in the gym were not positioned to be able to see child 4 once he left the gym. There were no staff in the hallway or at the cafeteria door way to provide sight and sound supervision of this child.
2. At approximately 3:53 pm, child 5 - age 5 years, was observed leaving the gym to fill her water bottle at the fountain located in the hallway. The staff in the gym were not positioned to be able to see child 5 once she left the gym. There were no staff in the hallway or at the cafeteria door way to provide sight and sound supervision of this child while she filled up her water bottle.
Plan of Correction: Administrative staff stated that adjustments will be made to staffing to ensure staff are able to see and hear children when they are walking to and from the gym and cafeteria.
Standard 8VAC20-780-40-M
Based on record review, the center failed to ensure that the written list of all children's allergies shall be dated.
Evidence:
1. The written allergy list for the program was not dated.
a. Administrative staff 1 stated that she was unaware that the allergy list needed to be dated.
Evidence:
1. The written allergy list for the program was not dated.
a. Administrative staff 1 stated that she was unaware that the allergy list needed to be dated.
Plan of Correction: Administrative staff stated that the allergy list would be revised to include a current date and monthly review.
Standard 8VAC20-780-540-C
Based on review and interview, the center failed to ensure that the required first aid kit shall contain all of the required elements.
Evidence:
1. The first aid kit for the facility lacked a thermometer.
a. Administrative staff stated a thermometer was not available.
Evidence:
1. The first aid kit for the facility lacked a thermometer.
a. Administrative staff stated a thermometer was not available.
Plan of Correction: Administrative staff stated that a thermometer will be obtained for the emergency kit.
Standard 8VAC20-780-560-J
Based on interview, the center failed to ensure that tables shall be sanitized before and after use for feeding.
Evidence:
1. Administrative staff 1 stated it was her process to clean the tables with soap and water before and after snack.
a. Staff 1 stated she sanitizes the tables at the end of the day.
Evidence:
1. Administrative staff 1 stated it was her process to clean the tables with soap and water before and after snack.
a. Staff 1 stated she sanitizes the tables at the end of the day.
Plan of Correction: Administrative staff stated that tables would be sanitized before and after snack going forward.
Standard 8VAC20-780-60-A
Based on record review and interview, the center failed to ensure that children's records contain all of the required elements.
Evidence:
1. The record for child 2, who was in care during the inspection lacked an enrollment form.
a. Administrative staff confirmed that an enrollment form was not available for child 2.
2. The enrollment record for child 1 lacked the following required information:
a. Work phone number for both parent's;
b. Home phone number for both parent's;
c. Place of employment for one parent.
3. Six of six enrollment records reviewed lacked documentation of the first date of attendance.
4. Written allergy care plans were not available for child 2 and child 3 who have diagnosed food allergies.
a. Administrative staff 1 confirmed that an emergency allergy action care plan was not on file for child 2 and child 3.
Evidence:
1. The record for child 2, who was in care during the inspection lacked an enrollment form.
a. Administrative staff confirmed that an enrollment form was not available for child 2.
2. The enrollment record for child 1 lacked the following required information:
a. Work phone number for both parent's;
b. Home phone number for both parent's;
c. Place of employment for one parent.
3. Six of six enrollment records reviewed lacked documentation of the first date of attendance.
4. Written allergy care plans were not available for child 2 and child 3 who have diagnosed food allergies.
a. Administrative staff 1 confirmed that an emergency allergy action care plan was not on file for child 2 and child 3.
Plan of Correction: Administrative staff stated that missing information would be obtained for the record of child 1.
Enrollment dates will be added to children's records.
A complete record will be obtained for child 2.
Enrollment dates will be added to children's records.
A complete record will be obtained for child 2.