Inspection · 2024-04-16
Date
2024-04-16
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.
780 Special Care Provisions and Emergencies
8VAC20-780 Special Services
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22 Checks Code, Carbon Monoxide.1 Background
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced monitoring inspection was initiated on 04/16/2024 with an on-site inspection from 4:10 pm - 5:50 pm. The inspection was completed on 04/26/2024 with a review of staff records at the Greenbrier North Family YMCA where staff records are maintained.
The inspector additionally investigated a serious injury, received by a child in care , that occurred on 02/07/2024, This serious injury was self-reported by YMCA administrative staff on 02/09/2024.
During the 04/16/2024 on-site inspection there were a total of 50 school age children in care with 3 staff present at the time of entrance.
Children were observed during outdoor play and engaged in various table games in the cafeteria. Records were reviewed for 6 children in care. Medication and emergency supplies additionally reviewed.
Four staff records were reviewed on 04/26/2024 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. These violations were reviewed with administrative staff during the exit interview.
Violations
7Standard 8VAC20-770-60-B
Based on record review and staff interview, the center failed to ensure that staff are not employed until the facility has the person's completed sworn statement or affirmation.
Evidence:
1. There was no sworn statement or affirmation on file for staff 1 who was observed caring for children during the on-site inspection on 04/16/2024.
a. Staff 1 has an approximate hire date of 45 days prior to the 04/16/2024 inspection according to administrative staff.
2. Administrative staff confirmed that a completed sworn statement or affirmation was not available for staff 1.
Evidence:
1. There was no sworn statement or affirmation on file for staff 1 who was observed caring for children during the on-site inspection on 04/16/2024.
a. Staff 1 has an approximate hire date of 45 days prior to the 04/16/2024 inspection according to administrative staff.
2. Administrative staff confirmed that a completed sworn statement or affirmation was not available for staff 1.
Plan of Correction: Administrative staff are working to complete staff 1's file to meet licensing standards.
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. There was no central registry finding on file for staff 1 who was observed caring for children during the on-site inspection on 04/16/2024.
2. Administrative staff confirmed that a central registry finding was not on file for staff 1.
a. Administrative staff stated that staff 1 had an approximate hire date of 45 days prior to the staff record review completed on 04/26/2024.
b. Administrative staff further stated they were unsure if a central registry check had been requested for staff 1.
Evidence:
1. There was no central registry finding on file for staff 1 who was observed caring for children during the on-site inspection on 04/16/2024.
2. Administrative staff confirmed that a central registry finding was not on file for staff 1.
a. Administrative staff stated that staff 1 had an approximate hire date of 45 days prior to the staff record review completed on 04/26/2024.
b. Administrative staff further stated they were unsure if a central registry check had been requested for staff 1.
Plan of Correction: Administrative staff are working to complete staff 1's file to meet licensing standards.
Standard 8VAC20-780-340-A
Based on staff interviews, record review and observation the center failed to ensure that when staff are supervising children, they shall always ensure their care and protection.
Evidence:
1. Staff 2 stated that she was by herself with more than 18 children when child 1, age 7 years, sustained a serious injury requiring outside medical attention. Child 1 fell in the gym on 02/07/2024 at approximately 3:00 pm. The required staff-to-child ratio for children ages 5 - 8 years is 1:18.
a. Staff 4 confirmed that staff 2 was alone in the gym with more than 18 children when child 1 was injured.
b. Staff 3 stated that staff 1 was actually alone with 39 children based on record review for this date.
2. The lack of sufficient staff resulted in staff 1 not being able to redirect child 1 when he was engaging in an unsafe activity.
a. Staff 2 stated that child 1, and several other children, were running in the gym when child 1 tripped and fell hitting his head on the door. This injury required 7 stitches.
b. Staff 2 stated she had asked child 1 to stop running however, she was not able to provide direct intervention due to the number of children she was responsible for during this time.
Evidence:
1. Staff 2 stated that she was by herself with more than 18 children when child 1, age 7 years, sustained a serious injury requiring outside medical attention. Child 1 fell in the gym on 02/07/2024 at approximately 3:00 pm. The required staff-to-child ratio for children ages 5 - 8 years is 1:18.
a. Staff 4 confirmed that staff 2 was alone in the gym with more than 18 children when child 1 was injured.
b. Staff 3 stated that staff 1 was actually alone with 39 children based on record review for this date.
2. The lack of sufficient staff resulted in staff 1 not being able to redirect child 1 when he was engaging in an unsafe activity.
a. Staff 2 stated that child 1, and several other children, were running in the gym when child 1 tripped and fell hitting his head on the door. This injury required 7 stitches.
b. Staff 2 stated she had asked child 1 to stop running however, she was not able to provide direct intervention due to the number of children she was responsible for during this time.
Plan of Correction: Administrative staff have recently hired several staff for the summer camp season. They have hired on individuals with an intent to continue working for the school programs beginning in the Fall. With the increase in staff and compliance with ratio, staff present will be able to more appropriately redirect children to prevent injury during program operation.
There will be two additional hiring events, one in June and one in July, to continuing increasing staff numbers to accommodate children present in the program.
There will be two additional hiring events, one in June and one in July, to continuing increasing staff numbers to accommodate children present in the program.
Standard 8VAC20-780-350-B-5
Based on observation, record review and staff interviews the center failed to maintain the required staff-to-children ratios whenever children are in care.
*School age eligible up to 9 years- ratio 1:18 (staff: children)
Evidence:
1. During the on-site inspection on 04/16/2024 staff 2 was observed alone, on the outdoor play area, with 26 children ages 5 years - 8 years at 4:10 pm.
a. Staff 2 stated that there was not a second staff present and that she had been the only staff supervising this group of children since 3:30 pm.
b. Staff 2 stated that "it was normal" for her to be alone with more than 18 children which is the required staff-to-child ratio for this age group.
2. Additional interviews with staff 2 and staff 3 indicated that staff 1 was alone, in the gymnasium, with 39 children, ages 5 - 8 years, on 02/07/2024 at approximately 3:00 pm.
a. A review of written attendance records, by staff 3, confirmed that staff 2 was alone with 39 children, ages 5 - 8 years, on 02/07/2024.
*School age eligible up to 9 years- ratio 1:18 (staff: children)
Evidence:
1. During the on-site inspection on 04/16/2024 staff 2 was observed alone, on the outdoor play area, with 26 children ages 5 years - 8 years at 4:10 pm.
a. Staff 2 stated that there was not a second staff present and that she had been the only staff supervising this group of children since 3:30 pm.
b. Staff 2 stated that "it was normal" for her to be alone with more than 18 children which is the required staff-to-child ratio for this age group.
2. Additional interviews with staff 2 and staff 3 indicated that staff 1 was alone, in the gymnasium, with 39 children, ages 5 - 8 years, on 02/07/2024 at approximately 3:00 pm.
a. A review of written attendance records, by staff 3, confirmed that staff 2 was alone with 39 children, ages 5 - 8 years, on 02/07/2024.
Plan of Correction: Administrative staff have recently hired several staff for the summer camp season. They have hired on individuals with an intent to continue working for the school programs beginning in the Fall.
They will be two additional hiring events, one in June and one in July, to continue increasing staff members to accommodate children present in program.
They will be two additional hiring events, one in June and one in July, to continue increasing staff members to accommodate children present in program.
Standard 8VAC20-780-540-C
Based on observation and interview, the center failed to ensure that the required first aid kit contained all of the required elements.
Evidence:
1. The facility first aid kit lacked band-aids, assorted types.
2. Center staff stated they could not locate band-aids in any of the first aid kits available during the on-site inspection on 04/16/2024.
Evidence:
1. The facility first aid kit lacked band-aids, assorted types.
2. Center staff stated they could not locate band-aids in any of the first aid kits available during the on-site inspection on 04/16/2024.
Plan of Correction: Staff will ensure that assorted sizes of band aids are kept onsite in first aid kits.
Standard 8VAC20-780-560-J
Based on observation, the center failed to ensure that tables shall be sanitized after each use for feeding.
*The definition of sanitized means that the surface of the item is sprayed with the disinfectant solution and allowed to air dry on the surface for a minimum of two minutes.
Evidence:
1. Staff 1 was observed using the same cloth towel to immediately wipe the tables down after application of the disinfectant spray.
*The definition of sanitized means that the surface of the item is sprayed with the disinfectant solution and allowed to air dry on the surface for a minimum of two minutes.
Evidence:
1. Staff 1 was observed using the same cloth towel to immediately wipe the tables down after application of the disinfectant spray.
Plan of Correction: Staff will be reminded of appropriate sanitizing procedures according to licensing standards. Surfaces will be spayed with disinfectant solution and will air dry for at least 2 minutes. Only disposable paper towels will be used and not cloths.
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 name, address and telephone number for a designated emergency contact was not maintained on site for staff 1 who was working in the after school program during the 04/16/2024 on-site inspection.
2. The employment file for staff 1 lacked documentation of a hire date, job title and completion of orientation training.
a. Administrative staff stated that staff 1 began work approximately 45 days prior to the inspection.
Evidence:
1. The name, address and telephone number for a designated emergency contact was not maintained on site for staff 1 who was working in the after school program during the 04/16/2024 on-site inspection.
2. The employment file for staff 1 lacked documentation of a hire date, job title and completion of orientation training.
a. Administrative staff stated that staff 1 began work approximately 45 days prior to the inspection.
Plan of Correction: Administrative staff are working to complete staff 1's file to meet licensing standards.