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YMCA of the Virginia Peninsulas - A.T. Johnson

Inspection · 2024-07-23

Date
2024-07-23
Complaint Related
No
Licensing Inspector
Cindy Horne
(804) 297-4469
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

Inspector Notes

An unannounced, on-site renewal inspection was initiated on 7/23/2024 and completed on 7/24/2024. The on-site inspection began at 9:30 a.m. and ended at 12:30 p.m. on 7/23/2024. The on-site inspection began at 12:30 p.m. and ended at 4:00 p.m. on 7/24/2024. The inspector reviewed compliance in the areas listed above. There were 17 children present and three staff. The inspector reviewed six children?s records and five staff records on-site. This inspection included:
? document review (emergency drill logs, medication administration logs, authorization forms),
? tour of the facility,
? interviews, and
? observations

Information gathered during the inspection determined non-compliance with applicable standards or law, and violations are documented on the violation notice issued to the program.

Please complete the plan of correction (POC) and date to be corrected sections for each violation cited on the violation notice. Specify how the deficient practice will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on 8/15/24. A POC submitted after this date will not appear on the public website.

Violations

6
Standard 22.1-289.011-F
Based on observation and interview, the center failed to ensure that the results of the most recent inspection were posted.

Evidence: The most current inspection (06/28/2023) violation notice was not posted. In an exit interview on 7/24/24, the Program Director acknowledged that the most recent inspection was not posted.
Plan of Correction: Director will post all required inspections on board.
Standard 22.1-289.035-A
(Repeat Violation) Based on review of a staff record an interview, the center did not obtain background checks every five years as required.

Evidence: The criminal history record check results in the record of Staff #3 were dated 9/05/18 and 12/06/23. The results of the criminal history record check dated 12/06/23 were outside the five-year timeframe. In an exit interview on 7/24/24, the Program Director acknowledged that the most recent criminal history record check was not requested within the required timeframe.
Plan of Correction: Director will implement a plan to update all background checks in the appropriate timeframe.
Standard 8VAC20-780-150-B
Based on review of a child?s record and interview, the center did not ensure that the immunization report was signed by a physician, his designee, or an official with the local health department.

Evidence: The immunization report contained in the record of Child #4 dated 7/27/23 was not signed by a physician, his designee, or an official with the local health department. In an exit interview on 7/24/24, the Program Director acknowledged that the immunizations for Child #4 weren?t signed by the doctor as required.
Plan of Correction: Director will request updated shot record with physician signature. Will be required for all children in program.
Standard 8VAC20-780-60-A
Based on review of children?s records and an interview, the center failed to maintain information in the children?s records as required.

Evidence:
1) The records of Child #1, Child #2, Child #3, Child #4, and Child #6 did not contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached. In an exit interview on 7/24/24, the Program Director acknowledged that the required information was not documented in the children?s records.
2) The records of Child #2 and Child #6 did not contain the names of persons authorized to pick up the children. In an exit interview on 7/24/24, the Program Director acknowledged that the required information was not documented in the children?s records.
Plan of Correction: Director will request updated information for each child due by Friday 8/16/24. Such information will be required upon registration effective 8/12/24.
Standard 8VAC20-780-70
Based on review of staff records and interview, the center failed to keep staff records as required.

Evidence: Staff #1?s date employment was 5/28/24. There was no documentation in the record that Staff #1 had completed orientation. In an exit interview on 7/24/24, the Program Director acknowledged the lack of orientation documentation in the record of Staff #1.
Plan of Correction: All rehired staff will have an updated orientation.
Standard 8VAC20-780-90-A
(Repeat Violation) Based on review of children?s records and interview, the center did not obtain written agreements with parents by the children?s first day of attendance.

Evidence: There were no written agreements between the parents and the center addressing emergency medical care, an ill child, or communicable diseases by the first day of attendance in the records of Child #2 and Child #6. Child #2?s first day of attendance was 07/11/2024. The first day of attendance was not documented in the record of Child #6. In an exit interview on 7/24/24, the Program Director acknowledged that the agreements were not in the children?s records as required.
Plan of Correction: Director will print all parent agreements for files. Will be required with first day of program.
View original record on Virginia Department of Social Services