Inspection · 2024-04-09
Date
2024-04-09
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.
8VAC20-820 THE LICENSE.
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 04/09/2024 with an on-site inspection from 3:45 pm - 5:05 pm. The inspection was concluded on 04/11/2024 with a review of staff records at the Greenbrier North branch of the YMCA of SHR which lasted from 10:30 am - 11:30 am.
There were a total of 42 school age children present with 2 staff supervising when the inspector arrived at 3:45 pm on 04/09/2024. A third staff arrived at 3:45 pm. When the inspector entered the cafeteria, children were finishing up dinner and beginning the transition to homework and table game activities.
Records were reviewed for 6 children in care. Medication and emergency supplies additionally reviewed.
Four staff records were reviewed on 04/11/2024.
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 at the exit interview.
Violations
9Standard 8VAC20-770-60-B
Based on record review and interview, the center failed to ensure that a staff person must not be employed until the agency or home has the person's completed sworn statement or affirmation.
Evidence:
1. Staff 2, hire date 12/04/2023, lacked a completed sworn statement or affirmation.
a. Staff 2 was observed working with children in the licensed program during the inspection on 04/09/2024.
2. Administrative staff confirmed that a completed sworn statement or affirmation was not on file for staff 2.
Evidence:
1. Staff 2, hire date 12/04/2023, lacked a completed sworn statement or affirmation.
a. Staff 2 was observed working with children in the licensed program during the inspection on 04/09/2024.
2. Administrative staff confirmed that a completed sworn statement or affirmation was not on file for staff 2.
Plan of Correction: Administrative staff stated that staff 2 will complete a sworn statement or affirmation.
Standard 8VAC20-770-60-C-2
Based on record review and interview, the center failed to obtain for each staff a central registry finding within 30 days of employment.
Evidence:
1. Staff 2, hire date 12/04/2023, lacks the results of a central registry finding.
a. Staff 2 was observed working in the licensed program during the on-site inspection which took place on 04/09/2024.
2. Administrative staff confirmed that a central registry finding was not available for staff 2.
Evidence:
1. Staff 2, hire date 12/04/2023, lacks the results of a central registry finding.
a. Staff 2 was observed working in the licensed program during the on-site inspection which took place on 04/09/2024.
2. Administrative staff confirmed that a central registry finding was not available for staff 2.
Plan of Correction: Administrative staff stated that a central registry check will be requested for staff 2.
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. The documentation of the screening shall have been completed within the last 30 calendar days of the date of employment.
Evidence:
1. Staff 2, hire date 12/04/2023, lacks documentation of a TB screening.
a. Administrative staff confirmed that a TB screening was not on file for staff 2.
2. The TB screening for staff 1 was completed on 01/30/2024, which is more than 30 days prior to her hire date of 03/04/2024.
Evidence:
1. Staff 2, hire date 12/04/2023, lacks documentation of a TB screening.
a. Administrative staff confirmed that a TB screening was not on file for staff 2.
2. The TB screening for staff 1 was completed on 01/30/2024, which is more than 30 days prior to her hire date of 03/04/2024.
Plan of Correction: Administrative staff stated that staff 2 had obtained a TB screening but had not provided the results. Staff 2 will be asked to obtain the results of the TB screening.
Going forward all staff will obtain, and provided a copy of results, for the TB screening within the required time frames.
Going forward all staff will obtain, and provided a copy of results, for the TB screening within the required time frames.
Standard 8VAC20-780-240-A
Based on record review and interview, the center failed to ensure that staff complete the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.
Evidence:
1. Staff 2, hire date 12/04/2023, lacks documentation of completion of Virginia Department of Education sponsored orientation course.
2. Administrative staff confirmed documentation was not on file to demonstrate that staff 2 had completed this training course.
Evidence:
1. Staff 2, hire date 12/04/2023, lacks documentation of completion of Virginia Department of Education sponsored orientation course.
2. Administrative staff confirmed documentation was not on file to demonstrate that staff 2 had completed this training course.
Plan of Correction: Staff 2 will complete Virginia Preservice training.
Standard 8VAC20-780-350-C
Based on staff interview and record review, the center failed to ensure that when children are in ongoing mixed age groups, the staff-to-children ratio and group size applicable to the youngest child in the group shall apply to the entire group.
*School age eligible up to 9 years - 1:18;
*9 years through 12 years - 1:20.
Evidence:
1. The written attendance record indicates that staff 3 was alone with 30 children, ages 5 years - 11 years when the program opened at 2:00pm.
a. 2 staff were needed to meet the required ratio of 1:18.
2. The written attendance record indicates that staff 3 was alone with 47 children, ages 5 years - 11 years, at 3:00 pm.
a. Staff 3 stated that a second staff, staff 1, arrived at 3:15 pm.
b. Staff 1 confirmed she arrived at 3:15 pm and verified that staff 3 was alone with the children when she arrived.
c. 3 staff were needed to meet the required ratio of 1:18.
3. When the inspector arrived at 3:45 pm, staff 1 and staff 3 were caring for 42 children, ages 5 years - 11 years.
a. 3 staff were needed to meet the required ratio of 1:18.
a. A third staff, staff 2, arrived at the same time as the inspector and opened the door for the inspector to enter the program.
4. Staff 3, who is the program director, confirmed that she had been alone with the children until staff 1 arrived at 3:15 pm.
a. Staff 3 confirmed that staff 3 arrived at the same time as the inspector.
*School age eligible up to 9 years - 1:18;
*9 years through 12 years - 1:20.
Evidence:
1. The written attendance record indicates that staff 3 was alone with 30 children, ages 5 years - 11 years when the program opened at 2:00pm.
a. 2 staff were needed to meet the required ratio of 1:18.
2. The written attendance record indicates that staff 3 was alone with 47 children, ages 5 years - 11 years, at 3:00 pm.
a. Staff 3 stated that a second staff, staff 1, arrived at 3:15 pm.
b. Staff 1 confirmed she arrived at 3:15 pm and verified that staff 3 was alone with the children when she arrived.
c. 3 staff were needed to meet the required ratio of 1:18.
3. When the inspector arrived at 3:45 pm, staff 1 and staff 3 were caring for 42 children, ages 5 years - 11 years.
a. 3 staff were needed to meet the required ratio of 1:18.
a. A third staff, staff 2, arrived at the same time as the inspector and opened the door for the inspector to enter the program.
4. Staff 3, who is the program director, confirmed that she had been alone with the children until staff 1 arrived at 3:15 pm.
a. Staff 3 confirmed that staff 3 arrived at the same time as the inspector.
Plan of Correction: Administrative staff stated they will look into the reasons for why staff failed to show up as scheduled. Schedules and staffing will be assessed and adjusted to ensure staff-to-child ratios are maintained at all times.
Standard 8VAC20-780-40-M
Based on record review and interview, the center failed to maintain, in a way that is accessible to all staff who work with children, a current written list of all children's allergies, sensitivities, and dietary restrictions.
Evidence:
1. The allergy list, maintained in a confidential place, did not list all of the children in care with diagnosed food allergies and food sensitivities.
a. Written enrollment records indicated that child 1 had diagnosed food allergies and that child 2 had a food sensitivity.
2. Staff 1 acknowledged that these food allergies and sensitivities were not included on the food allergy list.
Evidence:
1. The allergy list, maintained in a confidential place, did not list all of the children in care with diagnosed food allergies and food sensitivities.
a. Written enrollment records indicated that child 1 had diagnosed food allergies and that child 2 had a food sensitivity.
2. Staff 1 acknowledged that these food allergies and sensitivities were not included on the food allergy list.
Plan of Correction: The site director for the program indicated that the allergy record would be updated to include children not listed and that children's records would be reviewed to ensure that no child had been overlooked with food allergies and sensitivities that needed to be added to the allergy list.
Standard 8VAC20-780-540-E
Based on observation, the center failed to ensure there was one working battery-operated radio in each building used by children.
Evidence:
1. The battery- operated radio was not working during the inspection.
2. Both the inspector and the program director attempted to turn on the radio with no success.
Evidence:
1. The battery- operated radio was not working during the inspection.
2. Both the inspector and the program director attempted to turn on the radio with no success.
Plan of Correction: Administrative staff stated that the radio was working when checked recently.
A working batter-operated radio will be provided for the after school site.
A working batter-operated radio will be provided for the after school site.
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 enrollment record for child 3 lacked a physician written allergy care plan for multiple diagnosed food allergies.
a. Administrative staff confirmed that there was no physician written allergy care plan for child 3.
Evidence:
1. The enrollment record for child 3 lacked a physician written allergy care plan for multiple diagnosed food allergies.
a. Administrative staff confirmed that there was no physician written allergy care plan for child 3.
Plan of Correction: The site director indicated that an allergy care plan had been requested from the parent and that the parent had not yet provided the plan. The site director will request that the parent provide a written allergy care plan.
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 phone number of a person to notified in an emergency, which shall be kept at the center, was not available for staff 1.
a. Staff 1 was present and observed caring for children during the inspection on 04/09/2024.
b. Administrative staff confirmed that staff 1 had not completed an emergency contact sheet.
2. The employment files for staff 1 and staff 2 indicate a job title of program leader however, there is no written documentation on file to demonstrate how they meet the qualifications for program leader.
3. The employment file for staff 1 lacks documentation that she completed orientation training as required within seven days of employment.
4. The hire date for staff 1 is listed as 03/04/2024 in her employment file however, administrative staff stated that this date was not accurate as she began employment on 12/04/2023.
a. Administrative staff was not able to provide any written documentation of an accurate hire date for staff 1 beyond the documentation in the employment record.
Evidence:
1. The name, address and phone number of a person to notified in an emergency, which shall be kept at the center, was not available for staff 1.
a. Staff 1 was present and observed caring for children during the inspection on 04/09/2024.
b. Administrative staff confirmed that staff 1 had not completed an emergency contact sheet.
2. The employment files for staff 1 and staff 2 indicate a job title of program leader however, there is no written documentation on file to demonstrate how they meet the qualifications for program leader.
3. The employment file for staff 1 lacks documentation that she completed orientation training as required within seven days of employment.
4. The hire date for staff 1 is listed as 03/04/2024 in her employment file however, administrative staff stated that this date was not accurate as she began employment on 12/04/2023.
a. Administrative staff was not able to provide any written documentation of an accurate hire date for staff 1 beyond the documentation in the employment record.
Plan of Correction: Staff 1 completed an emergency contact sheet during the inspection.
Administrative staff stated that documentation of staff qualifications and completion of orientation training would be added to staff records.
Administrative staff stated that documentation of staff qualifications and completion of orientation training would be added to staff records.