Inspection · 2016-09-24
Date
2016-09-24
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)
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced monitoring inspection was conducted on 11/01/2022 with an inspection of the after school program which began at 2:50 pm and concluded at 4:08 pm. At the time of entrance there were 47 children in care with one staff. The children in care ranged in age from four years - ten years. Children were observed doing home work, eating snack and playing with table games in the cafeteria.
Three staff records were reviewed at the Greenbrier North YMCA on 11/02/2022.
Information gathered during the inspection determined non-compliances with applicable standards or law and violations were documented on the violation notice issued to the program.
Violations
22Standard 22.1-289.035-B-4
Based on a review of three staff records, it was determined that the facility did not ensure that sworn statement or affirmation statements and central registry checks are updated every five years from the last check.
Evidence:
1. The most recent central registry check on file for staff 3, the designated program director, was conducted on 11/10/2016.
2. The most recent sworn statement or affirmation on file for staff 3 was completed on 09/24/2016.
Evidence:
1. The most recent central registry check on file for staff 3, the designated program director, was conducted on 11/10/2016.
2. The most recent sworn statement or affirmation on file for staff 3 was completed on 09/24/2016.
Plan of Correction: Youth Development Director has already begun the process of updating the background checks and sworn statements.
All staff records will be reviewed and any expired background checks will be updated.
All staff records will be reviewed and any expired background checks will be updated.
Standard 8VAC20-770-60-C-2
Based on record review, the center failed to ensure that staff have a central registry finding within 30 days of employment.
Evidence:
1. Staff 2, hire date 05/28/2022, lacks a central registry finding.
Evidence:
1. Staff 2, hire date 05/28/2022, lacks a central registry finding.
Plan of Correction: Youth Development Director will follow up with Central Registry office for updates on background checks to ensure all staff clearances are in compliance.
Standard 8VAC20-780-130-A
Based on record review and interview, the center failed to 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 all required immunizations were not available for child 1, child 2, child 3, child 4, child 5 and child 6. These children were all in care during the inspection on 11/01/2022.
a. Administrative staff confirmed that she did not have this information on file nor did she have access to the electronic copy of children's enrollment information.
Evidence:
1. Documentation of all required immunizations were not available for child 1, child 2, child 3, child 4, child 5 and child 6. These children were all in care during the inspection on 11/01/2022.
a. Administrative staff confirmed that she did not have this information on file nor did she have access to the electronic copy of children's enrollment information.
Plan of Correction: Emergency contact binder with all required information has been updated and is onsite for staff.
Standard 8VAC20-780-140-A
Based on record review and interview, the center failed to ensure that each child shall have a physical examination by or under the direction of a physician before the child's attendance or within 30 days after the first day of attendance.
Evidence:
1. Documentation of a physical exam was not available for child 1, child 2, child 3, child 4, child 5 and child 6. These children were all in care during the inspection on 11/01/2022.
a. Administrative staff confirmed that she did not have this information on file nor did she have access to the electronic copy of children's enrollment information.
Evidence:
1. Documentation of a physical exam was not available for child 1, child 2, child 3, child 4, child 5 and child 6. These children were all in care during the inspection on 11/01/2022.
a. Administrative staff confirmed that she did not have this information on file nor did she have access to the electronic copy of children's enrollment information.
Plan of Correction: Emergency Contact Binder with all required information has been updated and is onsite for staff.
Standard 8VAC20-780-160-C
Based on record review, the center failed to ensure that staff shall obtain and submit the results of a follow-up tuberculosis screening at least every two years from the date of the initial screening or testing.
Evidence:
1. The most recent TB screening for staff 1 was conducted on 11/18/2019.
a. Staff 1 was caring for children during the inspection on 11/01/2022.
Evidence:
1. The most recent TB screening for staff 1 was conducted on 11/18/2019.
a. Staff 1 was caring for children during the inspection on 11/01/2022.
Plan of Correction: Staff with expired TB screenings will be sent to have them updated.
All staff records will be reviewed to ensure that all TB screenings are current.
All staff records will be reviewed to ensure that all TB screenings are current.
Standard 8VAC20-780-240-A
Based on record review, the center failed to ensure that staff shall complete The Virginia Department of Education - sponsored orientation course within 90 calendar days of employment.
Evidence:
1. Staff 2, hire date 05/28/2022, lacks documentation of completion of the Virginia Preservice training course.
Evidence:
1. Staff 2, hire date 05/28/2022, lacks documentation of completion of the Virginia Preservice training course.
Plan of Correction: Youth Development Director will ensure all staff complete the VDOE training within 90 days of employment.
Standard 8VAC20-780-245-A
Based on record review, the center failed to ensure that staff shall complete annually a minimum of 16 hours of training appropriate to the ages of children in care.
Evidence:
1. Staff 1, hire date 11/13/2019, lacks documentation of any annual training during the last 12 months.
2. Staff 3, hire date 09/30/2016, lacks documentation of any annual training during the last 12 months.
3. Staff 1 and staff 3 lack documentation of completion of the required three-hour Virginia preservice annual training.
Evidence:
1. Staff 1, hire date 11/13/2019, lacks documentation of any annual training during the last 12 months.
2. Staff 3, hire date 09/30/2016, lacks documentation of any annual training during the last 12 months.
3. Staff 1 and staff 3 lack documentation of completion of the required three-hour Virginia preservice annual training.
Plan of Correction: Youth Development Director has already begun the process of updating staff files.
All staff records will be reviewed and any missing annual training will be completed.
All staff records will be reviewed and any missing annual training will be completed.
Standard 8VAC20-780-245-J-3
Based on medication and record review, the center failed to ensure that for any child for whom emergency medications (such as albuterol, glucagon, and epinephrine auto injector) have been prescribed shall always be in the care of a staff member or independent contractor who meets the requirements of medication administration training -MAT.
Evidence:
1. There was a child present who had an inhaler (albuterol) on site.
2. Staff 1, who was the only staff present , did not have documentation of MAT certification.
Evidence:
1. There was a child present who had an inhaler (albuterol) on site.
2. Staff 1, who was the only staff present , did not have documentation of MAT certification.
Plan of Correction: Youth Development Director will ensure that staff have current MAT training.
Standard 8VAC20-780-340-A
Based on observation, the center failed to ensure that when staff are supervising children, they shall always ensure their care and protection.
Evidence:
1. The lack of sufficient staff on 11/01/2022 resulted in the one staff present not being able to properly care for and supervise the 47 children in care.
a. Five children were observed leaving the cafeteria, without knowledge of staff 1, to use the restroom.
b. Staff 1 was not able to implement required hand washing and sanitizing procedures as there was no one available to assist with these tasks.
c. A four-year old child tripped and fell while walking to his seat however, staff 1 did not see this as she was occupied on the other side of the cafeteria attending to another child.
d. Staff 1 put a ten year old child in charge of handing out snack as she was occupied with assisting other children and answering the door for parent pick-up.
e. Staff 1 stated that she had been alone with all of the children since 2:00 pm which put her behind in setting up the licensing board and implementing snack. Snack was handed out at 3:20 pm and the parent board was not set up until 3:00 pm.
Evidence:
1. The lack of sufficient staff on 11/01/2022 resulted in the one staff present not being able to properly care for and supervise the 47 children in care.
a. Five children were observed leaving the cafeteria, without knowledge of staff 1, to use the restroom.
b. Staff 1 was not able to implement required hand washing and sanitizing procedures as there was no one available to assist with these tasks.
c. A four-year old child tripped and fell while walking to his seat however, staff 1 did not see this as she was occupied on the other side of the cafeteria attending to another child.
d. Staff 1 put a ten year old child in charge of handing out snack as she was occupied with assisting other children and answering the door for parent pick-up.
e. Staff 1 stated that she had been alone with all of the children since 2:00 pm which put her behind in setting up the licensing board and implementing snack. Snack was handed out at 3:20 pm and the parent board was not set up until 3:00 pm.
Plan of Correction: Youth Development Director will ensure that all scheduled staff are present. If they are unable to work their scheduled shift they will follow the chain of command to report their absence.
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. Child 7, age 6 years, left the cafeteria to use the restroom without any staff supervision. The child was gone from approximately 3:30 pm - 3:36 pm.
a. The location of the bathrooms do not allow for sight or sound supervision as the bathrooms are approximately 35 feet from the cafeteria.
2. Child 11, age four years, left the cafeteria to use the restroom without any staff supervision at approximately 3:43 pm.
Evidence:
1. Child 7, age 6 years, left the cafeteria to use the restroom without any staff supervision. The child was gone from approximately 3:30 pm - 3:36 pm.
a. The location of the bathrooms do not allow for sight or sound supervision as the bathrooms are approximately 35 feet from the cafeteria.
2. Child 11, age four years, left the cafeteria to use the restroom without any staff supervision at approximately 3:43 pm.
Plan of Correction: Youth Development Director will ensure that all scheduled staff are present. If they are unable to work their scheduled shift they will follow the chain of command to report their absence.
Youth Development Director will review bathroom policy with staff that states students must remain within sight and sound.
Youth Development Director will review bathroom policy with staff that states students must remain within sight and sound.
Standard 8VAC20-780-340-G
Based on observation, the center failed to ensure that children 10 years of age and older shall be within actual sight and sound supervision of staff except when staff are able to hear children, are nearby so they can provide immediate intervention and there is a system to ensure that staff know where the children are and what they are doing.
Evidence:
1. Child 8, age 10 years, left the cafeteria to use the restroom without any staff supervision.
a. The location of the bathrooms do not allow for sound supervision as the bathrooms are located down the hall, approximately 35 feet, from the cafeteria.
b. There was no system in place for staff 1 to check on child 8. Additionally, staff 1 could not intervene as the proximately of the cafeteria to the bathrooms do not allow for immediate intervention.
2. Child 9 and child 10, both age 10 years, left the cafeteria to use the restroom at approximately 3:43 pm without the knowledge of staff 1 who was occupied with assisting children in the cafeteria.
Evidence:
1. Child 8, age 10 years, left the cafeteria to use the restroom without any staff supervision.
a. The location of the bathrooms do not allow for sound supervision as the bathrooms are located down the hall, approximately 35 feet, from the cafeteria.
b. There was no system in place for staff 1 to check on child 8. Additionally, staff 1 could not intervene as the proximately of the cafeteria to the bathrooms do not allow for immediate intervention.
2. Child 9 and child 10, both age 10 years, left the cafeteria to use the restroom at approximately 3:43 pm without the knowledge of staff 1 who was occupied with assisting children in the cafeteria.
Plan of Correction: Youth Development Director will ensure that all scheduled staff are present. If they are unable to work their scheduled shift they will follow the chain of command to report their absence.
Youth Development Director will review bathroom policy with staff that states students must remain within sight and sound.
Youth Development Director will review bathroom policy with staff that states students must remain within sight and sound.
Standard 8VAC20-780-350-C
Based on observation and interview, the center failed to ensure 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.
*Ratio Requirements: 1:10 for 3 years old up to school age eligible;
1:18 for school age eligible up to 9 years;
1: 20 for 9 years through 12 years.
*Maximum Group Size Requirements:
30 for 3 year olds up to school age eligible.
Evidence:
1. 47 children, ages 4 years - 10 years, were present with one staff when the inspector arrived at 2:50 pm. Four of these children were four year olds who are not school age eligible.
a. Five staff were needed to meet the 1:10 ratio required for the youngest children in the group who were four years of age.
b. The required group size of 30 was exceeded by 17 children for the four-year old children in care with the entire group of 47 children.
2. Staff 1 stated she had been alone with these 47 children since 2:00 pm.
3. When the inspector left at 4:08 pm staff 1 was alone with 43 children to include four year olds.
*Ratio Requirements: 1:10 for 3 years old up to school age eligible;
1:18 for school age eligible up to 9 years;
1: 20 for 9 years through 12 years.
*Maximum Group Size Requirements:
30 for 3 year olds up to school age eligible.
Evidence:
1. 47 children, ages 4 years - 10 years, were present with one staff when the inspector arrived at 2:50 pm. Four of these children were four year olds who are not school age eligible.
a. Five staff were needed to meet the 1:10 ratio required for the youngest children in the group who were four years of age.
b. The required group size of 30 was exceeded by 17 children for the four-year old children in care with the entire group of 47 children.
2. Staff 1 stated she had been alone with these 47 children since 2:00 pm.
3. When the inspector left at 4:08 pm staff 1 was alone with 43 children to include four year olds.
Plan of Correction: Youth Development Director will ensure that all scheduled staff are present. If they are unable to work their scheduled shift they will follow the chain of command to report their absence.
Additionally, Youth Development Director will ensure ratios are maintained.
Additionally, Youth Development Director will ensure ratios are maintained.
Standard 8VAC20-780-40-E
Based on observation and interview, the center failed to ensure that the center's activities, services and facilities are maintained in compliance with these standards.
Evidence:
1. Violations were cited in six of the eight areas of the standards for licensed child care centers to include: Administration, Staff Qualifications and Training, Staffing and Supervision, Programs, Special Care Provisions and Emergencies and Special Services. Violations cited in the areas of staffing and supervision , administration, staff qualifications and training, and special care provisions and emergencies with A2, B2, C2 and C3 risk ratings require a level of responsibility, knowledge, skills and /or abilities beyond those of direct care staff or aides to correct the violation or address the potential or actual consequences to children in care.
2. The lack of planning by the licensee resulted in inadequate staffing on 11/01/2022.
a. The licensee failed to provide for sufficient staffing on 11/01/2022, which resulted in having only one staff to provide care and supervision to 47 children ages four years - ten years.
b. Staff 1 stated she did not know why additional staff were not present and no one had reached out to her to alert her that she would be alone with the children on this date.
3. Records and information to include emergency contacts were not available for the majority of children in care during the information.
a. Hard copies of enrollment records were on file for approximately 15 of 47 children present in care during the inspection.
b. No electronic copies of children's records were able to be retrieved at the tablet provided to the staff was not working.
Evidence:
1. Violations were cited in six of the eight areas of the standards for licensed child care centers to include: Administration, Staff Qualifications and Training, Staffing and Supervision, Programs, Special Care Provisions and Emergencies and Special Services. Violations cited in the areas of staffing and supervision , administration, staff qualifications and training, and special care provisions and emergencies with A2, B2, C2 and C3 risk ratings require a level of responsibility, knowledge, skills and /or abilities beyond those of direct care staff or aides to correct the violation or address the potential or actual consequences to children in care.
2. The lack of planning by the licensee resulted in inadequate staffing on 11/01/2022.
a. The licensee failed to provide for sufficient staffing on 11/01/2022, which resulted in having only one staff to provide care and supervision to 47 children ages four years - ten years.
b. Staff 1 stated she did not know why additional staff were not present and no one had reached out to her to alert her that she would be alone with the children on this date.
3. Records and information to include emergency contacts were not available for the majority of children in care during the information.
a. Hard copies of enrollment records were on file for approximately 15 of 47 children present in care during the inspection.
b. No electronic copies of children's records were able to be retrieved at the tablet provided to the staff was not working.
Plan of Correction: Youth Development Director will ensure that all scheduled staff are present. If they are unable to work their scheduled shift they will follow the chain of commend to report their absence.
Emergency Contact Binder with all required information has been updated and is onsite for staff.
Emergency Contact Binder with all required information has been updated and is onsite for staff.
Standard 8VAC20-780-430-K
Based on observation, the center failed to make provision for an individual place for each child's personal belongings.
Evidence:
1. When the inspector arrived children's backpacks, lunch boxes and jackets were observed stored in a pile on three cafeteria tables. Approximately 6 jackets and backpacks were observed on the floor where it appeared they had fallen from the tables.
a. Staff 1 had a child set up the baskets for storage at approximately 3:15 pm however, only half of children's belongings were placed in baskets while many coats and backpacks remained in a pile on the table with some spilling onto the floor.
Evidence:
1. When the inspector arrived children's backpacks, lunch boxes and jackets were observed stored in a pile on three cafeteria tables. Approximately 6 jackets and backpacks were observed on the floor where it appeared they had fallen from the tables.
a. Staff 1 had a child set up the baskets for storage at approximately 3:15 pm however, only half of children's belongings were placed in baskets while many coats and backpacks remained in a pile on the table with some spilling onto the floor.
Plan of Correction: Youth Development Director will order baskets to contain all students' belongings upon arrival.
Standard 8VAC20-780-500-A
Based on observation, the center failed to ensure that children's hands shall be washed with soap and running water or disposable wipes before and after eating snack.
Evidence:
Children did not wash their hands with soap and water or a disposable wipe before and after eating snack on 11/01/2022.
Evidence:
Children did not wash their hands with soap and water or a disposable wipe before and after eating snack on 11/01/2022.
Plan of Correction: Youth Development Director will review the handwashing procedures with staff for both before and after snack is served.
Standard 8VAC20-780-530-A-1
Based on record review, the center failed to ensure that at least one staff in each classroom or area where children are present shall have current certification in cardiopulmonary resuscitation (CPR) as appropriate to the age of the children in care from an organization such as the American Red Cross, American Heart Association, American Safety and Health Institute, or National Safety Council.
Evidence:
The CPR certification for the only staff caring for children, staff 1, on 11/01/2022 expired on 08/25/2022.
Evidence:
The CPR certification for the only staff caring for children, staff 1, on 11/01/2022 expired on 08/25/2022.
Plan of Correction: Youth Development Director will ensure all staff have current first aid & CPR certifications.
Standard 8VAC20-780-530-A-2
Based on record review the center failed to ensure that at least one staff in each classroom or area where children are present shall have current certification in first aid.
Evidence:
1. The first aid certification for the only staff caring for children on 11/01/2022 (staff 1) expired on 08/25/2022.
Evidence:
1. The first aid certification for the only staff caring for children on 11/01/2022 (staff 1) expired on 08/25/2022.
Plan of Correction: Youth Development Director will ensure all staff have current first aid & CPR certifications.
Standard 8VAC20-780-560-F
Based on observation the center failed to ensure that when centers choose to provide meals or snacks, the following shall apply:
*Centers shall follow the most recent, age appropriate nutritional requirements of USDA;
*A menu listing foods to be served for snacks during the current one-week period shall be posted in a location conspicuous to parents or given to parents.
Evidence:
1. The snack served on 11/01/2022 lacked two required food components.
a. Children were provided a choice of either gold fish crackers or animal crackers.
b. Each child was given one package of cookies or crackers without a second food component.
2. The snack menu for 11/01/2022 was not posted on the parent board.
a. The posted menu was for the month of October 2022.
b. Staff 1 confirmed that the current snack menu was not posted.
*Centers shall follow the most recent, age appropriate nutritional requirements of USDA;
*A menu listing foods to be served for snacks during the current one-week period shall be posted in a location conspicuous to parents or given to parents.
Evidence:
1. The snack served on 11/01/2022 lacked two required food components.
a. Children were provided a choice of either gold fish crackers or animal crackers.
b. Each child was given one package of cookies or crackers without a second food component.
2. The snack menu for 11/01/2022 was not posted on the parent board.
a. The posted menu was for the month of October 2022.
b. Staff 1 confirmed that the current snack menu was not posted.
Plan of Correction: Youth Development Director will ensure that monthly menu is posted on the licensing board to reflect each week's snack menu.
A grain and fruit will be made available daily for students.
A grain and fruit will be made available daily for students.
Standard 8VAC20-780-560-J
Based on observation, the center failed to ensure that tables used for feeding shall be sanitized before and after each use for feeding.
Evidence:
1. The tables used for snack, which was served at approximately 3:30 pm, were not sanitized before or after use for feeding.
2. The tables were observed in use for children's activities before use for snack and after snack was completed.
Evidence:
1. The tables used for snack, which was served at approximately 3:30 pm, were not sanitized before or after use for feeding.
2. The tables were observed in use for children's activities before use for snack and after snack was completed.
Plan of Correction: Youth Development Director will review sanitizing protocols for before and after snack.
Standard 8VAC20-780-60-A
Based on record review and interview, the center failed to maintain and keep at the center a separate record for each child enrolled.
Evidence:
1. Enrollment records for child 1, child 2, child 4, child 5 and child 6 were not available. These children were all in care during the inspection on 11/01/2022.
a. Staff at the program, staff 1, confirmed that these enrollment records were not available and that she had no access to any information for these children.
2. A written emergency allergy care plan was not available for child 5 and child 6 who have diagnosed food allergies according to the facility allergy log.
a. Staff 1 verified that written allergy care plans were not available for these two children who were in care during the inspection on 11/01/2022.
Evidence:
1. Enrollment records for child 1, child 2, child 4, child 5 and child 6 were not available. These children were all in care during the inspection on 11/01/2022.
a. Staff at the program, staff 1, confirmed that these enrollment records were not available and that she had no access to any information for these children.
2. A written emergency allergy care plan was not available for child 5 and child 6 who have diagnosed food allergies according to the facility allergy log.
a. Staff 1 verified that written allergy care plans were not available for these two children who were in care during the inspection on 11/01/2022.
Plan of Correction: Emergency Contact binder with all required information has been updated and is onsite for staff.
Standard 8VAC20-780-70
Based on record review, the center failed to ensure that staff records contain all of the required elements.
1. Staff 1 is listed as a counselor in her employment file however, there is not written documentation to demonstrate that she possesses the education, certification and experience required by the job position.
a. Documentation of orientation training is lacking for staff 1 as well.
b. Staff 1 additionally stated to the inspector, during the inspection on 11/01/2022, that she was the program director for the program. No written documentation is on file to indicate how staff 1 meets program director qualifications.
2. Staff 2 is listed as a program leader in her employment file however, there is no written documentation to demonstrate that she possess the education, certification and experience required by the program leader job position.
1. Staff 1 is listed as a counselor in her employment file however, there is not written documentation to demonstrate that she possesses the education, certification and experience required by the job position.
a. Documentation of orientation training is lacking for staff 1 as well.
b. Staff 1 additionally stated to the inspector, during the inspection on 11/01/2022, that she was the program director for the program. No written documentation is on file to indicate how staff 1 meets program director qualifications.
2. Staff 2 is listed as a program leader in her employment file however, there is no written documentation to demonstrate that she possess the education, certification and experience required by the program leader job position.
Plan of Correction: Youth Development Director has already begun the process of updating staff files to reflect proper qualifications, education, and certifications to meet requirements. All staff records will be reviewed and updated.
Standard 8VAC20-780-90-A
Based on record review and interview, the center failed to ensure that a written agreement between the parent and center shall be in each child's record by the first day of the child's attendance.
Evidence:
1. A written parent agreement was not on file for child 1, child 2, child 3, child 4, child 5 and child 6.
a. Administrative staff confirmed that she did not have these agreements on file nor did she have access to the electronic copy of children's enrollment information.
Evidence:
1. A written parent agreement was not on file for child 1, child 2, child 3, child 4, child 5 and child 6.
a. Administrative staff confirmed that she did not have these agreements on file nor did she have access to the electronic copy of children's enrollment information.
Plan of Correction: Emergency contact binder with all required information has been updated and is onsite for staff.