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Young Men's Christian Association of Greater Richmond-Bryce Lane

Inspection · 2024-08-15

Date
2024-08-15
Complaint Related
No
Licensing Inspector
Heather Dapper
(804) 625-2304
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.
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect

Inspector Notes

An unannounced, on-site monitoring inspection was initiated on August 15, 2024 and completed on August 19, 2024. The on-site inspection began at 11:50 AM and ended at 1:15 PM. The inspector reviewed compliance in the areas listed above. There were 14 children present and five staff. The inspector reviewed five children?s records on site and five staff records, electronically on August 19, 2024. This inspection included document review, tour of the facility, interviews, and observation.

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 August 23, 2024. A POC submitted after this date will not appear on the public website.

Violations

8
Standard 22.1-289.035-B-1
Based on record review and interview, the center did not ensure one of five staff records had documentation of a completed sworn statement or affirmation prior to the first day of employment.

Evidence:
1. The record of staff #5 (employed 6/27/21) had documentation of a completed sworn statement or affirmation dated 2/19/24.
2. A member of management stated that staff #5 did not complete a sworn statement prior to hire.
Plan of Correction: Administration has communicated with HR department to remind them of having documentation prior to D.O.H.
Standard 22.1-289.035-B-2
Based on a review of staff records and interview, the center did not ensure staff had the satisfactory results of the fingerprint-based national criminal background check prior to employment.

Evidence:
The record for staff #5 (employed 6/27/21) did not contain the results of the fingerprint-based national criminal background check until 02/19/24.
A member of management confirmed the fingerprint-based national criminal background check for staff #1 were not obtained prior to employment.
Plan of Correction: Administration has communicated with HR and steps moving forward.
Standard 22.1-289.035-B-3
Based on record review and interview, the center did not have documentation of central registry findings for one of the five staff members.

Evidence:
1. The record for staff #5 (employed 6/27/21) did not contain documentation of central registry findings until 02/07/24.
2. A member of management confirmed that the central registry finding was not obtained. within the required timeframe.
Plan of Correction: Administration has communicated with HR and steps moving forward.
Standard 22.1-289.035-B-4
Based on record review and interview, the center did not ensure one of five staff records contained documentation of criminal history record results and a sex offender registry check results from any state in which the individual has resided in the past five years.

Evidence:
1. The record of staff #1 (employed 8/21/23) had documentation of out of state criminal history record results on 11/20/23 and out of state sex offender registry check results on 11/20/23.
2. The Sworn Statement or Affirmation of staff #1 stated that the individual lived outside of Virginia in the past five years. The out of state checks were not completed in the required time frame.
Plan of Correction: Administration is working with HR on how to prevent these issues.
Standard 8VAC20-780-140-A
Based on a review of children's records, the center did not ensure that each child shall have a physical examination by or under the direction of a physician before the child's attendance or within one month after attendance.

Evidence:
The records for child #3 (enrolled 10/18/23) and child #5 (enrolled 7/18/23), did not have a physical examination.
Plan of Correction: Administration and directors will ensure students have all documents before the start of attendance.
Standard 8VAC20-780-160-A
Based on review of records and interview, the center did not ensure that each staff member shall submit documentation of a negative tuberculosis screening (TB) at the time of employment and prior to coming in contact with children.

Evidence:
The record for staff #5 (employed 6/27/21) had a TB screening dated 2/02/24.
A member of management acknowledged that the TB screening was not completed prior to hire or before coming in contact with children.
Plan of Correction: Administration is working with HR
Standard 8VAC20-780-270-A
Based on observation, the center did not ensure areas and equipment of the center, inside and outside, shall be maintained in a clean, safe and operable condition.

In the two year old room, one broken toilet paper holder.
In the four year old classroom, one broken ceiling tile with exposed wires.
Plan of Correction: Maintenance ticket has been submitted.
Standard 8VAC20-780-550-P
Based on a review of the facility's injury reports, all required information was not documented.

Evidence:
Two injury reports were reviewed and two injury reports did not have any future action to prevent recurrence of the injury and one staff and parent signature or two staff signatures.
A member of management acknowledged that the injury reports did not have the required information documented.
Plan of Correction: Staff and directors have been retrained on how to submit all required information on SharePoint.
View original record on Virginia Department of Social Services