Rappahannock Area Young Men's Christian Association-Bowling Gree

8VAC20-790-600-D-1

“Based on a review of two staff records and interviews, the vendor did not ensure one staff member had current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care within 90 days of the date of employment. Evidence: The record of Staff #2, employed on 06/08/23, did not contain documentation that the staff has current certification in CPR. During interview, a member of management reported the center did not have documentation of current certification in CPR for Staff #2.”

8VAC20-790-600-F

“Based on a review of two staff records and interviews, the vendor did not ensure one staff member who works directly with children completed the department's health and safety update course annually. Evidence: The record of Staff #1, employed on 06/07/21, did not contain the department's health and safety update course. During interview, a member of management confirmed Staff #1 has not completed the training. The center was approved as a vendor on 03/28/22, therefore, the annual training should have been completed no later than 03/28/23.”

8VAC20-790-600-D-2

“Based on a review of two staff records and interviews, the vendor did not ensure one staff member had current certification in first aid appropriate to the ages of children in care within 90 days of the date of employment. Evidence: The record of Staff #2, employed on 06/08/23, did not contain documentation that the staff has current certification in first aid. During interview, a member of management reported the center did not have documentation of current certification in first aid for Staff #2.”

8VAC20-780-60-A

“(Repeat Violation) Based on a review of five children's records and interviews, the center did not ensure one child's record contained the required information. Evidence: The record of Child #1 (DOA: 05/28/19) did not contain documentation of child updates and confirmation of up-to-date information in the child's record as required by 8VAC20-780-420-E.3. During interview, a member of management acknowledged the record did not contain confirmation of up-to-date information.”

22.1-289.035-B-2

“(Repeat Violation) Based on a review of two staff records and interview, the center did not ensure one staff obtained a fingerprint-based national criminal background check prior to employment. Evidence: The results of the fingerprint-based national criminal background check in the record of Staff #2, employed on 06/08/23, were completed on 06/15/23. During interview, a member of management acknowledged the fingerprints for Staff #2 were received after Staff #2 received orientation training, for which she was compensated for on 06/08/23.”

8VAC20-770-60-B

“Based on a review of two staff records and interviews, the center did not ensure one staff had a completed sworn statement or affirmation prior to employment. Evidence: The record of Staff #2, employed on 06/08/23, did not contain documentation of a completed sworn statement. During interview, a member of management acknowledged that a completed sworn statement was not on file for Staff #2.”

8VAC20-780-160-A

“Based on a review of two staff records and interviews, the center did not ensure one staff member submitted documentation of a negative tuberculosis (TB) screening within the required timeframe. Evidence: The record of Staff #2, employed on 06/08/23, did not contain documentation of a negative TB screening. During interview, a member of management reported documentation of a negative TB screening could not be located for Staff #2.”

8VAC20-770-60-C-2

“Based on a review of two staff record and interviews, the center did not ensure one staff had a central registry finding within 30 days of employment. Evidence: The record of Staff #2, employed on 06/08/23, did not contain the results of the central registry finding. During interview, a member of management reported the results of the central registry finding for Staff #2 could not be located.”

8VAC20-780-70

“(Repeat Violation) Based on observations and a review of documentation on 02/27/24, the center did not ensure that the required information for each staff was kept at the center. Evidence: During the inspection on 02/27/24, Staff #1 and Staff #2 were observed at the center. The emergency contact information and information about any health problems which may interfere with fulfilling the job responsibilities were not observed at the center for the staff. The center should maintain at the center the name, address and telephone number of a person to be notified in an emergency and information about any health problems which may interfere with fulfilling the job responsibilities for each staff member.”

8VAC20-780-160-C

“Based on a review of two staff records and interviews, the center did not obtain documentation that one staff had a follow-up tuberculosis (TB) screening at least every two years from the date of the first initial screening or testing. Evidence: The most recent TB screening in the record of Staff #1, employed on 06/14/21, was dated 09/03/21. During interview, a member of management reported an updated TB screening was not on file for Staff #1. An updated TB screening should have been obtained no later than 09/03/23.”

8VAC20-790-600-D-1

“Based on a review of two staff records and interviews, the vendor did not ensure one staff member had current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care within 90 days of the date of employment. Evidence: The record of Staff #2, employed on 06/08/23, did not contain documentation that the staff has current certification in CPR. During interview, a member of management reported the center did not have documentation of current certification in CPR for Staff #2.”

8VAC20-790-600-F

“Based on a review of two staff records and interviews, the vendor did not ensure one staff member who works directly with children completed the department's health and safety update course annually. Evidence: The record of Staff #1, employed on 06/07/21, did not contain the department's health and safety update course. During interview, a member of management confirmed Staff #1 has not completed the training. The center was approved as a vendor on 03/28/22, therefore, the annual training should have been completed no later than 03/28/23.”

8VAC20-790-600-D-2

“Based on a review of two staff records and interviews, the vendor did not ensure one staff member had current certification in first aid appropriate to the ages of children in care within 90 days of the date of employment. Evidence: The record of Staff #2, employed on 06/08/23, did not contain documentation that the staff has current certification in first aid. During interview, a member of management reported the center did not have documentation of current certification in first aid for Staff #2.”

8VAC20-780-60-A

“(Repeat Violation) Based on a review of five children's records and interviews, the center did not ensure one child's record contained the required information. Evidence: The record of Child #1 (DOA: 05/28/19) did not contain documentation of child updates and confirmation of up-to-date information in the child's record as required by 8VAC20-780-420-E.3. During interview, a member of management acknowledged the record did not contain confirmation of up-to-date information.”

22.1-289.035-B-2

“(Repeat Violation) Based on a review of two staff records and interview, the center did not ensure one staff obtained a fingerprint-based national criminal background check prior to employment. Evidence: The results of the fingerprint-based national criminal background check in the record of Staff #2, employed on 06/08/23, were completed on 06/15/23. During interview, a member of management acknowledged the fingerprints for Staff #2 were received after Staff #2 received orientation training, for which she was compensated for on 06/08/23.”

8VAC20-770-60-B

“Based on a review of two staff records and interviews, the center did not ensure one staff had a completed sworn statement or affirmation prior to employment. Evidence: The record of Staff #2, employed on 06/08/23, did not contain documentation of a completed sworn statement. During interview, a member of management acknowledged that a completed sworn statement was not on file for Staff #2.”

8VAC20-780-160-A

“Based on a review of two staff records and interviews, the center did not ensure one staff member submitted documentation of a negative tuberculosis (TB) screening within the required timeframe. Evidence: The record of Staff #2, employed on 06/08/23, did not contain documentation of a negative TB screening. During interview, a member of management reported documentation of a negative TB screening could not be located for Staff #2.”

8VAC20-770-60-C-2

“Based on a review of two staff record and interviews, the center did not ensure one staff had a central registry finding within 30 days of employment. Evidence: The record of Staff #2, employed on 06/08/23, did not contain the results of the central registry finding. During interview, a member of management reported the results of the central registry finding for Staff #2 could not be located.”

8VAC20-780-70

“(Repeat Violation) Based on observations and a review of documentation on 02/27/24, the center did not ensure that the required information for each staff was kept at the center. Evidence: During the inspection on 02/27/24, Staff #1 and Staff #2 were observed at the center. The emergency contact information and information about any health problems which may interfere with fulfilling the job responsibilities were not observed at the center for the staff. The center should maintain at the center the name, address and telephone number of a person to be notified in an emergency and information about any health problems which may interfere with fulfilling the job responsibilities for each staff member.”

8VAC20-780-160-C

“Based on a review of two staff records and interviews, the center did not obtain documentation that one staff had a follow-up tuberculosis (TB) screening at least every two years from the date of the first initial screening or testing. Evidence: The most recent TB screening in the record of Staff #1, employed on 06/14/21, was dated 09/03/21. During interview, a member of management reported an updated TB screening was not on file for Staff #1. An updated TB screening should have been obtained no later than 09/03/23.”

8VAC20-790-600-D-1

“Based on a review of two staff records, the vendor did not ensure one staff member had current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. Evidence: The CPR certification in the record of Staff #1 expired on 11/14/2022.”

8VAC20-790-600-D-2

“Based on a review of two staff records, the vendor did not ensure one staff member had current certification in first aid appropriate to the ages of children in care. Evidence: The first aid certification in the record of Staff #1 expired on 11/14/2022.”

8VAC20-790-600-F

“Based on a review of two staff records and interview, the vendor did not ensure two staff members who work directly with children completed the department's health and safety update course annually. Evidence: 1) The record of Staff #1 (DOE: 06/07/21) and the record of Staff #2 (DOE: 06/14/21) did not contain the department's health and safety update course. 2) During interview, a member of management confirmed Staff #1 and Staff #2 have not completed the training. The center was approved as a vendor on 03/28/22, therefore, the annual training should have been completed no later than 03/28/23.”

8VAC20-780-60-A

“Based on a review of five children's records and interview, the center did not ensure one child's record contained the required information. Evidence: 1) The record of Child #3, enrolled 8/16/22, indicated the child had a diagnosed food allergy, but the record did not include a written care plan to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction. 2) During interview, staff confirmed a written allergy care plan was not available for Child #3.”

22.1-289.035-B-4

“Based on a review of two staff records, the center did not obtain the results of a sex offender registry check and a search of the child abuse and neglect registry or equivalent registry from any state in which one staff member had resided in the preceding five years within the required timeframe. Evidence: 1) The record of Staff #2, employed 06/14/21, indicated the staff had resided in another state outside of Virginia within the last five years. The record did not contain a sex offender registry check or a search of the child abuse and neglect registry. The out-of-state sex offender registry check is required to be obtained prior to employment. The out-of-state search for founded complaints of child abuse or neglect is required to be requested within the first 30 days of employment. 2) During interview, management confirmed the required out-of-state checks were not obtained for Staff #2 within the required timeframe.”

8VAC20-780-40-M

“Based on a review of documentation and interview, the center did not ensure all children with a diagnosed food allergy were included in the center's written list of children with allergies, sensitivities, and dietary restrictions. Evidence: 1) The record of Child #3, enrolled 08/16/22, and the record of Child #5, enrolled 08/17/22, indicated the children had diagnosed food allergies. 2) The inspector reviewed the center's written list of all children's allergies, sensitivities, and dietary restrictions during the inspection on 03/29/23. The list did not include Child #3 or Child #5. 3) During interview, staff reported they were aware of the children's allergies, but did not realize they were not listed on the written allergy list on site.”

8VAC20-790-600-D-1

“Based on a review of two staff records, the vendor did not ensure one staff member had current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. Evidence: The CPR certification in the record of Staff #1 expired on 11/14/2022.”

8VAC20-790-600-D-2

“Based on a review of two staff records, the vendor did not ensure one staff member had current certification in first aid appropriate to the ages of children in care. Evidence: The first aid certification in the record of Staff #1 expired on 11/14/2022.”

8VAC20-790-600-F

“Based on a review of two staff records and interview, the vendor did not ensure two staff members who work directly with children completed the department's health and safety update course annually. Evidence: 1) The record of Staff #1 (DOE: 06/07/21) and the record of Staff #2 (DOE: 06/14/21) did not contain the department's health and safety update course. 2) During interview, a member of management confirmed Staff #1 and Staff #2 have not completed the training. The center was approved as a vendor on 03/28/22, therefore, the annual training should have been completed no later than 03/28/23.”

8VAC20-780-60-A

“Based on a review of five children's records and interview, the center did not ensure one child's record contained the required information. Evidence: 1) The record of Child #3, enrolled 8/16/22, indicated the child had a diagnosed food allergy, but the record did not include a written care plan to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction. 2) During interview, staff confirmed a written allergy care plan was not available for Child #3.”

22.1-289.035-B-4

“Based on a review of two staff records, the center did not obtain the results of a sex offender registry check and a search of the child abuse and neglect registry or equivalent registry from any state in which one staff member had resided in the preceding five years within the required timeframe. Evidence: 1) The record of Staff #2, employed 06/14/21, indicated the staff had resided in another state outside of Virginia within the last five years. The record did not contain a sex offender registry check or a search of the child abuse and neglect registry. The out-of-state sex offender registry check is required to be obtained prior to employment. The out-of-state search for founded complaints of child abuse or neglect is required to be requested within the first 30 days of employment. 2) During interview, management confirmed the required out-of-state checks were not obtained for Staff #2 within the required timeframe.”

8VAC20-780-40-M

“Based on a review of documentation and interview, the center did not ensure all children with a diagnosed food allergy were included in the center's written list of children with allergies, sensitivities, and dietary restrictions. Evidence: 1) The record of Child #3, enrolled 08/16/22, and the record of Child #5, enrolled 08/17/22, indicated the children had diagnosed food allergies. 2) The inspector reviewed the center's written list of all children's allergies, sensitivities, and dietary restrictions during the inspection on 03/29/23. The list did not include Child #3 or Child #5. 3) During interview, staff reported they were aware of the children's allergies, but did not realize they were not listed on the written allergy list on site.”

8VAC20-780-550-P

“Based on a review of documentation on 09/27/2022, the center did not ensure that written injury records contained the required information. Evidence: Three injury records were reviewed. The three injury records did not contain documentation of any future action to prevent recurrence of the injury. The center should maintain a written record of children's serious and minor injuries in which entries are made the day of occurrence. The record shall include the following: date and time of injury; name of injured child; type and circumstance of the injury; staff present and treatment; date and time when parents were notified; any future action to prevent reoccurrence of the injury; staff and parent signatures or two staff signatures; and documentation on how parent was notified.”

22.1-289.035-B-2

“Based on a review of two staff records and interview, the center did not ensure one staff obtained a fingerprint-based national criminal background check prior to employment. Evidence: 1) The record of Staff #1, employed 06/14/21, did not contain the results of a fingerprint-based national criminal background check. 2) During interview, management confirmed the fingerprint-based national criminal background check for Staff #1 could not be located.”

22.1-289.035-B-4

“Based on a review of two staff records, the center did not obtain the results of a sex offender registry check and a search of the child abuse and neglect registry or equivalent registry from any state in which one staff member had resided in the preceding five years within the required timeframe. Evidence: 1) The record of Staff #1, employed 06/14/21, indicated the staff had resided in another state outside of Virginia within the last five years. The record did not contain a sex offender registry check or a search of the child abuse and neglect registry. The out-of-state sex offender registry check is required to be obtained prior to employment. The out-of-state search for founded complaints of child abuse or neglect is required to be requested within the first 30 days of employment. 2) During interview, management confirmed the required out-of-state checks were not obtained for Staff #1 within the required timeframe.”

8VAC20-780-70

“Based on staff interview and observation on 09/27/2022, the center did not ensure that the required information for each staff was kept at the center. Evidence: 1) Staff #1 and Staff #2 were observed at the center on 09/27/2022. 2) Staff interviewed stated that an emergency contact and information about any health problems staff have were not available for review at the center. The center should maintain at the center the name, address, and telephone number of a person to be notified in an emergency and information about any health problems that may interfere with fulfilling the job responsibilities for each staff member.”

8VAC20-780-550-P

“Based on a review of documentation on 09/27/2022, the center did not ensure that written injury records contained the required information. Evidence: Three injury records were reviewed. The three injury records did not contain documentation of any future action to prevent recurrence of the injury. The center should maintain a written record of children's serious and minor injuries in which entries are made the day of occurrence. The record shall include the following: date and time of injury; name of injured child; type and circumstance of the injury; staff present and treatment; date and time when parents were notified; any future action to prevent reoccurrence of the injury; staff and parent signatures or two staff signatures; and documentation on how parent was notified.”

22.1-289.035-B-2

“Based on a review of two staff records and interview, the center did not ensure one staff obtained a fingerprint-based national criminal background check prior to employment. Evidence: 1) The record of Staff #1, employed 06/14/21, did not contain the results of a fingerprint-based national criminal background check. 2) During interview, management confirmed the fingerprint-based national criminal background check for Staff #1 could not be located.”

22.1-289.035-B-4

“Based on a review of two staff records, the center did not obtain the results of a sex offender registry check and a search of the child abuse and neglect registry or equivalent registry from any state in which one staff member had resided in the preceding five years within the required timeframe. Evidence: 1) The record of Staff #1, employed 06/14/21, indicated the staff had resided in another state outside of Virginia within the last five years. The record did not contain a sex offender registry check or a search of the child abuse and neglect registry. The out-of-state sex offender registry check is required to be obtained prior to employment. The out-of-state search for founded complaints of child abuse or neglect is required to be requested within the first 30 days of employment. 2) During interview, management confirmed the required out-of-state checks were not obtained for Staff #1 within the required timeframe.”

8VAC20-780-70

“Based on staff interview and observation on 09/27/2022, the center did not ensure that the required information for each staff was kept at the center. Evidence: 1) Staff #1 and Staff #2 were observed at the center on 09/27/2022. 2) Staff interviewed stated that an emergency contact and information about any health problems staff have were not available for review at the center. The center should maintain at the center the name, address, and telephone number of a person to be notified in an emergency and information about any health problems that may interfere with fulfilling the job responsibilities for each staff member.”

8VAC20-780-550-B

“Based on a review of documentation, the center's emergency preparedness plan does not contain all the required information. Evidence: 1) The center's emergency preparedness plan was reviewed, the plan did not include procedural components for the continuity of operations to ensure that essential functions are maintained during an emergency.”

8VAC20-780-40-K

“Based on interviews, the center has not developed written procedures for prevention of shaken baby syndrome or abusive head trauma, including coping with crying babies, safe sleeping practices, and sudden infant death syndrome awareness. Evidence: 1) During interview, a member of management reported the required written procedures for prevention of shaken baby syndrome or abusive head trauma have not been developed.”

8VAC20-780-350-F

“Based on interviews, the center has not developed a written policy and procedure that describes how the center will ensure that each group of children receives care by consistent staff or team of staff members. Evidence: 1) During interview, a member of management reported the center is practicing care by consistent staff, but written policies and procedures are not listed in official policy format.”

8VAC20-780-70

“Based on observations and a review of documentation on 03/08/22, the center did not ensure that the required information for each staff was kept at the center. Evidence: 1) During the inspection, Staff #1 and Staff #2 were observed at the center. 2) The emergency contact information and information about any health problems which may interfere with fullfilling the job responsibilities were not observed at the center for Staff #2 (DOH: 01/17/20). The center should maintain at the center the name, address and telephone number of a person to be notified in an emergency and information about any health problems which may interfere with fulfilling the job responsibilities for each staff member.”

63.2(17)-1720.1-B-2

“Based on a review of three staff records and interview, the center did not ensure one staff member completed a national fingerprint-based criminal history check before the first day of employment. Evidence: 1) The record for Staff #1, hired on 06/14/2021, did not contain the results of a national fingerprint-based criminal history check prior to hire. 2) During interview, a member of management confirmed the required results of a national fingerprint-based criminal history check were not obtained for Staff #1 prior to hire.”

22VAC40-185-70-A

“Based on a review of three staff records, the center did not ensure one staff member's record was complete. Evidence: 1) The two telephone reference checks in the record for Staff #1, hired on 06/14/2021, did not include the dates of contact or signature of the person making the call. Each staff record should contain documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering. If a reference check is taken over the phone, documentation shall include: dates of contact; names of persons contacted; the firms contacted; the results; and signature of person making call.”

63.2(17)-1720.1-B-4

“Based on a review of three staff records and interview, the center did not obtain a copy of a sex offender registry check and a search of the child abuse and neglect registry or equivalent registry from any state in which one staff member has resided in the preceding five years within the required time frame. Evidence: 1) The record for Staff #1, hired on 06/14/21, indicated the staff has resided outside of Virginia in the last five years. The record did not contain a sex offender registry check or the results of a child abuse and neglect search from the state Staff #1 had resided. The state is a National Fingerprint File (NFF) state; therefore, an out of state criminal history name check is not required. 2) During interview, a member of management reported the required out-of-state background checks have not been requested. The sex offender registry is required to be obtained prior to hiring. The out-of-state search of child abuse or neglect is required to be requested within the first 30 days of being hired.”

22VAC40-185-160-C

“Based on a review of three staff records and interview, the center did not ensure that one staff resubmit tuberculosis (TB) test results every two years from the date of the first initial screening or testing, or more frequently as if recommended by a licensed physician or the local health department. Evidence: 1) The most recent TB screening in the record for Staff #3, hired on 04/02/19, was dated 05/28/19. The TB screening expired on 05/28/21. 2) During interview, a member of management confirmed this is the most recent TB screening on file for Staff #3. Staff should resubmit TB test results at least every two years from the date of the first initial screening or testing, or more frequently as if recommended by a licensed physician or the local health department.”