The YMCA of South Hampton Roads - Deep Creek Elementary

8VAC20-780-340-A

“Based on a review of children’s records and interviews, it was determined the center did not ensure that when staff are supervising children they shall always ensure their care and protection. Evidence: 1.On 9/7/23, the center had Child #9 (a 6 year old) in care without having any contact information, no pick up authorizations and no records on site or available to staff caring for Child #9. Child # 9?s first day of attendance in this program was 9/5/2023. 2. On 9/7/2023 at approximately 5:53pm the child had not been picked up and the program closed at 6pm. Staff #4 stated she called the corporate office to obtain contact information for Child #9, however Staff #4 stated corporate was closed and no one answered the phone. a.Staff #4 contacted another program site and a staff member there said they knew the child’s mother and gave Staff #4 a contact phone number to call. b.Staff #4 called the number given and spoke to someone about this child; this person told them she was a non-custodial parent of Child #9 and gave them a contact phone contact number for the father who she stated was the custodial parent. 3. Staff #4 called the number given and spoke to someone else about this child; he indicated that he would send a woman to pick up Child #9 and gave Staff #4 the name of this person. a.When the child was picked up at approximately 6:17pm, staff did not check the ID of the woman who had been verbally authorized to pick up the child by the custodial parent, but did release Child #9 to this person. b.The custodial parent of Child #9 confirmed that staff did not check the ID of the person picking up the child on 9/7/2023. c.Without enrollment records, Staff #4 had no way to verify the parties that were spoken to, or whether the woman who picked up the child had actually been authorized to do so by the person who enrolled Child #9 in the program. 4. On 9/14/23, Child #8 was in care, however he was not listed on the roster, and staff did not have any records on this child. His first day of attendance was 9/5/2023. a.On 9/18/23 Child #8 was on the roster however Staff #4 stated there were no records for Child #8 available on site.”

8VAC20-780-320-B

“Based on observation and interviews, it was determined that the center did not ensure that bathrooms are equipped with paper towels. Evidence: Repeat Violation 1. In the girls bathroom a child was trying to dry her hands but the paper towel dispenser was not working. The child stated ?when there are no paper towels we just shake our hands?.”

8VAC20-780-130-A

“Based on record review and interviews, it was determined the center did not ensure that the documentation was obtained that each child in care had received immunizations as required by the State Board of Health before the child attends the center. Evidence: The record for Child #1, Child #5, and Child #8 did not contain documentation of immunizations.”

8VAC20-780-560-F

“Based on observation and interviews, it was determined that the center did not ensure that a menu listing foods to be served for meals and snacks was posted in a location conspicuous to parents. Evidence: Repeat Violation 1. The inspector observed that there was no snack menu posted on the Parent Board. 2. Staff #4 (Program Director) confirmed the snack menu was not posted.”

8VAC20-780-510-P

“Based on observation and interviews, it was determined the center did not ensure that when medication expires, the parent is notified and the medication is returned to the parent within 14 days. Evidence: Repeat Violation Medication for Child #11 (enrollment ended 6/16/23) expired April 2023 was not returned to the parent and was on-site on the day of the inspection.”

8VAC20-780-510-G

“Based on observation and interviews, it was determined the center did not ensure that medication was labeled with the child’s name. Evidence: The box of emergency medication for Child #13 was not labeled with the child’s name. Staff #4 (Program Director) confirmed there was no name on the box.”

8VAC20-780-430-K

“Based on observation and interviews, it was determined the center did not ensure that a provision was made for an individual place for each child’s personal belongings. Evidence: 1. Children’s backpacks, lunchboxes and sweaters were piled on top of each other on a table in the cafeteria. 2. Backpacks and lunch boxes were falling on the floor as children attempted to reach their own belongings. 3. Staff #4 (Program Director) confirmed the children did not have an individual place for children to place their belongings.”

8VAC20-780-40-M

“Based on a review of children’s records and interviews, it was determined the center did not ensure that the program maintained a current written list of all children's allergies, sensitivities, and dietary restrictions. Evidence: Repeat Violation 1.The allergy list available to staff was no longer current as it was dated for the previous school year (2022-2023). a.Three out of the four children listed on the expired allergy list were no longer enrolled. 2.Staff #4 (Program Director) confirmed the allergy list was not current.”

8VAC20-780-90-A

“Based on record review and interviews, it was determined the center did not ensure that the required written and signed agreements between the parent and the center shall be in each child’s record by the first day of the child’s attendance. Evidence: 1. Seven out nine children (Child #1, #2, #3, #5, #6, #8, #9) who were in attendance on the day of the inspection, records did not contained signed agreements between the parent and the center. 2. Staff #4 (Program Director) confirmed the parental agreements were not signed.”

8VAC20-780-60-A

“Based on review of children’s records and interviews, it was determined that the center did not ensure that each child’s record contains all required information. Evidence: Repeat Violation 1. There was no record on file for Child #8. The child was in care during the inspection. 2. Staff #4 (Program Director) confirmed there were no enrollment records available for Child #8. 3. Eight out of nine children’s files reviewed, did not have all of the required information. 4.The record for Child #9 did not contain two emergency contacts. 5. The record for Child #1 did not contain parents? names, addresses, home and work phone numbers, physicians name and phone number, two emergency contacts, authorizations for pick up, and proof of identity. 6. The record for Child #2 did not include documentation of proof of identity. 7. The record for Child #3 did not contain parents? names, addresses, home and work phone numbers, physicians name and phone number, two emergency contacts and proof of identity. 8. The record for Child #4 did not include documentation of viewing proof of identity. 9. The record for Child #5 did not contain parent work phone number, physicians name and phone number, two emergency contacts and proof of identity. 10.The record for Child #6 did not include documentation of viewing proof of identity. 11. Staff #4 (Program Director) confirmed the records for the children listed above did not contain the required information.”

8VAC20-780-510-E

“Based upon review of medication, the facility has not ensured that the procedures for administering medication include methods to prevent the use of outdated medication and that expired medication is returned to the parent within 14 days or the medication is disposed of by the facility. Evidence: 1. There was an EpiPen stored for emergency administration to child 9. The medication expired in April 2023 and was not returned to the parent or disposed of. 2. Staff 1 confirmed that the medication was expired.”

8VAC20-780-320-B

“Based upon observation, the facility has not ensured that bathrooms are equipped with paper towels. Evidence: The girls were taken to the bathroom at the end of the hallway outside of the gymnasium to wash their hands prior to eating afternoon snack. The girls came out of the bathroom shaking off their hands to dry them and said that there were no paper towels. The inspector mentioned this to staff 2 who sent an assistant to retrieve paper towels.”

8VAC20-780-60-A

“Based upon review of children's records and staff interview, the facility has not ensured that each child's record includes the names, addresses and telephone numbers of two persons to be contacted when a parent cannot be reached. In addition, each child's record must include a written care plan for any child with a physician diagnosed food allergy. Evidence: 1. The record provided for child 6 included only one emergency contact person other than parents. 2. Staff 1 acknowledged that there was only one emergency contact person in the record provided for child 6. 3. The written care plan in the record provided for child 9 indicated that diphenhydramine is to be administered if there is a mild allergic reaction, however the facility did not have diphenhydramine for emergency administration to the child,”

8VAC20-780-550-D

“Based upon review pf records and staff interview, the facility has not ensured that they have implemented a monthly evacuation drill. Evidence: 1. The written record of emergency drills did not include documentation of an emergency evacuation drill in April 2023. 2. Staff 1 acknowledged that an evacuation drill had not been documented in the emergency drill record.”

8VAC20-780-340-A

“Based upon observation, the facility has not ensured that when staff are supervising children, they ensure their care and protection. Evidence: Based upon documentation, the facility has three children with food allergies. At snack time, the children are provided with a snack but are also allowed to eat whatever is still in their lunch boxes that they brought to public school. Staff 1 told the group of 23 children that if they had anything with peanuts or peanut butter to move to another table at the far end of the cafeteria. No staff checked to ensure that there were no peanut products being eaten near the children with allergies.”

8VAC20-780-60-A

“Based upon review of records, the facility has not ensured that children's records include all required information. Evidence: The record provided for child 2 did not include any information regarding the parents or the parent contact information. The record also did not include the names, addresses and telephone numbers for two persons to be contacted in an emergency when a parent cannot be reached.”

8VAC20-780-350-C

“Based upon observation, the facility has not ensured that when children are in ongoing mixed age groups, the staff-to-children ratio applicable to the youngest child in the group applies to the entire group. Evidence: When a group of children moved from the gymnasium to the cafeteria for snack, there were 23 children, aged 4 years and older, with two staff. The required ratio for children to staff in a group with 4 year old children is no more than 10 children per staff person. As the children were eating, three additional children joined the group with the two staff, totaling 26 children with two staff.”

8VAC20-780-550-F

“Based upon review of records, the facility has not ensured that lockdown procedures are practiced at least annually. Evidence: Based upon the records provided, there was no lockdown drill conducted last school year and no lockdown drill has been conducted this school year.”

8VAC20-780-510-P

“Based upon observation and staff interview, the facility has not ensured that when medication expires, the parent is notified and the medication is returned to the parent within 14 days. Evidence: 1. There was epinephrine for potential emergency administration to child 2. The epinephrine expired in December 2022 and was not returned to the parent. 2. Staff 1 acknowledged that the epinephrine for child 2 had expired and the parent was not notifed.”

8VAC20-780-510-E

“Based upon review of medication stored for emergency administration to the children, the facility has not followed their own policy requiring parent authorization for any medication to potentially be administered to the child by program staff. Evidence: There was diphenhydramine stored for potential administration to child 3. There was no written parent authorization for the diphenhydramine to be administered.”

8VAC20-780-260-A

“Based upon records provided, the facility has not ensured that there is an annual fire inspection from the fire official having jurisdiction. Evidence: The most recent fire marshal inspection provided is dated 11/10/2021.”

8VAC20-780-245-J-3

“Based upon review of documentation, staff interview and observation, the facility has not ensured that any child for whom emergency medication has been prescribed is always in the care of a staff member who has medication administration training (MAT) certification. Evidence: 1. From 2:00 PM until 2:30 PM, child 1, child 2 and child 3, all of whom have allergies that may require the administration of epinephrine, were in care without a MAT certified caregiver. 2. Staff 1 acknowledged that staff 1 is the only caregiver with MAT certification and that she does not arrive until around 2:30 PM.”

8VAC20-780-340-A

“Based upon observation, the facility has not ensured that when staff are supervising children, they ensure their care and protection. Evidence: Based upon documentation, the facility has three children with food allergies. At snack time, the children are provided with a snack but are also allowed to eat whatever is still in their lunch boxes that they brought to public school. Staff 1 told the group of 23 children that if they had anything with peanuts or peanut butter to move to another table at the far end of the cafeteria. No staff checked to ensure that there were no peanut products being eaten near the children with allergies.”

8VAC20-780-60-A

“Based upon review of records, the facility has not ensured that children's records include all required information. Evidence: The record provided for child 2 did not include any information regarding the parents or the parent contact information. The record also did not include the names, addresses and telephone numbers for two persons to be contacted in an emergency when a parent cannot be reached.”

8VAC20-780-350-C

“Based upon observation, the facility has not ensured that when children are in ongoing mixed age groups, the staff-to-children ratio applicable to the youngest child in the group applies to the entire group. Evidence: When a group of children moved from the gymnasium to the cafeteria for snack, there were 23 children, aged 4 years and older, with two staff. The required ratio for children to staff in a group with 4 year old children is no more than 10 children per staff person. As the children were eating, three additional children joined the group with the two staff, totaling 26 children with two staff.”

8VAC20-780-550-F

“Based upon review of records, the facility has not ensured that lockdown procedures are practiced at least annually. Evidence: Based upon the records provided, there was no lockdown drill conducted last school year and no lockdown drill has been conducted this school year.”

8VAC20-780-510-P

“Based upon observation and staff interview, the facility has not ensured that when medication expires, the parent is notified and the medication is returned to the parent within 14 days. Evidence: 1. There was epinephrine for potential emergency administration to child 2. The epinephrine expired in December 2022 and was not returned to the parent. 2. Staff 1 acknowledged that the epinephrine for child 2 had expired and the parent was not notifed.”

8VAC20-780-510-E

“Based upon review of medication stored for emergency administration to the children, the facility has not followed their own policy requiring parent authorization for any medication to potentially be administered to the child by program staff. Evidence: There was diphenhydramine stored for potential administration to child 3. There was no written parent authorization for the diphenhydramine to be administered.”

8VAC20-780-260-A

“Based upon records provided, the facility has not ensured that there is an annual fire inspection from the fire official having jurisdiction. Evidence: The most recent fire marshal inspection provided is dated 11/10/2021.”

8VAC20-780-245-J-3

“Based upon review of documentation, staff interview and observation, the facility has not ensured that any child for whom emergency medication has been prescribed is always in the care of a staff member who has medication administration training (MAT) certification. Evidence: 1. From 2:00 PM until 2:30 PM, child 1, child 2 and child 3, all of whom have allergies that may require the administration of epinephrine, were in care without a MAT certified caregiver. 2. Staff 1 acknowledged that staff 1 is the only caregiver with MAT certification and that she does not arrive until around 2:30 PM.”

8VAC20-780-140-A

“Based upon review of records, the facility has not ensured that each child has a physical examination by or under the direction of a physician. Evidence: The record provided for child 5, whose first date of attendance was recorded as 9/6/2022, did not have documentation of a physical examination.”

8VAC20-780-40-E

“Based upon observation and staff interview, the facility has not ensured that the center's activities are maintained in compliance with the center's own policies and procedures. Evidence: Upon arrival of the children from school, staff were observed asking other children if children who were enrolled in the after school program were in school that day. Staff 1 was heard asking children if children absent from the program were in school that day. When asked by the licensing inspector how the absence of a child arriving from another program was confirmed, staff 1 stated that she asked the other children if the child was in school that day. The center's policy states that the office personnel at the elementary school was to be contacted to confirm children's absences.”

8VAC20-780-60-A

“Based upon review of records, the facility ahs not ensured that children's records include all required information. Evidence: The record provided for child 2 did not include two persons other than the parents to be contacted in an emergency when a parent cannot be reached.”

8VAC20-780-245-J-3

“Based upon review of medication and staff interview, the facility has not ensured any child for whom emergency medication has been prescribed is always in the care of a staff member who has medication administration training (MAT) certification. Evidence: 1. From 12:05 PM until 12:15 PM, child 2, child 3 and child 4, all of whom have allergies that may require the administration of epinephrine, were in care without a MAT certified caregiver. 2. Staff 1 acknowledged that staff 1 is the only caregiver with MAT certification and that staff 1 did not arrive until 12:15 PM.”

8VAC20-780-260-B

“Based upon review of documentation and staff interview, the facility has not ensured that there is documentation of annual approval of the health department. Evidence: 1. The facility could not provide documentation of annual approval of the health department. 2. Staff 1 verified that documentation of annual approval of the health department was not available.”

8VAC20-780-510-P

“Based upon observation and staff interview, the facility has not ensured that when medication expires, the parent is notified and the medication is returned to the parent within 14 days. Evidence: 1. There was epinephrine stored for potential administration to child 2. The epinephrine expired in December 2022 and was not returned to the parent. 2. Staff 1 acknowledged that the epinephrine for child 2 had expired and the parent ws not notified.”

8VAC20-780-550-P

“Based upon review of records and staff interview, the facility has not ensured that they maintain a written record of children's injuries that includes are required documentation. Evidence: 1. A written injury record dated 12/15/2021 did not include the time the parent was notified of the injury. 2. Staff 1 verified that the injury record of 12/15/2021 did not include the time the parent was notified of the injury.”

8VAC20-780-560-F

“Based upon observation and staff interview, the facility has not ensured that a menu of foods to be served for snack was posted. Evidence: 1. There was no snack menu for the current week posted. 2. Staff 1 acknowledged that the menu had not been posted for the current week.”

8VAC20-780-160-A

“Based upon review of documentation, the facility ash not ensured that each staff member submits documentation of a negative tuberculosis screening that was completed within the last 30 calendar days of the date of employment. Evidence: 1. The date of employment of staff 1 was 4/20/2022. The date of the tuberculosis screening was 6/3/2021. 2. The date of employment of staff 2 was 10/31/2022. The date of the tuberculosis screening was 7/23/2022.”

8VAC20-780-140-A

“Based upon review of records, the facility has not ensured that each child has a physical examination by or under the direction of a physician. Evidence: The record provided for child 5, whose first date of attendance was recorded as 9/6/2022, did not have documentation of a physical examination.”

8VAC20-780-40-E

“Based upon observation and staff interview, the facility has not ensured that the center's activities are maintained in compliance with the center's own policies and procedures. Evidence: Upon arrival of the children from school, staff were observed asking other children if children who were enrolled in the after school program were in school that day. Staff 1 was heard asking children if children absent from the program were in school that day. When asked by the licensing inspector how the absence of a child arriving from another program was confirmed, staff 1 stated that she asked the other children if the child was in school that day. The center's policy states that the office personnel at the elementary school was to be contacted to confirm children's absences.”

8VAC20-780-60-A

“Based upon review of records, the facility ahs not ensured that children's records include all required information. Evidence: The record provided for child 2 did not include two persons other than the parents to be contacted in an emergency when a parent cannot be reached.”

8VAC20-780-245-J-3

“Based upon review of medication and staff interview, the facility has not ensured any child for whom emergency medication has been prescribed is always in the care of a staff member who has medication administration training (MAT) certification. Evidence: 1. From 12:05 PM until 12:15 PM, child 2, child 3 and child 4, all of whom have allergies that may require the administration of epinephrine, were in care without a MAT certified caregiver. 2. Staff 1 acknowledged that staff 1 is the only caregiver with MAT certification and that staff 1 did not arrive until 12:15 PM.”

8VAC20-780-260-B

“Based upon review of documentation and staff interview, the facility has not ensured that there is documentation of annual approval of the health department. Evidence: 1. The facility could not provide documentation of annual approval of the health department. 2. Staff 1 verified that documentation of annual approval of the health department was not available.”

8VAC20-780-510-P

“Based upon observation and staff interview, the facility has not ensured that when medication expires, the parent is notified and the medication is returned to the parent within 14 days. Evidence: 1. There was epinephrine stored for potential administration to child 2. The epinephrine expired in December 2022 and was not returned to the parent. 2. Staff 1 acknowledged that the epinephrine for child 2 had expired and the parent ws not notified.”

8VAC20-780-550-P

“Based upon review of records and staff interview, the facility has not ensured that they maintain a written record of children's injuries that includes are required documentation. Evidence: 1. A written injury record dated 12/15/2021 did not include the time the parent was notified of the injury. 2. Staff 1 verified that the injury record of 12/15/2021 did not include the time the parent was notified of the injury.”

8VAC20-780-560-F

“Based upon observation and staff interview, the facility has not ensured that a menu of foods to be served for snack was posted. Evidence: 1. There was no snack menu for the current week posted. 2. Staff 1 acknowledged that the menu had not been posted for the current week.”

8VAC20-780-160-A

“Based upon review of documentation, the facility ash not ensured that each staff member submits documentation of a negative tuberculosis screening that was completed within the last 30 calendar days of the date of employment. Evidence: 1. The date of employment of staff 1 was 4/20/2022. The date of the tuberculosis screening was 6/3/2021. 2. The date of employment of staff 2 was 10/31/2022. The date of the tuberculosis screening was 7/23/2022.”

8VAC20-780-160-C

“Based on review of our staff records, it was determined that the facility did not ensure that each staff member had an updated tuberculosis (Tb) screening every two years from the date of the last screening. Evidence: The Tb screening for staff #3, who was on duty at the time of the inspection, expired "this past summer" according to the Coordinator of the program.”

8VAC20-780-60-A

“Based on review of two children's records it was determined that the facility did not ensure that there was a record available for each child enrolled. Evidence: The record was requested for child #1, who was in care at the time of the inspection, did not have a record on site.”

8VAC20-780-70

“Based on review of four staff records, it was determined that the facility did not ensure that all elements were present in each staff member's record. Evidence: The record for staff #4, who was on duty at the time of the inspection, did not contain the telephone number for the emergency contact person.”

8VAC20-780-160-C

“Based on review of our staff records, it was determined that the facility did not ensure that each staff member had an updated tuberculosis (Tb) screening every two years from the date of the last screening. Evidence: The Tb screening for staff #3, who was on duty at the time of the inspection, expired "this past summer" according to the Coordinator of the program.”

8VAC20-780-60-A

“Based on review of two children's records it was determined that the facility did not ensure that there was a record available for each child enrolled. Evidence: The record was requested for child #1, who was in care at the time of the inspection, did not have a record on site.”

8VAC20-780-70

“Based on review of four staff records, it was determined that the facility did not ensure that all elements were present in each staff member's record. Evidence: The record for staff #4, who was on duty at the time of the inspection, did not contain the telephone number for the emergency contact person.”