YMCA - Midlothian

8VAC20-790-600-D-2

“Based on review of five staff records, the vendor did not ensure all staff who work directly with children obtained current certification in first aid within 90 days of the date of employment. Evidence: 1. The records for Staff #3 (Date of Employment 06/05/2023) and Staff #4 (Date of Employment 06/05/2023) did not contain current certification in first aid. 2. A member of management confirmed Staff #3 and Staff #4 did not current first aid certification.”

8VAC20-780-280-B

“Based on observations, the center did not ensure all hazardous substances such as cleaning materials, were kept in a locked place using a safe locking method that prevented access by children. Evidence: Three cabinets in three classrooms contained unlocked cleaning chemicals. Children were observed in the three classrooms during the inspection.”

8VAC20-780-150-B

“Based on review of five children’s records, the center did not ensure one child’s immunization records was not signed by a physician, his designee, or an official of a local health department. Evidence: The record for Child #1 (First day of attendance 08/21/2023) contained immunizations records that were not signed and dated by a physician.”

22.1-289.035-B-4

“Based on record review, the center did not ensure one of ten staff records contained documentation of criminal history record results from any state in which the individual has resided in the past five years, prior to employment. Evidence: The record of staff #10 (employment date: 5/8/2023) did not have documentation of out of state criminal history record results.”

8VAC20-780-70

“Based on record review, the center did not ensure three of ten staff records contained all of the required documentation. Evidence: 1. The record of staff #2 (employment date: 6/12/2023) did not have documentation to demonstrate that the individual possesses the experience required by the job position. 2. The record of staff #5 (employment date: 6/7/2023) did not have documentation to demonstrate that the individual possesses the experience required by the job position and orientation training. 3. The record of staff #8 (employment date: 6/6/2023) did not have documentation to demonstrate that the individual possesses the experience required by the job position. 4. The record of staff #9 (employment date: 5/25/2023) did not have documentation to demonstrate that the individual possesses the experience required by the job position.”

8VAC20-780-60-A

“Based on record review, the center did not ensure five of ten child records contained all required documentation Evidence: 1. The record of child #2 (enrollment date: 6/5/23) did not contain documentation of a written allergy care plan. The child's record and the center's allergy list showed that child #2 has a food allergy. 2. The record of child #4 (enrollment date: 6/5/23) did not have documentation of one of the two required emergency contacts. 3. The record of child #7 (enrollment date: 6/5/23) did not have documentation of two of the two required emergency contacts; persons authorized to pick up the child; and proof of the child's identity and age. 4. The record of child #8 (enrollment date: 6/5/23) did not have documentation of two of the two required emergency contacts. 5. The record of child #4 (enrollment date: 6/5/23) did not have documentation of two of the two required emergency contacts and proof of the child's identity and age.”

22.1-289.035-B-4

“Based on record review, the center did not ensure one of ten staff records contained documentation of criminal history record results from any state in which the individual has resided in the past five years, prior to employment. Evidence: The record of staff #10 (employment date: 5/8/2023) did not have documentation of out of state criminal history record results.”

8VAC20-780-70

“Based on record review, the center did not ensure three of ten staff records contained all of the required documentation. Evidence: 1. The record of staff #2 (employment date: 6/12/2023) did not have documentation to demonstrate that the individual possesses the experience required by the job position. 2. The record of staff #5 (employment date: 6/7/2023) did not have documentation to demonstrate that the individual possesses the experience required by the job position and orientation training. 3. The record of staff #8 (employment date: 6/6/2023) did not have documentation to demonstrate that the individual possesses the experience required by the job position. 4. The record of staff #9 (employment date: 5/25/2023) did not have documentation to demonstrate that the individual possesses the experience required by the job position.”

8VAC20-780-60-A

“Based on record review, the center did not ensure five of ten child records contained all required documentation Evidence: 1. The record of child #2 (enrollment date: 6/5/23) did not contain documentation of a written allergy care plan. The child's record and the center's allergy list showed that child #2 has a food allergy. 2. The record of child #4 (enrollment date: 6/5/23) did not have documentation of one of the two required emergency contacts. 3. The record of child #7 (enrollment date: 6/5/23) did not have documentation of two of the two required emergency contacts; persons authorized to pick up the child; and proof of the child's identity and age. 4. The record of child #8 (enrollment date: 6/5/23) did not have documentation of two of the two required emergency contacts. 5. The record of child #4 (enrollment date: 6/5/23) did not have documentation of two of the two required emergency contacts and proof of the child's identity and age.”

8VAC20-790-600-F

“Based on a review of five staff records and interview, the vendor did not ensure one staff member who works directly with children completed the department's health and safety update course annually. Evidence: 1) The record of Staff #5 (DOE: 05/23/22) did not have documentation of the department's health and safety update course. 2) During interview, a member of management reported the center does not have documentation that the staff completed the course. The course should have been completed no later than 05/23/23.”

8VAC20-780-160-C

“Based on a review of five staff records, the center did not ensure one staff obtained and submitted the results of a follow-up tuberculosis (TB) screening at least every two years. Evidence: The most recent TB screening in the record of Staff #1 (DOE: 01/06/21) was completed on 02/18/23. The previous TB screening was completed on 12/31/20. A new TB screening should have been obtained no later than 12/31/22.”

8VAC20-770-60-C-2

“Based on a review of five staff records and interview, the center did not ensure one staff member had a central registry finding within 30 days of employment. Evidence: 1) The central registry finding in the record of Staff #2 (DOE: 06/15/22) was completed on 10/03/22. 2) During interview, a member of management confirmed the central registry finding for Staff #2 was not received within 30 days of employment. The record did not contain documentation of any further contact with the Office of Background Investigations, and the staff member had been continuously employed.”

22.1-289.035-A

“Based on a review of five staff records and interview, the center did not ensure one staff completed three required background checks every five years. Evidence: 1) The most recent results of the fingerprint-based national criminal background check in the record of Staff #3 (DOE: 11/23/10) was completed on 04/17/23. The previous fingerprint-based national criminal background check was completed on 04/02/18. The new results should have been obtained no later than 04/02/23. 2) The most recent central registry check in the record of Staff #3 was completed on 05/09/22. The previous central registry check in the record was completed on 04/17/17. A new search of the central registry should have been obtained no later than 04/17/22. 3) The most recent sworn statements in the record of Staff #3 were completed on 08/30/22 and 11/11/22. The previous sworn statement in the record was completed on 08/01/17. A new sworn statement should have been completed no later than 08/01/22. 4) During interview, a member of management acknowledged the background checks for Staff #3 were not completed every five years as required.”

8VAC20-780-550-P

“Based on a review of documentation, the center did not ensure that written injury records contained the required information. Evidence: Six written injury records were reviewed. The following documentation was missing: 1) Injury record #1 did not contain documentation of the date and time when parents were notified; documentation of how parent was notified; and any future action to prevent reoccurrence of the injury. 2) Injury record #2 did not contain documentation of the date and time when parents were notified; documentation of how parent was notified; and any future action to prevent reoccurrence of the injury. 3) Injury record #3 did not contain documentation of the type and circumstance of the injury; staff present and treatment; future action to prevent reoccurrence of the injury; the date and time when parents were notified; and documentation of how parent was notified. 4) Injury record #4 did not contain documentation of the date and time when parents were notified; documentation of how parent was notified; staff present; and future action to prevent reoccurrence of the injury. 5) Injury record #5 did not contain documentation of the type and circumstance of the injury; staff present and treatment; future action to prevent reoccurrence of the injury; the date and time when parents were notified; and documentation of how parent was notified. 6) Injury record #6 did not contain documentation of the staff present; the date and time when parents were notified; documentation of how parent was notified; and future action to prevent reoccurrence. The center shall 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.”

8VAC20-780-160-A

“Based on a review of five staff records and interview, the center did not ensure one staff member submitted documentation of a negative tuberculosis (TB) screening within the required timeframe. Evidence: The TB screening in the record of Staff #5 (DOE: 05/23/22) was completed on 12/19/22. There was no documentation a TB screening was completed prior to this date. Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children.”

8VAC20-780-240-A

“Based on a review of five staff records and interview, the center did not ensure one staff complete within 90 calendar days of employment the Virginia Department of Education-sponsored orientation course. Evidence: 1) The record of Staff #5 (DOE:05/23/22) did not contain the Virginia Department of Education-sponsored orientation course. 2) During interview, a member of management reported the staff member has not completed the orientation to date.”

8VAC20-790-600-F

“Based on a review of five staff records and interview, the vendor did not ensure one staff member who works directly with children completed the department's health and safety update course annually. Evidence: 1) The record of Staff #5 (DOE: 05/23/22) did not have documentation of the department's health and safety update course. 2) During interview, a member of management reported the center does not have documentation that the staff completed the course. The course should have been completed no later than 05/23/23.”

8VAC20-780-160-C

“Based on a review of five staff records, the center did not ensure one staff obtained and submitted the results of a follow-up tuberculosis (TB) screening at least every two years. Evidence: The most recent TB screening in the record of Staff #1 (DOE: 01/06/21) was completed on 02/18/23. The previous TB screening was completed on 12/31/20. A new TB screening should have been obtained no later than 12/31/22.”

8VAC20-770-60-C-2

“Based on a review of five staff records and interview, the center did not ensure one staff member had a central registry finding within 30 days of employment. Evidence: 1) The central registry finding in the record of Staff #2 (DOE: 06/15/22) was completed on 10/03/22. 2) During interview, a member of management confirmed the central registry finding for Staff #2 was not received within 30 days of employment. The record did not contain documentation of any further contact with the Office of Background Investigations, and the staff member had been continuously employed.”

22.1-289.035-A

“Based on a review of five staff records and interview, the center did not ensure one staff completed three required background checks every five years. Evidence: 1) The most recent results of the fingerprint-based national criminal background check in the record of Staff #3 (DOE: 11/23/10) was completed on 04/17/23. The previous fingerprint-based national criminal background check was completed on 04/02/18. The new results should have been obtained no later than 04/02/23. 2) The most recent central registry check in the record of Staff #3 was completed on 05/09/22. The previous central registry check in the record was completed on 04/17/17. A new search of the central registry should have been obtained no later than 04/17/22. 3) The most recent sworn statements in the record of Staff #3 were completed on 08/30/22 and 11/11/22. The previous sworn statement in the record was completed on 08/01/17. A new sworn statement should have been completed no later than 08/01/22. 4) During interview, a member of management acknowledged the background checks for Staff #3 were not completed every five years as required.”

8VAC20-780-550-P

“Based on a review of documentation, the center did not ensure that written injury records contained the required information. Evidence: Six written injury records were reviewed. The following documentation was missing: 1) Injury record #1 did not contain documentation of the date and time when parents were notified; documentation of how parent was notified; and any future action to prevent reoccurrence of the injury. 2) Injury record #2 did not contain documentation of the date and time when parents were notified; documentation of how parent was notified; and any future action to prevent reoccurrence of the injury. 3) Injury record #3 did not contain documentation of the type and circumstance of the injury; staff present and treatment; future action to prevent reoccurrence of the injury; the date and time when parents were notified; and documentation of how parent was notified. 4) Injury record #4 did not contain documentation of the date and time when parents were notified; documentation of how parent was notified; staff present; and future action to prevent reoccurrence of the injury. 5) Injury record #5 did not contain documentation of the type and circumstance of the injury; staff present and treatment; future action to prevent reoccurrence of the injury; the date and time when parents were notified; and documentation of how parent was notified. 6) Injury record #6 did not contain documentation of the staff present; the date and time when parents were notified; documentation of how parent was notified; and future action to prevent reoccurrence. The center shall 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.”

8VAC20-780-160-A

“Based on a review of five staff records and interview, the center did not ensure one staff member submitted documentation of a negative tuberculosis (TB) screening within the required timeframe. Evidence: The TB screening in the record of Staff #5 (DOE: 05/23/22) was completed on 12/19/22. There was no documentation a TB screening was completed prior to this date. Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children.”

8VAC20-780-240-A

“Based on a review of five staff records and interview, the center did not ensure one staff complete within 90 calendar days of employment the Virginia Department of Education-sponsored orientation course. Evidence: 1) The record of Staff #5 (DOE:05/23/22) did not contain the Virginia Department of Education-sponsored orientation course. 2) During interview, a member of management reported the staff member has not completed the orientation to date.”