YMCA-SACC and Summer Camp at Lewis & Clark

8VAC20-790-600-F

“(Repeat violation) Based on record review, the center failed to have staff complete the departments annual update health and safety course. Evidence: 1. The record for staff #1 did not contain documentation of the annual update health and safety course. 2. The director confirmed the annual 3-hour update for staff #1 had not been completed.”

8VAC20-790-600-D-1

“(Repeat Violations) Based on review of staff records, the center failed to ensure that all staff had current certification in CPR. Evidence: 1. Staff #2's CPR certification expired on 4/20/2023. 2. Administration verified that the CPR certification was expired.”

8VAC20-790-600-D-2

“(Repeat Violations) Based on review of staff records, the center failed to ensure that all staff held a current certification in First Aid. Evidence: 1. Staff #1's first aid certification expired on 4/20/2023. 2. Administration verified that the first aid certification had expired.”

8VAC20-780-60-A

“Based on review of children's records, the center did not ensure that all children’s records contain all required information. Evidence: 1. Child #4's record was missing both parents work name, work phone numbers, and work addresses.”

8VAC20-780-510-E

“Based on review of medication and staff interview, the center did not ensure that their procedures for the administration of medication are followed. Evidence: 1. There was a bottle of Benadryl stored for emergency administration to child A. There was no written parent authorization for the medication to be administered.”

8VAC20-790-600-D-1

“Based on a review of documents, the vendor did not ensure two staff members had current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. Evidence: 1) The CPR certification in the record of Staff #1 expired on 04/20/2023. 2) The CPR certification in the record of Staff #5 expired on 11/14/22.”

8VAC20-790-600-D-2

“Based on a review of documents, the vendor did not ensure two staff members had current certification in first aid appropriate to the ages of children in care. Evidence: 1) The first aid certification in the record of Staff #1 expired on 04/20/2023. 2) The first aid certification in the record of Staff #5 expired on 11/14/22.”

8VAC20-780-130-A

“Based on a review of five children's records and interview, the center did not obtain documentation that one child had received the immunizations required by the State Board of Health before the child attended the center. Evidence: 1) The immunization documentation in the record of Child #2, date of attendance 02/27/23, was dated 02/28/23. 2) During interview, a member of management confirmed the center did not obtain documentation of the child's immunizations before the child attended the center.”

22.1-289.035-B-4

“Based on a review of four staff records and interview, 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 #3, employed on 02/01/23, 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. An out-of-state criminal history record information check was not required because the state participates in the National Fingerprint File (NFF) program through the FBI. 2) During interview, a member of management confirmed the required out-of-state checks were not obtained for Staff #3 within the required timeframe.”

8VAC20-770-60-B

“Based on a review of four staff records and interview, the center did not ensure one staff had a completed sworn statement or affirmation prior to employment. Evidence: 1) The sworn statement in the record of Staff #1, employed on 11/12/22, was not signed. 2) During interview, a member of management confirmed the sworn statement for Staff #1 was not complete at the time of employment.”

22.1-289.035-B-2

“Based on a review of four staff records and interview, the center did not ensure two staff had the satisfactory results of the fingerprint-based national criminal background check prior to employment. Evidence: 1) The fingerprint-based national criminal background check in the record of Staff #1, employed on 11/12/22, was dated 01/04/23. 2) The record of Staff #3, employed on 02/01/23, did not contain the results of the fingerprint-based national criminal background check requested by the current employer. 3) During interview, a member of management confirmed the fingerprint-based national criminal background check for Staff #1 and Staff #3 were not obtained at the time of employment.”

8VAC20-780-550-D

“Based on a review of documentation and interview, the center did not implement a monthly practice evacuation drill. Evidence: 1) The licensing inspector observed the emergency drill log for the year 2022. An evacuation drill was not conducted for January, March, or May 2022. 2) During interview, management reported the documentation of the drills could not be located and was not able to determine if the drills were conducted. The center shall implement a monthly practice evacuation drill.”

8VAC20-780-550-E

“Based on a review of documentation and interview, the center did not practice shelter-in-place procedures a minimum of twice per year. Evidence: 1) The licensing inspector observed the emergency drill log for the year 2022. There was no documentation that shelter-in-place drills were practiced. 2) During interview, management reported the documentation of the drills could not be located and was not able to determine if the drills were conducted. Shelter-in-place procedures shall be practiced a minimum of twice per year.”

8VAC20-780-550-F

“Based on a review of documentation and interview, the center did not practice lockdown procedures at least annually. Evidence: 1) The licensing inspector observed the emergency drill log for the year 2022. There was no documentation that a lockdown drill was practiced. 2) During interview, management reported the documentation of the drills could not be located and was not able to determine if a lockdown drill was conducted. Lockdown procedures shall be practiced at least annually.”

8VAC20-780-550-P

“Based on a review of documentation on 04/12/2023, the center did not ensure that written injury records contained the required information. Evidence: Three out of three written injury records reviewed did not contain the date and time parents were notified of the injuries. 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.”

8VAC20-780-530-A

“Based on a review of records, observation, and interview, the center did not ensure that there shall be at least one staff member with current certification in cardiopulmonary resuscitation (CPR) and current certification in first aid where children are present. Evidence: 1) On 4/12/23, Staff #5 was observed providing transportation to four children that attend the program from another school. Staff #5 was the only staff member present during transportation. 2) The First Aid and CPR certificate in the record of Staff #5 expired on 11/14/22. 3) During interview, a member of management confirmed the CPR and First Aid certification of Staff #5 was expired.”

8VAC20-780-70

“Based on staff interview and observations on 04/12/23, the center did not ensure that the required information for each staff was kept at the center. Evidence: 1) Staff #1, Staff #2, Staff #4, Staff #5, and Staff #6 were observed at the center on 04/12/23. 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.”

8VAC20-780-60-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 #2, enrolled on 02/27/23, did not contain documentation of two emergency contacts. 2) During interview, a member of management confirmed the center did not have documentation of two emergency contacts for Child #2. Each child record shall contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.”

8VAC20-780-160-A

“Based on a review of four staff records and interview, the center did not ensure four staff members submitted documentation of a negative tuberculosis screening within the required timeframe. Evidence: 1) The most recent tuberculosis (TB) screening in the record of Staff #1, employed on 11/12/22, was dated 02/19/21 and expired on 02/19/23. 2) The most recent TB screening in the record of Staff #2, employed on 12/17/22, was dated 08/31/21. 3) The record of Staff #3, employed on 02/01/23, did not contain documentation of a negative tuberculosis screening. 4) The TB screening in the record of Staff #4, employed on 03/13/23, was dated 03/22/23. 5) During interview, a member of management confirmed Staff #1, Staff #2, Staff #3, and Staff #4 did not submit documentation of a negative tuberculosis screening within the required timeframe. Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children; and the documentation shall have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician's designee, or an official of the local health department.”

8VAC20-770-60-C-2

“Based on a review of four staff records and interview on 04/25/23, the center did not ensure two staff members had a central registry finding within 30 days of employment. Evidence: 1) The central registry finding in the record of Staff #1, employed on 11/12/22, was dated 01/07/23. 2) During interview, a member of management confirmed the results of the central registry for Staff #1 were received more than 30 days after 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. 3) The record of Staff #4, employed on 03/13/23, did not have a central registry finding. 4) During interview, a member of management confirmed the results of the central registry for Staff #4 had not been received to date. The record did not contain documentation of any further contact with the Office of Background Investigations, and the staff member had been continuously employed.”

8VAC20-790-600-D-1

“Based on a review of documents, the vendor did not ensure two staff members had current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. Evidence: 1) The CPR certification in the record of Staff #1 expired on 04/20/2023. 2) The CPR certification in the record of Staff #5 expired on 11/14/22.”

8VAC20-790-600-D-2

“Based on a review of documents, the vendor did not ensure two staff members had current certification in first aid appropriate to the ages of children in care. Evidence: 1) The first aid certification in the record of Staff #1 expired on 04/20/2023. 2) The first aid certification in the record of Staff #5 expired on 11/14/22.”

8VAC20-780-130-A

“Based on a review of five children's records and interview, the center did not obtain documentation that one child had received the immunizations required by the State Board of Health before the child attended the center. Evidence: 1) The immunization documentation in the record of Child #2, date of attendance 02/27/23, was dated 02/28/23. 2) During interview, a member of management confirmed the center did not obtain documentation of the child's immunizations before the child attended the center.”

22.1-289.035-B-4

“Based on a review of four staff records and interview, 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 #3, employed on 02/01/23, 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. An out-of-state criminal history record information check was not required because the state participates in the National Fingerprint File (NFF) program through the FBI. 2) During interview, a member of management confirmed the required out-of-state checks were not obtained for Staff #3 within the required timeframe.”

8VAC20-770-60-B

“Based on a review of four staff records and interview, the center did not ensure one staff had a completed sworn statement or affirmation prior to employment. Evidence: 1) The sworn statement in the record of Staff #1, employed on 11/12/22, was not signed. 2) During interview, a member of management confirmed the sworn statement for Staff #1 was not complete at the time of employment.”

22.1-289.035-B-2

“Based on a review of four staff records and interview, the center did not ensure two staff had the satisfactory results of the fingerprint-based national criminal background check prior to employment. Evidence: 1) The fingerprint-based national criminal background check in the record of Staff #1, employed on 11/12/22, was dated 01/04/23. 2) The record of Staff #3, employed on 02/01/23, did not contain the results of the fingerprint-based national criminal background check requested by the current employer. 3) During interview, a member of management confirmed the fingerprint-based national criminal background check for Staff #1 and Staff #3 were not obtained at the time of employment.”

8VAC20-780-550-D

“Based on a review of documentation and interview, the center did not implement a monthly practice evacuation drill. Evidence: 1) The licensing inspector observed the emergency drill log for the year 2022. An evacuation drill was not conducted for January, March, or May 2022. 2) During interview, management reported the documentation of the drills could not be located and was not able to determine if the drills were conducted. The center shall implement a monthly practice evacuation drill.”

8VAC20-780-550-E

“Based on a review of documentation and interview, the center did not practice shelter-in-place procedures a minimum of twice per year. Evidence: 1) The licensing inspector observed the emergency drill log for the year 2022. There was no documentation that shelter-in-place drills were practiced. 2) During interview, management reported the documentation of the drills could not be located and was not able to determine if the drills were conducted. Shelter-in-place procedures shall be practiced a minimum of twice per year.”

8VAC20-780-550-F

“Based on a review of documentation and interview, the center did not practice lockdown procedures at least annually. Evidence: 1) The licensing inspector observed the emergency drill log for the year 2022. There was no documentation that a lockdown drill was practiced. 2) During interview, management reported the documentation of the drills could not be located and was not able to determine if a lockdown drill was conducted. Lockdown procedures shall be practiced at least annually.”

8VAC20-780-550-P

“Based on a review of documentation on 04/12/2023, the center did not ensure that written injury records contained the required information. Evidence: Three out of three written injury records reviewed did not contain the date and time parents were notified of the injuries. 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.”

8VAC20-780-530-A

“Based on a review of records, observation, and interview, the center did not ensure that there shall be at least one staff member with current certification in cardiopulmonary resuscitation (CPR) and current certification in first aid where children are present. Evidence: 1) On 4/12/23, Staff #5 was observed providing transportation to four children that attend the program from another school. Staff #5 was the only staff member present during transportation. 2) The First Aid and CPR certificate in the record of Staff #5 expired on 11/14/22. 3) During interview, a member of management confirmed the CPR and First Aid certification of Staff #5 was expired.”

8VAC20-780-70

“Based on staff interview and observations on 04/12/23, the center did not ensure that the required information for each staff was kept at the center. Evidence: 1) Staff #1, Staff #2, Staff #4, Staff #5, and Staff #6 were observed at the center on 04/12/23. 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.”

8VAC20-780-60-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 #2, enrolled on 02/27/23, did not contain documentation of two emergency contacts. 2) During interview, a member of management confirmed the center did not have documentation of two emergency contacts for Child #2. Each child record shall contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.”

8VAC20-780-160-A

“Based on a review of four staff records and interview, the center did not ensure four staff members submitted documentation of a negative tuberculosis screening within the required timeframe. Evidence: 1) The most recent tuberculosis (TB) screening in the record of Staff #1, employed on 11/12/22, was dated 02/19/21 and expired on 02/19/23. 2) The most recent TB screening in the record of Staff #2, employed on 12/17/22, was dated 08/31/21. 3) The record of Staff #3, employed on 02/01/23, did not contain documentation of a negative tuberculosis screening. 4) The TB screening in the record of Staff #4, employed on 03/13/23, was dated 03/22/23. 5) During interview, a member of management confirmed Staff #1, Staff #2, Staff #3, and Staff #4 did not submit documentation of a negative tuberculosis screening within the required timeframe. Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children; and the documentation shall have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician's designee, or an official of the local health department.”

8VAC20-770-60-C-2

“Based on a review of four staff records and interview on 04/25/23, the center did not ensure two staff members had a central registry finding within 30 days of employment. Evidence: 1) The central registry finding in the record of Staff #1, employed on 11/12/22, was dated 01/07/23. 2) During interview, a member of management confirmed the results of the central registry for Staff #1 were received more than 30 days after 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. 3) The record of Staff #4, employed on 03/13/23, did not have a central registry finding. 4) During interview, a member of management confirmed the results of the central registry for Staff #4 had not been received to date. The record did not contain documentation of any further contact with the Office of Background Investigations, and the staff member had been continuously employed.”

8VAC20-780-510-F

“Based on a review of four medications and interview, the center did not ensure the medication authorization for four medications were available to staff during the entire time they were effective. Evidence: 1) On 08/04/22, two medications were observed on site for Child #4. 2) During interview, staff reported the medication authorizations were not available on site. 3) On 08/04/2022, two medications were observed on site for Child #5. 4) During interview, staff reported the medication authorizations were not available on site.”

8VAC20-780-510-G

“Based on observation and interview, the center did not ensure that two medications were labeled with the child's name, the name of the medication, the dosage amount, and the time or times to be given. Evidence: 1) On 08/04/2022, two prescription medications were observed on site for Child #4. The medications were observed in a plastic bag, but the medications did not have a label with the child's name, the name of the medication, the dosage amount, and the time or times to be given. 2) Staff interviewed stated the label for the medications were not given to staff upon receipt of the medications.”

8VAC20-780-60-A-8

“Based on a review of five children's records and interview, the center did not ensure two children with a diagnosed food allergy had 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. Evidence: 1) Child #4, enrolled 06/21/22, has a diagnosed food allergy. During the inspection on 08/04/22, staff interviewed reported the child's written care plan was not available for review on site. 2) Child #5, enrolled on 10/25/21, has a diagnosed food allergy. During the inspection on 08/04/22, staff interviewed reported the child's written care plan was not available for review on site.”

8VAC20-780-70

“Based on staff interview on 08/04/2022, the center did not ensure that the required information for each staff was kept at the center. Evidence: 1) Staff #1, Staff #2, and Staff #3 were observed at the center on 08/04/2022. 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.”

8VAC20-780-510-F

“Based on a review of four medications and interview, the center did not ensure the medication authorization for four medications were available to staff during the entire time they were effective. Evidence: 1) On 08/04/22, two medications were observed on site for Child #4. 2) During interview, staff reported the medication authorizations were not available on site. 3) On 08/04/2022, two medications were observed on site for Child #5. 4) During interview, staff reported the medication authorizations were not available on site.”

8VAC20-780-510-G

“Based on observation and interview, the center did not ensure that two medications were labeled with the child's name, the name of the medication, the dosage amount, and the time or times to be given. Evidence: 1) On 08/04/2022, two prescription medications were observed on site for Child #4. The medications were observed in a plastic bag, but the medications did not have a label with the child's name, the name of the medication, the dosage amount, and the time or times to be given. 2) Staff interviewed stated the label for the medications were not given to staff upon receipt of the medications.”

8VAC20-780-60-A-8

“Based on a review of five children's records and interview, the center did not ensure two children with a diagnosed food allergy had 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. Evidence: 1) Child #4, enrolled 06/21/22, has a diagnosed food allergy. During the inspection on 08/04/22, staff interviewed reported the child's written care plan was not available for review on site. 2) Child #5, enrolled on 10/25/21, has a diagnosed food allergy. During the inspection on 08/04/22, staff interviewed reported the child's written care plan was not available for review on site.”

8VAC20-780-70

“Based on staff interview on 08/04/2022, the center did not ensure that the required information for each staff was kept at the center. Evidence: 1) Staff #1, Staff #2, and Staff #3 were observed at the center on 08/04/2022. 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.”

8VAC20-780-70

“Based on a review of three staff records, observations, and interviews, the center did not ensure three staff records contained the required information. Evidence: 1) The record for Staff #1, hired on 06/07/21, did not contain the results of a negative tuberculosis (TB) screening within 21 days of beginning employment. 2) The record for Staff #2, hired on 07/26/21, did not contain the results of a negative tuberculosis (TB) screening within 21 days of beginning employment. 3) During interview, a member of management acknowledged the TB results for Staff #1 and Staff #2 were not obtained within 21 of beginning employment. Staff hired prior to 10/13/21 were required to obtain TB results within 21 days of beginning employment and such documentation was to be retained in the staff record. 3) The record kept at the center for Staff #2, hired on 07/26/21, did not contain the name, address and telephone number of a person to be notified in an emergency or information about any health problems which may interfere with fulfilling the job responsibilities. 4) Staff #2 was observed at the center during the inspection. 5) The record for Staff #2 did not contain documentation to demonstrate that the individual completed orientation training.”

8VAC20-780-60-A

“Based on a review of three children's records, the center did not ensure one child's record contained the required information. Evidence: 1) The record for Child #1, enrolled on 11/29/21, did not contain the address for the second emergency contact listed. Each child record shall contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.”

8VAC20-770-60-C-2

“Based on a review of three staff records and interviews, the center did not ensure that one staff member had a central registry finding within 30 days of employment. Evidence: 1) The record for Staff #2, hired on 07/26/21, did not contain the results of a central registry finding. The record did not contain documentation of any further contact, and the staff has been continuously employed. 2) During interviews, a member of management reported the central registry finding for Staff #2 could not be located.”

8VAC20-780-160-C

“Based on a review of three staff records and interviews, the center did not ensure that one staff resubmit tuberculosis (TB) test results at least every two years from the date of the first initial screening or testing. Evidence: 1) The most recent TB screening in the record for Staff #3, hired on 10/24/19, was dated 11/13/2019. The TB screening expired on 11/13/2021. 2) During interview, a member of management reported the TB screening for Staff #3 expired on 11/13/2021 and a new one has not been obtained.”

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 #3, hired on 08/23/21, 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 #3 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-A

“Based on a review of three staff records, the center did not ensure that two staff members submitted documentation of a negative tuberculosis (TB) screening within the required time frame. Evidence: 1) The record for Staff #1, hired on 06/07/21, did not contain documentation of a negative tuberculosis screening. 2) The record for Staff #2, hired on 07/26/21, did not contain documentation of a negative tuberculosis screening. Each staff member and individual from an independent contractor shall submit documentation of a negative tuberculosis screening. Documentation of the screening shall be submitted no later than 21 days after employment or volunteering and shall have been completed within 12 months prior to or 21 days after employing or volunteering.”

22VAC40-191-60-C-2

“Based on a review of three staff records and interview, the center did not ensure two staff members had a central registry finding within 30 days of employment. Evidence: 1) The record for Staff #2, hired on 07/26/21, did not contain the results of a central registry finding. 2) The record for Staff #3, hired on 08/23/2021, did not contain the results of a central registry finding. 3) During interview, a member of management reported the central registry finding for Staff #2 and Staff #3 had not been received within 30 days of employment.”

22VAC40-185-60-A

“Based on a review of three children's records, the center did not ensure one child's record contained the required information. Evidence: 1) The record for Child #2, enrolled on 08/16/21, did not contain two emergency contacts other than the parents. Each child record shall contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.”