Young Mens Christian Association of Greater Richmond-Shady Grove

8VAC20-780-60-A

“A written care plan for each child with a diagnosed food allergy, 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 is required. Child 4 has a diagnosed food allergy, but no written allergy care plan in their file.”

8VAC20-780-510-E

“Long-term prescription drug use and over-the- counter medication may be allowed with written authorization from the child's physician and parent. The parent did not renew the written authorization for one medication for Child 1 every ten working days and physician authorization was not obtained. There was no written parent authorization to administer one medication to Child 1. There was no written parent or physician authorization to administer medications to Child 6.”

8VAC20-780-510-P

“When an authorization for medication expires, the facility shall notify parents that that the medication must be picked up within 14 days of the authorization expiring or that a new authorization should be completed. The medication authorization for Child 3 expired 5/11/2024. The authorization had not been renewed and the medications were not returned or destroyed as required. The medication was on site.”

8VAC20-780-60-A

“A written care plan for each child with a diagnosed food allergy, 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 is required. Child 4 has a diagnosed food allergy, but no written allergy care plan in their file.”

8VAC20-780-510-E

“Long-term prescription drug use and over-the- counter medication may be allowed with written authorization from the child's physician and parent. The parent did not renew the written authorization for one medication for Child 1 every ten working days and physician authorization was not obtained. There was no written parent authorization to administer one medication to Child 1. There was no written parent or physician authorization to administer medications to Child 6.”

8VAC20-780-510-P

“When an authorization for medication expires, the facility shall notify parents that that the medication must be picked up within 14 days of the authorization expiring or that a new authorization should be completed. The medication authorization for Child 3 expired 5/11/2024. The authorization had not been renewed and the medications were not returned or destroyed as required. The medication was on site.”

8VAC20-790-600-D-1

“Repeat violation. Based on review of six staff records, the facility failed to have each staff current in cardiopulmonary resuscitation (CPR). Evidence: Staff 1 and Staff 3 did not have current CPR certification.”

8VAC20-790-600-D-2

“Repeat violation. Based on review of six staff records, the facility failed to have each staff current in first aid certification. Evidence: Staff 1 and Staff 3 did not have current first aid certification.”

8VAC20-780-350-B-5

“(Repeat violation) Based on observation and staff interview, the facility failed to maintain the required ratio of one staff for every 18 children ages "school age eligible" to 9 years. Evidence: on 2/05/2024, Staff 4 was alone with 21 children, ages 5 through 8 years. Staff 2 was alone with 19 children, ages 8 through 10 years.”

8VAC20-780-530-A-1

“(Repeat violation) Based on staff interview and record review, the facility failed to have one staff in each grouping of children with cardiopulmonary resuscitation (CPR) certification. Evidence: Staff 1 was alone with 21 school age children, but did not have documentation of current CPR certification on file. Management confirmed that CPR expired 12/04/2023. Staff 3 was alone with 14 school age children, but did not have documentation of current CPR on file. Management confirmed Staff 3 did not have CPR.”

8VAC20-780-550-E

“Based on review of the emergency drill log, the facility failed to conduct a shelter in place drill a minimum of twice per year. Evidence: there was documentation of only one shelter in place drill in the past year.”

8VAC20-780-60-A

“(Repeat violation) Based on review of five children's files, the facility failed to have required information in each child's file. Evidence: Child 4 did not have documentation of the name, address, and phone number of two (non-parent) designated people to contact in an emergency if a parent cannot be reached.”

8VAC20-780-530-A-2

“(Repeat violation) Based on staff interview and record review, the facility failed to have one staff in each grouping of children with first aid certification. Evidence: Staff 1 was alone with 21 school age children, but did not have documentation of current first aid certification on file. Management confirmed that first aid expired 12/04/2023. Staff 3 was alone with 14 school age children, but did not have documentation of current first aid certification on file. Management confirmed Staff 3 did not have first aid.”

8VAC20-790-600-D-1

“Repeat violation. Based on review of six staff records, the facility failed to have each staff current in cardiopulmonary resuscitation (CPR). Evidence: Staff 1 and Staff 3 did not have current CPR certification.”

8VAC20-790-600-D-2

“Repeat violation. Based on review of six staff records, the facility failed to have each staff current in first aid certification. Evidence: Staff 1 and Staff 3 did not have current first aid certification.”

8VAC20-780-350-B-5

“(Repeat violation) Based on observation and staff interview, the facility failed to maintain the required ratio of one staff for every 18 children ages "school age eligible" to 9 years. Evidence: on 2/05/2024, Staff 4 was alone with 21 children, ages 5 through 8 years. Staff 2 was alone with 19 children, ages 8 through 10 years.”

8VAC20-780-530-A-1

“(Repeat violation) Based on staff interview and record review, the facility failed to have one staff in each grouping of children with cardiopulmonary resuscitation (CPR) certification. Evidence: Staff 1 was alone with 21 school age children, but did not have documentation of current CPR certification on file. Management confirmed that CPR expired 12/04/2023. Staff 3 was alone with 14 school age children, but did not have documentation of current CPR on file. Management confirmed Staff 3 did not have CPR.”

8VAC20-780-550-E

“Based on review of the emergency drill log, the facility failed to conduct a shelter in place drill a minimum of twice per year. Evidence: there was documentation of only one shelter in place drill in the past year.”

8VAC20-780-60-A

“(Repeat violation) Based on review of five children's files, the facility failed to have required information in each child's file. Evidence: Child 4 did not have documentation of the name, address, and phone number of two (non-parent) designated people to contact in an emergency if a parent cannot be reached.”

8VAC20-780-530-A-2

“(Repeat violation) Based on staff interview and record review, the facility failed to have one staff in each grouping of children with first aid certification. Evidence: Staff 1 was alone with 21 school age children, but did not have documentation of current first aid certification on file. Management confirmed that first aid expired 12/04/2023. Staff 3 was alone with 14 school age children, but did not have documentation of current first aid certification on file. Management confirmed Staff 3 did not have first aid.”

8VAC20-790-600-D-2

“Based on staff interview and review of two staff records, the facility failed to have each staff current in first aid certification. Evidence: Staff 2 had first aid certification that expired 3/11/2023 and Staff 4 had first aid certification that expired 12/17/2022.”

8VAC20-790-600-D-1

“Based on staff interview and review of six staff records, the facility failed to have each staff current in cardiopulmonary resuscitation (CPR). Evidence: Staff 2 had CPR certification that expired 3/11/2023 and Staff 4 had CPR certification that expired 12/17/2022.”

8VAC20-780-350-B-5

“Based on observation and staff interview, the facility failed to maintain the required ratio of one staff for every 18 children ages "school age eligible" to 9 years. Evidence: on 5/4/2023, Staff 2 was alone with 22 children, ages 8 through 10 years. Staff 2 stated "I thought I had 17 children". Staff 1 stated that one of the staff called out today.”

8VAC20-780-60-A

“Based on review of eight children's files, the facility failed to have required information in each child's file. Evidence: Child 1, Child 2, and Child 4 did not have documentation of the name, address, and phone number of two (non-parent) designated people to contact in an emergency if a parent cannot be reached. Child 3 only had one (non-parent) emergency contact name, address, and phone number listed. Child 4 did not have the name and phone number of the parent's employment.”

8VAC20-780-530-A-1

“Based on staff interview and record review, the facility failed to have one staff in each grouping of children with cardiopulmonary resuscitation (CPR) certification. Evidence: Staff 2 was alone with 22 school age children, but did not have documentation of current CPR certification on file. Management confirmed that CPR expired 3/11/2023. Staff 4 was alone with 12 school age children, but did not have documentation of current CPR on file. Management confirmed that CPR expired 12/17/2022.”

8VAC20-780-70

“Based on review of six staff records, the facility failed to have required documentation in each file. Two references as to character, reputation, and competence should be checked prior to employment. Evidence: Staff 2 (date of employment 10/14/2020) did not have documentation of two references on file.”

22.1-289.035-B-2

“Based on review of six staff records, the facility failed to obtain a fingerprint based national criminal check prior to employment for each staff as required. Evidence: Staff 2 (date of employment 10/14/2020) did not have a fingerprint result on file until 11/2/2020.”

8VAC20-780-530-A-2

“Based on staff interview and record review, the facility failed to have one staff in each grouping of children with first aid certification. Evidence: Staff 2 was alone with 22 school age children, but did not have documentation of current first aid certification on file. Management confirmed that first aid certification expired 3/11/2023. Staff 4 was alone with 12 school age children, but did not have documentation of current first aid on file. Management confirmed that first aid certification expired 12/17/2022.”

8VAC20-780-160-C

“Based on a review of six staff records, the facility failed to have a repeat tuberculosis (TB) test or screening at least every two years from the date of the initial screening. Evidence: Staff 2 had a tuberculosis test that expired 11/13/2022.”

8VAC20-780-190-A

“Based on review of one staff file and discussion with management, the center failed to have a qualified program director. Evidence: Staff 1 is identified as the program director (date of promotion 8/2022). There is no documentation to support that Staff 1 meets the qualification of program director.”

8VAC20-790-600-D-2

“Based on staff interview and review of two staff records, the facility failed to have each staff current in first aid certification. Evidence: Staff 2 had first aid certification that expired 3/11/2023 and Staff 4 had first aid certification that expired 12/17/2022.”

8VAC20-790-600-D-1

“Based on staff interview and review of six staff records, the facility failed to have each staff current in cardiopulmonary resuscitation (CPR). Evidence: Staff 2 had CPR certification that expired 3/11/2023 and Staff 4 had CPR certification that expired 12/17/2022.”

8VAC20-780-350-B-5

“Based on observation and staff interview, the facility failed to maintain the required ratio of one staff for every 18 children ages "school age eligible" to 9 years. Evidence: on 5/4/2023, Staff 2 was alone with 22 children, ages 8 through 10 years. Staff 2 stated "I thought I had 17 children". Staff 1 stated that one of the staff called out today.”

8VAC20-780-60-A

“Based on review of eight children's files, the facility failed to have required information in each child's file. Evidence: Child 1, Child 2, and Child 4 did not have documentation of the name, address, and phone number of two (non-parent) designated people to contact in an emergency if a parent cannot be reached. Child 3 only had one (non-parent) emergency contact name, address, and phone number listed. Child 4 did not have the name and phone number of the parent's employment.”

8VAC20-780-530-A-1

“Based on staff interview and record review, the facility failed to have one staff in each grouping of children with cardiopulmonary resuscitation (CPR) certification. Evidence: Staff 2 was alone with 22 school age children, but did not have documentation of current CPR certification on file. Management confirmed that CPR expired 3/11/2023. Staff 4 was alone with 12 school age children, but did not have documentation of current CPR on file. Management confirmed that CPR expired 12/17/2022.”

8VAC20-780-70

“Based on review of six staff records, the facility failed to have required documentation in each file. Two references as to character, reputation, and competence should be checked prior to employment. Evidence: Staff 2 (date of employment 10/14/2020) did not have documentation of two references on file.”

22.1-289.035-B-2

“Based on review of six staff records, the facility failed to obtain a fingerprint based national criminal check prior to employment for each staff as required. Evidence: Staff 2 (date of employment 10/14/2020) did not have a fingerprint result on file until 11/2/2020.”

8VAC20-780-530-A-2

“Based on staff interview and record review, the facility failed to have one staff in each grouping of children with first aid certification. Evidence: Staff 2 was alone with 22 school age children, but did not have documentation of current first aid certification on file. Management confirmed that first aid certification expired 3/11/2023. Staff 4 was alone with 12 school age children, but did not have documentation of current first aid on file. Management confirmed that first aid certification expired 12/17/2022.”

8VAC20-780-160-C

“Based on a review of six staff records, the facility failed to have a repeat tuberculosis (TB) test or screening at least every two years from the date of the initial screening. Evidence: Staff 2 had a tuberculosis test that expired 11/13/2022.”

8VAC20-780-190-A

“Based on review of one staff file and discussion with management, the center failed to have a qualified program director. Evidence: Staff 1 is identified as the program director (date of promotion 8/2022). There is no documentation to support that Staff 1 meets the qualification of program director.”

8VAC20-780-510-B

“Based on review of 23 medications, the facility failed to have written parental authorization for each medication. Evidence: The medication authorization for Child L did not include written parental authorization for the facility to administer.”

8VAC20-780-510-P

“Based on review of 23 medications, the facility failed to notify the parents that the medication authorization had expired and the medication need to be picked up within 14 days if a new authorization was not renewed. The medication authorization for Child F expired 2/10/2022, Child I expired 5/27/2022, and Child J expired 4/27/2022. The medications were still on site 7/21/2022 and had not been disposed of or returned to the parent.”

8VAC20-780-240-B

“Based on review of 10 staff records, the facility failed to have documentation of orientation prior to working alone with children. Evidence: Staff 6 (date of employment 6/9/2022), Staff 7 (date of employment 6/9/2022), Staff 8 (date of employment 6/14/2022), and Staff 9 (date of employment 6/9/2022) did not have documentation of orientation on file.”

8VAC20-770-60-C-2

“Based on review of 10 staff records, the facility failed to have documentation of a search of the central registry ( CPS check) for each staff within 30 days. Evidence: Staff 4 (date of employment 12/7/2021) had a CPs check dated 6/19/2022. Staff 6 (date of employment 6/9/2022), Staff 7 (date of employment (6/9/2022), and Staff 9 (date of employment 6/9/2022) did not have documentation of a CPS check or documentation of having submitted a CPs check within 7 days of hire as required.”

8VAC20-780-160-A

“Based on review of 10 staff records, the facility failed to have documentation of a negative tuberculosis screening or test (TB) at the time of employment and prior to coming in contact with children. Evidence: Staff 6 (date of employment 6/9/2022) did not have documentation of a TB test or screening until 7/11/2022.”

8VAC20-780-510-B

“Based on review of 23 medications, the facility failed to have written parental authorization for each medication. Evidence: The medication authorization for Child L did not include written parental authorization for the facility to administer.”

8VAC20-780-510-P

“Based on review of 23 medications, the facility failed to notify the parents that the medication authorization had expired and the medication need to be picked up within 14 days if a new authorization was not renewed. The medication authorization for Child F expired 2/10/2022, Child I expired 5/27/2022, and Child J expired 4/27/2022. The medications were still on site 7/21/2022 and had not been disposed of or returned to the parent.”

8VAC20-780-240-B

“Based on review of 10 staff records, the facility failed to have documentation of orientation prior to working alone with children. Evidence: Staff 6 (date of employment 6/9/2022), Staff 7 (date of employment 6/9/2022), Staff 8 (date of employment 6/14/2022), and Staff 9 (date of employment 6/9/2022) did not have documentation of orientation on file.”

8VAC20-770-60-C-2

“Based on review of 10 staff records, the facility failed to have documentation of a search of the central registry ( CPS check) for each staff within 30 days. Evidence: Staff 4 (date of employment 12/7/2021) had a CPs check dated 6/19/2022. Staff 6 (date of employment 6/9/2022), Staff 7 (date of employment (6/9/2022), and Staff 9 (date of employment 6/9/2022) did not have documentation of a CPS check or documentation of having submitted a CPs check within 7 days of hire as required.”

8VAC20-780-160-A

“Based on review of 10 staff records, the facility failed to have documentation of a negative tuberculosis screening or test (TB) at the time of employment and prior to coming in contact with children. Evidence: Staff 6 (date of employment 6/9/2022) did not have documentation of a TB test or screening until 7/11/2022.”

8VAC20-780-510-B

“Based on review of 15 medications and staff interview, the facility failed to have written parental authorization to administer medication for each medicine on site. Evidence: two medication authorization forms for Child 1 and two forms for Child 4 did not have signed parental authorization for the facility to administer. The physicians had completed the forms, but the parents had not completed their part.”

8VAC20-780-70

“Based on review of five staff files, the facility failed to have all required documents in each file. Evidence: Staff 4 (date of hire (7/30/2020)did not have documentation that two or more references - as to character and reputation as well as competency - were checked before employment. Administrative staff stated the references could not be located.”

8VAC20-780-510-B

“Based on review of 15 medications and staff interview, the facility failed to have written parental authorization to administer medication for each medicine on site. Evidence: two medication authorization forms for Child 1 and two forms for Child 4 did not have signed parental authorization for the facility to administer. The physicians had completed the forms, but the parents had not completed their part.”

8VAC20-780-70

“Based on review of five staff files, the facility failed to have all required documents in each file. Evidence: Staff 4 (date of hire (7/30/2020)did not have documentation that two or more references - as to character and reputation as well as competency - were checked before employment. Administrative staff stated the references could not be located.”