Young Men's Christian Association of Greater Richmond - S.P.E.

8VAC20-780-130-A

“Based on a review of five child records and interview, the center did not ensure to obtain documentation that one child had the immunizations required by the State Board of Health before the first date of attendance as required. Evidence: 1. The record of child #4 (date of attendance: 8/21/2023) contained an immunization record dated 8/22/2023. 2. Administration acknowledged that the immunization report in the record was received after the first date of attendance.”

8VAC20-780-70

“Based on a review of five staff records and interview, the center did not ensure that two records were kept that contained the required information. Evidence: 1. The records of staff #2 (date of employment: 8/18/2023) and staff #3 (date of employment: 6/25/2023) did not contain documentation to demonstrate that the individuals possessed the certification/training required by the job position. The records did not contain the 24 hours of training required for program leaders who had a minimum of 6 months of experience and a high school diploma as the highest level of education. 2. Administration acknowledged that staff #2 and staff #3 were program leaders and that the 24 hours of training documentation was not in the records.”

8VAC20-770-60-B

“Based on a review of five staff records and interview, the center did not ensure to obtain a sworn statement for one staff prior to employment as required. Evidence: 1. The record of staff #3 (date of employment: 6/25/2023) contained a sworn statement dated 6/30/2023. 2. Administration acknowledged that the record of staff #3 did not contain a sworn statement dated prior to 6/25/2023.”

8VAC20-790-600-F

“Based on a review of five (5) staff records and interview, the vendor did not ensure that one (1) staff who worked directly with children annually completed the department's health and safety update course. Evidence: 1. The record of staff #3 (date of employment:9/3/2020) contained a health and training certificate dated 3/11/2021. The record did not contain a 2022 annual health and safety training certificate. 2. The vendor acknowledged that the 2022 training had not been completed.”

8VAC20-780-60-A

“Based on a review of five (5) child records and interview, the center did not ensure to maintain a complete record for two (2) children. Evidence: 1. Children's records are required to contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached. The record of child #2 (date of attendance: 8/29/2022) contained two emergency contacts with missing addresses. The record of child #4 (date of attendance: 8/29/2022) was missing two (2) complete emergency contacts. 2. Administration acknowledged that the records were incomplete.”

8VAC20-780-40-E

“Based on review of documentation, observation, and interview, the center did not ensure that the center's services were maintained in compliance with the center's own policies and procedures that are required by the standards. Evidence: 1. The record of child #1 (date of enrollment: 10/27/2021) contained a current medication authorization. The medication in the center's lock box expired in January of 2023. The center's procedure for methods to prevent use of outdated medication stated that if medication is found to be out-of-date, the medication must be immediately returned to the locked location. When the child is picked up that same day, the medication must be handed in person to the parent/legal guardian for their disposal. Staff are responsible for completing a medication checklist once a month in order to stay on top of expiring medications and authorization forms. 2. Administration acknowledged that the medication was expired and had not been returned to the parent.”

8VAC20-790-600-F

“Based on a review of five (5) staff records and interview, the vendor did not ensure that one (1) staff who worked directly with children annually completed the department's health and safety update course. Evidence: 1. The record of staff #3 (date of employment:9/3/2020) contained a health and training certificate dated 3/11/2021. The record did not contain a 2022 annual health and safety training certificate. 2. The vendor acknowledged that the 2022 training had not been completed.”

8VAC20-780-60-A

“Based on a review of five (5) child records and interview, the center did not ensure to maintain a complete record for two (2) children. Evidence: 1. Children's records are required to contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached. The record of child #2 (date of attendance: 8/29/2022) contained two emergency contacts with missing addresses. The record of child #4 (date of attendance: 8/29/2022) was missing two (2) complete emergency contacts. 2. Administration acknowledged that the records were incomplete.”

8VAC20-780-40-E

“Based on review of documentation, observation, and interview, the center did not ensure that the center's services were maintained in compliance with the center's own policies and procedures that are required by the standards. Evidence: 1. The record of child #1 (date of enrollment: 10/27/2021) contained a current medication authorization. The medication in the center's lock box expired in January of 2023. The center's procedure for methods to prevent use of outdated medication stated that if medication is found to be out-of-date, the medication must be immediately returned to the locked location. When the child is picked up that same day, the medication must be handed in person to the parent/legal guardian for their disposal. Staff are responsible for completing a medication checklist once a month in order to stay on top of expiring medications and authorization forms. 2. Administration acknowledged that the medication was expired and had not been returned to the parent.”

8VAC20-790-600-D-2

“Based on a review of five (5) staff records and interview, the vendor did not ensure that one (1) staff had current certification in first aid appropriate to the ages of children in care within 90 days of employment. Evidence: 1. The record of staff #3 (date of employment: 7/12/2022) did not contain documentation of a current first aid certification. 2. Administration acknowledged that the staff did not have a current certification.”

8VAC20-790-600-D-1

“Based on a review of five (5) staff records and interview, the vendor did not ensure that one (1) staff had current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care within 90 days of the date of employment. Evidence: 1. The record of staff #3 (date of employment: 7/12/2022) did not contain documentation of a current CPR certification. 2. Administration acknowledged the staff did not have a current certification.”

8VAC20-780-240-A

“Based on a review of five (5) staff records and interview, the center did not ensure that one (1) staff completed the Virginia Department of Education-sponsored orientation within 90 calendar days of employment as required. Evidence: 1. The record of staff #3 (date of employment: 7/12/2022) did not contain documentation of the department sponsored course. 2. Administration acknowledged that it had not been completed.”

8VAC20-770-60-C-2

“Based on a review of five (5) staff records and interview, the center did not ensure that one (1) staff had a central registry finding within 30 days of employment as required. Evidence: 1. The record of staff # 5 (date of employment: 10/3/2022) did not contain a central registry finding. 2. Administration acknowledged that the finding had not been obtained.”

8VAC20-780-60-A

“Based on a review of five (5) children's records and interview, the center did not ensure that one (1) child had a record that contained the required information. Evidence: 1. The record of child #4 was missing one (1) emergency contact. The records are required to have the name address, and phone number of two (2) designated people to call in an emergency if a parent could not be reached. 2. Administration acknowledged that the record was incomplete.”

8VAC20-780-550-D

“Based on review of documentation and interview, the center did not ensure to implement a monthly practice evacuation drill. Evidence: 1. A drill was not documented in October of 2022. 2. Administration acknowledged that the evacuation drill was not completed.”

8VAC20-780-70

“Based on a review of five (5) staff records and interview, the center did not ensure to keep a complete record for three (3) staff as required. Evidence: 1. The record of staff #1 (date of employment: 10/10/2022) did not contain documentation that the employee possessed the orientation and training required by the job position. The record of staff #3 (date of employment: 7/12/2022) did not contain documentation to demonstrate the individual possessed the education and training required by the job position. The record of staff #4 (date of employment: 5/20/2022) did not contain documentation that the individual possessed the orientation required by the job position. 2. Administration acknowledged that the documentation was missing from each record.”

8VAC20-780-60-A-8

“Based on a review of five (5) children's records and interview, the center did not ensure to have a written care plan for one (1) 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. Evidence: 1. The record of child #1 (date of attendance: 10/27/2021) did not contain an allergy care plan. The child had a diagnosed food allergy. 2. Administration acknowledged that the allergy care plan had not been obtained.”

8VAC20-790-600-D-2

“Based on a review of five (5) staff records and interview, the vendor did not ensure that one (1) staff had current certification in first aid appropriate to the ages of children in care within 90 days of employment. Evidence: 1. The record of staff #3 (date of employment: 7/12/2022) did not contain documentation of a current first aid certification. 2. Administration acknowledged that the staff did not have a current certification.”

8VAC20-790-600-D-1

“Based on a review of five (5) staff records and interview, the vendor did not ensure that one (1) staff had current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care within 90 days of the date of employment. Evidence: 1. The record of staff #3 (date of employment: 7/12/2022) did not contain documentation of a current CPR certification. 2. Administration acknowledged the staff did not have a current certification.”

8VAC20-780-240-A

“Based on a review of five (5) staff records and interview, the center did not ensure that one (1) staff completed the Virginia Department of Education-sponsored orientation within 90 calendar days of employment as required. Evidence: 1. The record of staff #3 (date of employment: 7/12/2022) did not contain documentation of the department sponsored course. 2. Administration acknowledged that it had not been completed.”

8VAC20-770-60-C-2

“Based on a review of five (5) staff records and interview, the center did not ensure that one (1) staff had a central registry finding within 30 days of employment as required. Evidence: 1. The record of staff # 5 (date of employment: 10/3/2022) did not contain a central registry finding. 2. Administration acknowledged that the finding had not been obtained.”

8VAC20-780-60-A

“Based on a review of five (5) children's records and interview, the center did not ensure that one (1) child had a record that contained the required information. Evidence: 1. The record of child #4 was missing one (1) emergency contact. The records are required to have the name address, and phone number of two (2) designated people to call in an emergency if a parent could not be reached. 2. Administration acknowledged that the record was incomplete.”

8VAC20-780-550-D

“Based on review of documentation and interview, the center did not ensure to implement a monthly practice evacuation drill. Evidence: 1. A drill was not documented in October of 2022. 2. Administration acknowledged that the evacuation drill was not completed.”

8VAC20-780-70

“Based on a review of five (5) staff records and interview, the center did not ensure to keep a complete record for three (3) staff as required. Evidence: 1. The record of staff #1 (date of employment: 10/10/2022) did not contain documentation that the employee possessed the orientation and training required by the job position. The record of staff #3 (date of employment: 7/12/2022) did not contain documentation to demonstrate the individual possessed the education and training required by the job position. The record of staff #4 (date of employment: 5/20/2022) did not contain documentation that the individual possessed the orientation required by the job position. 2. Administration acknowledged that the documentation was missing from each record.”

8VAC20-780-60-A-8

“Based on a review of five (5) children's records and interview, the center did not ensure to have a written care plan for one (1) 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. Evidence: 1. The record of child #1 (date of attendance: 10/27/2021) did not contain an allergy care plan. The child had a diagnosed food allergy. 2. Administration acknowledged that the allergy care plan had not been obtained.”

8VAC20-780-60-A

“Based on review of 5 children's records and interview, the center did not ensure to maintain a record for 2 children that contained the required information. Evidence: 1. The records of child #1 (DOE:10/27/2021) and child #5 (DOE:10/27/2021) did not contain complete emergency contact information. Each record must contain the name, address, and phone number of two designated people to call in an emergency if a parent could not be reached. 2. Administration acknowledged that the records were not complete.”

8VAC20-780-70

“Based on a review of 4 staff records and interview, the center did not ensure that 1 staff record contained documentation of the required orientation training. Evidence: 1. The record of staff #2 (DOH:9/15/2021) was missing documentation of a completed orientation training. 2. Administration acknowledged that the staff's orientation was missing from the record.”

8VAC20-770-60-B

“Based on a review of 4 staff records and interview, the center did not ensure 1 staff had a completed sworn statement of affirmation prior to the first date of employment as required. Evidence: 1. The record of staff #4 (DOH:8/27/2021) contained an incomplete sworn statement dated 8/18/2021. The sworn statement was missing the check marked responses to the questions. 2. Administration acknowledged that a completed sworn statement was missing from the staff's record.”

8VAC20-770-60-C-2

“Based on record review and interview, the center did not ensure to obtain the results of a central registry background check within 30 days for 3 staff as required. Evidence: 1. The records of staff #1 (DOH: 9/15/2021) and the record of staff #2 (DOH: 12/7/2021) did not contain the results of a central registry background check. 2. The record of staff number #3 (DOH: 8/27/2021) contained the results of a central registry background check dated 12/6/2021. 3. Administration acknowledged that the central registry results were not obtained within the required time frame.”

22.1-289.035-B-4

“Based on record review and interview, the center did not ensure to obtain the results of an out of state criminal history background check from any state in which the individual had resided in the preceding five years prior to hire for one staff as required. Evidence: 1. The record of staff #3 (DOH: 8/27/2021) contained a sworn statement that indicated that the individual had resided outside of the state within the preceding 5 years. The record did not contain the results of an out of state criminal history background check prior to the first date of employment. 2. Administration acknowledged that the background check had not been obtained.”