Young Men's Christian Association of the Virginia Peninsulas

8VAC20-780-150-B

“Based on child record review, the provider failed to assure that each report of physical examination shall be signed by a physician, the physician’s designee, or an official of a local health department. Evidence: The physical examination for C1 was not signed by the licensed physician, the physician’s designee, or an official of a local health department.”

8VAC20-780-60-A

“Based on child record review, the provider failed to ensure that four of five records contained required documentation. Evidence: Record for C2, enrolled 03/15/2023 did not document the name, address, and phone number for two emergency contacts. Record for C3, enrolled 02/20/2023, C4, enrolled 11/08/2022, and C5, enrolled 11/08/2023 did not document proof of the child’s identity, immunizations, and physical examination (nothing in the record).”

8VAC20-780-550-G

“Evidence: The emergency drill documentation dated October 2022 ? February 2023 did not document the weather conditions during the drills and the method used for notification of the drills.”

8VAC20-780-550-F

“8VAC20-550.F Based on interview, the provider failed to ensure that lockdown procedures shall be practiced at least annually. Evidence: The program director was unable to locate documentation showing that the lockdown procedures were practiced.”

8VAC20-780-260-A

“Based on interview, the provider failed to provide the licensing representative an annual fire inspection report from the appropriate fire official having jurisdiction. Evidence: The fire inspection available during the inspection was dated 03/08/2022. The annual inspection should have been completed by 03/08/2023. There was no updated fire inspection available for review during the inspection.”

8VAC20-780-260-B

“Based on interview, the provider failed to provide the licensing representative an annual health department inspection report from the appropriate health official having jurisdiction. Evidence: The last health inspection was dated 01/12/2022. The annual inspection should have been completed by 01/12/2023. There was no updated health inspection available for review during the inspection.”

22.1-289.058

“Based on observation, provider failed to ensure the center was equipped with at least one carbon monoxide detector. Evidence: No carbon monoxide was located in the area used by the program.”

8VAC20-780-530-A

“Based on interview and record review, the provider did not ensure that at least one staff in each area where children are present shall have current cardiopulmonary resuscitation (CPR) and first aid certification. Evidence: Record for S3 did not contain current certification in CPR and first aid. The record for S2 did not document certification until 03/14/2023. The program director confirmed that when S2 and S3 worked together between 01/16/2023 and 03/14/2023 no staff were CPR and first aid certified.”

8VAC20-780-550-E

“Based on interview, the provider failed to ensure that shelter in place procedures shall be practiced a minimum of twice per year. Evidence: The program director was unable to locate documentation showing that the shelter in place procedures were practiced.”

8VAC20-780-240-A

“Based on record review, the provider did not ensure that one of three staff completed the Virginia Department of Education (VDOE) sponsored orientation course within 90 calendar days of employment. Evidence: The record for S3, employed 06/06/2022 did not document completion of the 10-hour VDOE orientation course.”

8VAC20-780-70

“Based on record review, the provider did not ensure three of three staff records contained all the required documentation. Evidence: The records for S1, employed 09/06/2022, S2, employed 11/04/2022, S3, employed 06/06/2022 did not document information about any health problems that may interfere with fulfilling the job responsibilities.”

8VAC20-780-40-J

“Based on interview, the provider failed to update annually the injury prevention procedures based on documentation of injuries and a review of the activities and services. Evidence: The program director acknowledged that the injury prevention procedures had not been reviewed annually.”

8VAC20-780-60-A

“Based on child record review, the provider failed to ensure that four of five records contained required documentation. Evidence: Record for C2, enrolled 03/15/2023 did not document the name, address, and phone number for two emergency contacts. Record for C3, enrolled 02/20/2023, C4, enrolled 11/08/2022, and C5, enrolled 11/08/2023 did not document proof of the child’s identity, immunizations, and physical examination (nothing in the record).”

8VAC20-780-550-G

“Evidence: The emergency drill documentation dated October 2022 ? February 2023 did not document the weather conditions during the drills and the method used for notification of the drills.”

8VAC20-780-550-F

“8VAC20-550.F Based on interview, the provider failed to ensure that lockdown procedures shall be practiced at least annually. Evidence: The program director was unable to locate documentation showing that the lockdown procedures were practiced.”

8VAC20-780-260-A

“Based on interview, the provider failed to provide the licensing representative an annual fire inspection report from the appropriate fire official having jurisdiction. Evidence: The fire inspection available during the inspection was dated 03/08/2022. The annual inspection should have been completed by 03/08/2023. There was no updated fire inspection available for review during the inspection.”

8VAC20-780-260-B

“Based on interview, the provider failed to provide the licensing representative an annual health department inspection report from the appropriate health official having jurisdiction. Evidence: The last health inspection was dated 01/12/2022. The annual inspection should have been completed by 01/12/2023. There was no updated health inspection available for review during the inspection.”

22.1-289.058

“Based on observation, provider failed to ensure the center was equipped with at least one carbon monoxide detector. Evidence: No carbon monoxide was located in the area used by the program.”

8VAC20-780-530-A

“Based on interview and record review, the provider did not ensure that at least one staff in each area where children are present shall have current cardiopulmonary resuscitation (CPR) and first aid certification. Evidence: Record for S3 did not contain current certification in CPR and first aid. The record for S2 did not document certification until 03/14/2023. The program director confirmed that when S2 and S3 worked together between 01/16/2023 and 03/14/2023 no staff were CPR and first aid certified.”

8VAC20-780-550-E

“Based on interview, the provider failed to ensure that shelter in place procedures shall be practiced a minimum of twice per year. Evidence: The program director was unable to locate documentation showing that the shelter in place procedures were practiced.”

8VAC20-780-240-A

“Based on record review, the provider did not ensure that one of three staff completed the Virginia Department of Education (VDOE) sponsored orientation course within 90 calendar days of employment. Evidence: The record for S3, employed 06/06/2022 did not document completion of the 10-hour VDOE orientation course.”

8VAC20-780-70

“Based on record review, the provider did not ensure three of three staff records contained all the required documentation. Evidence: The records for S1, employed 09/06/2022, S2, employed 11/04/2022, S3, employed 06/06/2022 did not document information about any health problems that may interfere with fulfilling the job responsibilities.”

8VAC20-780-40-J

“Based on interview, the provider failed to update annually the injury prevention procedures based on documentation of injuries and a review of the activities and services. Evidence: The program director acknowledged that the injury prevention procedures had not been reviewed annually.”

8VAC20-780-40-J

“Based on interview, the provider failed to ensure that the injury prevention procedures were updated at least annually based on documentation of injuries and review of the activities and services. Evidence: The Program Director reported that this update has not been done for this YMCA site.”

8VAC20-780-380-A

“Based on observation, the provider failed to ensure that a daily schedule is posted. Evidence: The bulletin board used by the YMCA program to meet the posting requirements did not include the daily schedule for the program.”

8VAC20-780-550-H

“Based on interview, the provider failed to maintain a record of the dates of the practice emergency evacuation drills. Evidence: The Program Director was unable to locate the emergency evacuation drill records during the inspection.”

8VAC20-820-120-E-2

“Based on observation, the provider failed to ensure the findings of the most recent inspection of the program were posted in a place conspicuous to the public. Evidence: The inspection documents were placed in a plastic sleeve covered by other documents on the bulletin board used by the YMCA program to meet the posting requirements of 8VAC20-780-40.”

8VAC20-780-70

“Based on staff record review, the provider failed to ensure that 3 of 3 records contained required information. Evidence: 1. Record for S1, employed 06/20/22 did not contain: health information required by 8VAC20-780-160.C; information about any health problems that may interfere with fulfilling the job responsibilities; First Aid and CPR training orientation; completion of the 10 hour Pre-Service training; and orientation and training required in 8VAC20-780-240. 2. Record for S2, employed 04/18/22 did not contain: health information required by 8VAC20-780-160.C; information about any health problems that may interfere with fulfilling the job responsibilities; First Aid and CPR training orientation; completion of the 10 hour Pre-Service training; and orientation and training required in 8VAC20-780-240. 3. Record for S3, employed 10/19/20 did not contain: health information required by 8VAC20-780-160.C; information about any health problems that may interfere with fulfilling the job responsibilities; First Aid and CPR training orientation; completion of the 10 hour Pre-Service training; and orientation and training required in 8VAC20-780-240.”

8VAC20-780-60-A

“Based on child record review, the provider failed to ensure that five of five records contained the required information for each child enrolled. Evidence: 1. The records for enrolled children, C1, C2, C3, C4, and C5 failed to contain the written agreements between the parent and the center required by 8VAC20-780-90.A.10. 2. The records for C3 enrolled 09/12/2022 and C5 enrolled 08/15/2022 did not contain health information as required by 8VAC20-780-140. 3. The record for C3 enrolled 09/12/2022 did not contain the name, address, and phone number for two designated people to call in an emergency if a parent cannot be reached. The record contained one of the two contacts.”

8VAC20-780-40-J

“Based on interview, the provider failed to ensure that the injury prevention procedures were updated at least annually based on documentation of injuries and review of the activities and services. Evidence: The Program Director reported that this update has not been done for this YMCA site.”

8VAC20-780-380-A

“Based on observation, the provider failed to ensure that a daily schedule is posted. Evidence: The bulletin board used by the YMCA program to meet the posting requirements did not include the daily schedule for the program.”

8VAC20-780-550-H

“Based on interview, the provider failed to maintain a record of the dates of the practice emergency evacuation drills. Evidence: The Program Director was unable to locate the emergency evacuation drill records during the inspection.”

8VAC20-820-120-E-2

“Based on observation, the provider failed to ensure the findings of the most recent inspection of the program were posted in a place conspicuous to the public. Evidence: The inspection documents were placed in a plastic sleeve covered by other documents on the bulletin board used by the YMCA program to meet the posting requirements of 8VAC20-780-40.”

8VAC20-780-70

“Based on staff record review, the provider failed to ensure that 3 of 3 records contained required information. Evidence: 1. Record for S1, employed 06/20/22 did not contain: health information required by 8VAC20-780-160.C; information about any health problems that may interfere with fulfilling the job responsibilities; First Aid and CPR training orientation; completion of the 10 hour Pre-Service training; and orientation and training required in 8VAC20-780-240. 2. Record for S2, employed 04/18/22 did not contain: health information required by 8VAC20-780-160.C; information about any health problems that may interfere with fulfilling the job responsibilities; First Aid and CPR training orientation; completion of the 10 hour Pre-Service training; and orientation and training required in 8VAC20-780-240. 3. Record for S3, employed 10/19/20 did not contain: health information required by 8VAC20-780-160.C; information about any health problems that may interfere with fulfilling the job responsibilities; First Aid and CPR training orientation; completion of the 10 hour Pre-Service training; and orientation and training required in 8VAC20-780-240.”

8VAC20-780-60-A

“Based on child record review, the provider failed to ensure that five of five records contained the required information for each child enrolled. Evidence: 1. The records for enrolled children, C1, C2, C3, C4, and C5 failed to contain the written agreements between the parent and the center required by 8VAC20-780-90.A.10. 2. The records for C3 enrolled 09/12/2022 and C5 enrolled 08/15/2022 did not contain health information as required by 8VAC20-780-140. 3. The record for C3 enrolled 09/12/2022 did not contain the name, address, and phone number for two designated people to call in an emergency if a parent cannot be reached. The record contained one of the two contacts.”

8VAC20-770-60-C-2

“Based on a review of staff records, the center did not ensure that each staff record reviewed contained a central registry finding within 30 days of employment. Evidence: 1. The record of Staff #1 (hired on 10/18/21) contained documentation of a central registry finding dated 12/1/1. 2. The record of Staff #2 (hired on 10/11/21) contained documentation of a central registry finding dated 11/18/21.”

8VAC20-780-150-B

“Based on a review of children's records, the center did not ensure that immunizations received shall be signed by a physician, his designee, or an official of the local health department. Evidence: The record of child #2 contained documentation of immunizations that were not signed by a physician, his designee, or an official of a local health department.”

8VAC20-780-160-A-1

“Based on a review of staff records, the center did not ensure that each staff submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children. Evidence: The record of staff #1 (hired on 10/18/21) did not contain documentation of a tuberculosis screening.”

8VAC20-780-160-B

“Based on a review of staff records, the center failed to obtain an acceptable form of documentation of tuberculosis screening. Evidence: The record of staff #3 contained documentation of a tuberculosis screening that was not signed by a physician, physician's designee or an official of the local health department.”

8VAC20-780-340-D

“Based on a review of staff records and interview, the center failed to ensure that there is a qualified program leader regularly present in each grouping of children. Evidence: Staff #3 was identified by administration as the program leader for the after school program. Staff #3 does not meet the qualifications for the position. There was no documentation of 24 hours of training as a program leader. Administration confirmed staff #3 did not have the required training.”

8VAC20-770-60-C-2

“Based on a review of staff records, the center did not ensure that each staff record reviewed contained a central registry finding within 30 days of employment. Evidence: 1. The record of Staff #1 (hired on 10/18/21) contained documentation of a central registry finding dated 12/1/1. 2. The record of Staff #2 (hired on 10/11/21) contained documentation of a central registry finding dated 11/18/21.”

8VAC20-780-150-B

“Based on a review of children's records, the center did not ensure that immunizations received shall be signed by a physician, his designee, or an official of the local health department. Evidence: The record of child #2 contained documentation of immunizations that were not signed by a physician, his designee, or an official of a local health department.”

8VAC20-780-160-A-1

“Based on a review of staff records, the center did not ensure that each staff submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children. Evidence: The record of staff #1 (hired on 10/18/21) did not contain documentation of a tuberculosis screening.”

8VAC20-780-160-B

“Based on a review of staff records, the center failed to obtain an acceptable form of documentation of tuberculosis screening. Evidence: The record of staff #3 contained documentation of a tuberculosis screening that was not signed by a physician, physician's designee or an official of the local health department.”

8VAC20-780-340-D

“Based on a review of staff records and interview, the center failed to ensure that there is a qualified program leader regularly present in each grouping of children. Evidence: Staff #3 was identified by administration as the program leader for the after school program. Staff #3 does not meet the qualifications for the position. There was no documentation of 24 hours of training as a program leader. Administration confirmed staff #3 did not have the required training.”