Young Men’s Christian Association of Greater Richmond -Whiteside

The medication authorization for a child shall be available to staff during the entire time it is effective.

“The record for child #3 did not contain a complete medication authorization for one prescription medication stored for the child on-site.”

Rule 8VAC20-780-510-F.

When an authorization for medication expires, the facility shall notify parents that the medication must be picked up within 14 days of the authorization expiring or that a new authorization should be completed.

“Medication for Child #2 was onsite, but the medication authorization had expired over 4 months ago. The medication had not been administered past the expiration of the authorization. The authorization had not been renewed, and the medication was not returned or disposed of as required.”

Rule 8VAC20-780-510-P.

**Repeat Violation** Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information.

“The record for Child #1, enrolled for over 7 months, was missing the following required components: the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached. The record for Child #3, enrolled for over 7 months, was missing the following required components: the name, address, and phone number of one designated person to call in an emergency if a parent cannot be reached.”

Rule 8VAC20-780-60-A.

A written care plan is required 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.

“Child #3, who has been enrolled for over 7 months, has a diagnosed food allergy and did not have a written care plan in their file.”

Rule 8VAC20-780-60-A-7.

**Repeat Violation** Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information.

“The record for Child #1, enrolled for eight months, was missing the following required components: the name, address, and phone number of one designated person to call in an emergency if a parent cannot be reached.”

Rule 8VAC20-780-60-A.

The center shall ensure that areas and equipment of the center, inside and outside, are maintained in a clean, safe and operable condition.

“There was an exposed pipe covered by grass on the ground in an area used for children playing outside. Child #1 was seriously injured as a result of tripping over the pipe and falling to the ground. The injury required immediate outside medical attention.”

Rule 8VAC20-780-270-A.

Based on the review of children’s records, the center did not ensure each child record contained immunizations signed by a physician, his designee or an official of a local health department.

“Evidence: 1. The record for child #1 contained an immunization record without a signature of a physician, his designee or an official of a local health department.”

Rule 8VAC20-780-150-B.

8VAC20-780-60-A Based on review of children’s records, the center did not ensure each child record contained all required information.

“Evidence: 1. The record for child #1 and #5 contained no emergency contacts that were not the parent. 2. The record for child #3 contained only one emergency contact listed in his file and on his emergency card that was not a parent. 3. The record for child #1 did not contain employment information and a work phone number for either parent listed. The record for child #2 and #5 did not contain a work phone number for either parent listed.”

Rule 8VAC20-780-60-A.

Based on review of children’s records and documentation, the center did not obtain 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.

“Evidence: 1. The record for child #3 documented a diagnosed food allergy from a physician and did not contain a written care plan with 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.”

Rule 8VAC20-780-60-A-8.

8VAC20-770-60-C-2

“Based on staff record review, the provider failed to have central registry findings within 30 days of employment. Evidence: The record for S1, employed 01/23/2024 did not contain findings of a central registry search within 30 days of employment. The results were dated 04/10/2024.”

Rule 8VAC20-770-60-C-2.

8VAC20-780-130-A

“Based on record review, the provider failed to ensure that each child has received the immunizations required by the State Board of Health before the child can attend the center. Evidence: The record for C2, enrolled 08/28/2023 documented immunizations being received 10/12/2023. The record for C3, enrolled 08/28/2023 documented immunizations being received 10/27/2023.”

Rule 8VAC20-780-130-A.

8VAC20-780-160-C

“Based on staff record review, the provider failed to ensure that one of five staff shall obtain and submit the results of a follow-up tuberculosis (TB) screening at least every two years or more frequently if recommended. Evidence: The TB screening for S5 was dated 03/03/2022.”

Rule 8VAC20-780-160-C.

8VAC20-780-240-B

“Based on record review, the provider failed to ensure that staff shall completed orientation training required by 8VAC20-780-240.C prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities. Evidence: The record for S2, employed 02/20/2024 documented orientation being completed 03/04/2024.”

Rule 8VAC20-780-240-B.

8VAC20-780-270-A

“(Repeat Violation) Based on observation, the provider did not ensure that all areas of the center be maintained in a clean, safe, and operable condition. Evidence: The outdoor concrete basketball court was observed to have cracks in the court area creating a tripping hazard.”

Rule 8VAC20-780-270-A.

8VAC20-780-510-I

“Based on child medication records, the provider failed to obtain written authorization from a parent to administer prescription medication to the child. Evidence: The medication authorization form for C6 was signed by the prescribing professional but not the parent of the child. The medication was administered to the child on 11/07/2023 and 12/28/2023.”

Rule 8VAC20-780-510-I.

Based on review of staff records, the center staff did not ensure all staff who work directly with children have current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care.

“Evidence: The center verified via email provided on 5/18/2023 that Staff #5 (date of hire: 9/1/2022) is pending completion of certification in cardiopulmonary resuscitation (CPR).”

Rule 8VAC20-790-600-D-1.

Based on review of staff records, the center staff did not ensure all staff who work directly with children have current certification in first aid appropriate to the ages of children in care.

“Evidence: The center verified via email provided on 5/18/2023 that Staff #5 (date of hire: 9/1/2022) is pending completion of certification in first aid.”

Rule 8VAC20-790-600-D-2.

Based on review of staff records and interview, the vendor did not ensure that each staff complete annually the Virginia Annual Health and Safety Update Course sponsored by the Department.

“Evidence: 1.The documentation provided for review for Staff #1 (date of hire: 5/4/2021), Staff #3 (date of hire: 09/17/2021), and Staff #4 (date of hire: 10/13/2021) did not include documentation of the Virginia Annual Health and Safety Update Course. 2.The center verified via email on 5/18/2023 that the Virginia Annual Health and Safety Update Course for Staff #1, Staff #3 and Staff #4, ?needs to renew?.”

Rule 8VAC20-790-600-F.

Based on observation, the center failed to ensure the findings of the most recent inspection were posted in a conspicuous place.

“Evidence: 1.The most recent inspection findings posted at the center were from a 2021 inspection. 2. During an interview, Staff #1 verified the most recent inspection findings were not posted.”

Rule 22.1-289.011-F.

Based on review of staff records, the center failed to ensure that every two years from the date of the initial testing or screening, staff members obtain and submit the results of a tuberculosis test or screening.

“Evidence: 1.The record for Staff #1 documents a tuberculosis test dated, 04/25/2021. 2. The record for Staff #2 documents a tuberculosis test dated, 03/14/2021.”

Rule 8VAC20-780-160-C.

Based on review of records and interview the center failed to provide an annual fire inspection report from the appropriate fire official having jurisdiction.

“Evidence: 1.The most recent fire inspection report reviewed at the center was dated 5/9/2022. 2. During an interview, Staff #1 verified that an annual fire inspection has not been conducted.”

Rule 8VAC20-780-260-A.

Based on review of records and interview, the center failed to provide an annual health approval from the health department.

“Evidence: 1.The most recent health approval was dated 8/3/2021. 2. During an interview, Staff #1 verified that an annual health approval has not been conducted.”

Rule 8VAC20-780-260-B.

Based on observation and interview, the center did not ensure that areas and equipment of the center, inside and outside, were maintained in a clean, safe and operable condition.

Rule 8VAC20-780-270-A.

Based on observations and interview, the center did not ensure that playground equipment had resilient surfacing that complies with the minimum safety standards when tested in accordance with the procedures described in the American Society for Testing and Materials.

“Evidence: 1.The slides, seesaw, swing and climbing wall located on the center’s playground did not have enough resilient surfacing throughout the fall zones. 2. The center had approximately 0 to1 inch of wooden mulch, decomposed mulch and dirt in the fall zones. 3. During an interview with Staff #1, it was acknowledged that the amount of mulch was out of compliance.”

Rule 8VAC20-780-330-B.

Based on record review and interview, the center did not meet the proof of child identity and age requirements as stated in 22.1-289.049 of the Code of Virginia for one child.

“Evidence: 1. The record for Child #1 (start date:8/29 /2022) did not contain documentation of viewing proof of the child’s identity and age as required by 22.1-289.049. 2. During an interview, Staff #1 acknowledged that the center did not have proof of the child’s identity and age as required.”

Rule 8VAC20-780-40-G.

Based on observation and interview, the center did not ensure constructive behavioral guidance and age appropriate guidance was provided.

“Evidence: 1. During the inspection, Staff #3 was heard from inside the building stating two times, ?you have lost your mind?. 2.Within a minute of Staff #3 being heard making the remark, Staff #3 entered the building holding a 5 year old child by the hand while stating, ?he has lost his mind?. The child was observed striking Staff #3 with his hand as they entered the center. 3. Staff #1 was sitting at the same table with the inspector and acknowledged hearing the comments made by Staff #3.”

Rule 8VAC20-780-400-B.

Based on review of drills and interview, the center failed to ensure monthly drills were practiced.

“Evidence: 1. Based on drills posted, the center failed to conduct a practice drill for April 2023. 2. During an interview, Staff #1 verified a drill was not conducted in April 2023.”

Rule 8VAC20-780-550-D.

Based on record review and interview, the center failed to ensure that the separate record for each child enrolled contains all of the elements as required by the standards.

“Evidence: 1.The record for Child #5, did not document two designated people to call in an emergency if a parent cannot be reached. 2. During an interview with Staff #1, it was acknowledged that two designated people were not documented in the record.”

Rule 8VAC20-780-60-A.

Based on review of four staff records, the center did not ensure one staff obtained current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care within 90 days of the date of employment.

“Evidence: The record of staff #2, hired 10/13/2021, did not have documentation of CPR certification exceeding 90 days from employment.”

Rule 8VAC20-790-600-D-1.

Based on review of four staff records, the center did not ensure one staff obtained certification in first ad appropriate to the ages of children in care within 90 days of employment.

“Evidence: The record of staff #2, hired 10/13/2021, did not have documentation of first aid certification exceeding 90 days from employment.”

Rule 8VAC20-790-600-D-2.

Based on review of four staff records, the center did not obtain the results of a national fingerprint background check for one staff prior to employment.

“Evidence: The record of staff #4, hired 09/08/2020, contained results of the national fingerprint background check dated 10/13/2020 exceeding the first day of employment.”

Rule 22.1-289.035-B-2.

Based on review of four staff records, the center did not obtain results of the central registry check within 30 days of employment for two staff members.

“Evidence: 1. The record of staff #2, hired 10/13/2021, contained a central registry dated 12/06/2021. There was no documentation of a follow up to the agency regarding the status of the central registry. 2. The record of staff #3, hired 09/17/2021, contained a central registry dated 12/06/2021. There was no documentation of a follow up to the agency regarding the status of the central registry.”

Rule 8VAC20-770-60-C-2.

Based on review of staff records and interview, the center did not ensure a qualified program director was on employed.

“Evidence: The record of staff #4, identified as the program director, did not have documentation to meet the qualifications regarding education and management experience. The administrator stated there was no additional educational or management experience documentation to meet the qualifications.”

Rule 8VAC20-780-190-A.