The Young Men’s Christian Association of Danville, Virginia

SYSTEMIC VIOLATION The center is required to obtain background checks from any state in which the individual has resided in the preceding five years.

“Staff 4 (employed for three months) did not have documentation of requesting a central registry check and sex offender search from one state.”

Rule 22.1-289.035-B-4.

SYSTEMIC VIOLATION Every applicant for licensure shall undergo a background check every five years.

“The most recent search of the child abuse and neglect registry for Applicant/Agent 3 was overdue by 5 days and Applicant/Agent 4 was overdue by 14 days.”

Rule 22.1-289.036-A.

SYSTEMIC VIOLATION Every applicant for licensure shall provide a sworn statement or affirmation by the end of the 30th day for new board officers.

“The sworn statement or affirmation for Applicant/Agent 2 (an officer for one year and nine months) was overdue by one year and 8 months.”

Rule 22.1-289.036-B-1.

Staff shall complete annually a minimum of 16 hours training appropriate to the age of children in care.

“There was no documentation of 16 hours of annual training for Staff 5.”

Rule 8VAC20-780-245-A.

REPEAT VIOLATION There shall always be at least one staff member on duty who has obtained within the last three years instruction in performing the daily heath observation of children.

“There was no staff member on duty who has obtained instruction in performing the daily health observation.”

Rule 8VAC20-780-245-L.

Staff records shall be kept for each staff person that contain all of the required information.

“The records for Staff 1, Staff 2, Staff 3, Staff 4, and Staff 5, were missing required components.”

Rule 8VAC20-780-70.

The program is required to submit to VDH (Virginia Department of Health) and implement a plan to test potable water for lead.

“The program did not have evidence of a testing plan submitted to VDH and/or the program did not have evidence of the implementation of the required testing plan.”

Rule 22.1-289.057-A.

The program is required to submit results of potable water testing to VDH (Virginia Department of Health).

“The program did not have evidence of submitting test results to VDH.”

Rule 22.1-289.057-B.

There shall always be at least one staff member on duty who has obtained within the last three years instruction in performing the daily heath observation of children.

“There was no staff member on duty who has obtained instruction in performing the daily health observation.”

Rule 8VAC20-780-245-L.

Staff shall complete orientation training prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities.

“There was no orientation training for Staff 5 who had been employed for over 2 months.”

Rule 8VAC20-780-240-B.

Prior to working alone with children and within seven days of the first day of employment, staff shall be provided in writing all of the required information.

“There was no documentation of required information provided in writing to Staff 5 who had been employed for over 2 months.”

Rule 8VAC20-780-240-D.

Documentation of at least 2 references to character, reputation, and competency are to be checked prior to employment.

“Staff 5, who has been employed for over two months, did not have any completed reference verifications on file.”

Rule 8VAC20-780-70.

The center is required to obtain a completed sworn statement prior to the employee’s first day of employment.

“There was no sworn statement for Staff 5, who has been employed for over 11 months.”

Rule 22.1-289.035-B-1.

The center is required to have applicants undergo a background checks every five years.

“The most recent central registry check for applicant #1 was overdue by approximately one year and one month. The most recent national criminal background check for applicant #1 was overdue by approximately one year and two months.”

Rule 22.1-289.036-A.

Every applicant for licensure shall provide a sworn statement or affirmation.

“There was no sworn statement for Applicant #4 available at the time of the inspection.”

Rule 22.1-289.036-B-1.

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 #5, who has been enrolled for approximately seven weeks, has a diagnosed food allergy and did not have a written care plan in their file.”

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

Based on observation, record review and interviews with staff, the provider failed to obtain the finding from a search of the central registry within 30 days of employment.

“Evidence: The record for Staff 2 contained a documented hire date of 06/10/2023. There were no central registry search results available for review during the inspection. Staff 2 was observed providing direct care and supervision to children. Staff 4 confirmed there were no central registry search results available for review during the inspection.”

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

Based on record review and interview with staff, the center failed to ensure that at least every two years from the date of the initial screening or testing, staff members shall obtain and submit the results of a follow-up tuberculosis screening.

“Evidence: The most recent tuberculosis screening for Staff 1 was dated 01/27/2022: there was not a follow-up test/screening for 2024 available for review. Staff 4 confirmed there was no 2024 test/ screening available for review.”

Rule 8VAC20-780-160-C.

22.1-289.035-A

Rule 22.1-289.035-A.

8VAC20-770-60-B

“Based on record review, the center failed to ensure that an employee must not be employed until the agency has the person’s completed sworn statement or affirmation. Evidence: The record for Staff 2 contained a documented hire date of 01/12/2022. The sworn statement was dated 01/31/2022.”

Rule 8VAC20-770-60-B.

Based on record review, the center failed to ensure that each staff member shall submit documentation of a negative tuberculosis screening 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.

“Evidence: 1. The record for Staff 2 contained a documented hire date of 01/12/2022. The documentation of a negative tuberculosis screening was dated 02/11/2022. 2. The record for Staff 3 contained a documented hire date of 06/13/2022. The documentation of a negative tuberculosis screening was dated 08/28/2022.”

Rule 8VAC20-780-160-A.

22.1-289.035-A

“Based on record review and discussion with staff, the center failed to ensure that all employees shall undergo a background check in accordance with the Code of Virginia prior to employment or beginning to serve as a volunteer and every five years thereafter. Evidence: The most recent sworn statement for Staff 1 was dated 02/14/2017. Staff 3 confirmed there was not a sworn statement for 2022 available during the inspection.”

Rule 22.1-289.035-A.

22.1-289.036-A

Rule 22.1-289.036-A.

8VAC20-770-60-C-2

“Based on record review and discussion with staff, the center failed to obtain the findings from a search of the central registry within 30 days of employment. Evidence: The record for Staff 2 contained a documented hire date of 06/20/2022. Staff 3 confirmed there was not a finding from the search of the central registry available for review.”

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

8VAC20-780-60-A-8

“Based on record review and discussion with staff, the center failed to ensure 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: The record review for Child 1 documented a diagnosed food allergy. Staff 3 confirmed no allergy care plan was available for review.”

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

Based on record review and discussion with the staff, the center failed to ensure that all employees shall undergo a background check in accordance with the Code of Virginia prior to employment and every five years thereafter.

“Evidence: The record for Staff 2 contained the findings from a search of the central registry dated 02/14/2017; the five year (02/14/2022) repeat search of the central registry was not available for review during the 03/02/2022 inspection.”

Rule 22.1-289.035-A.

Based on record review and discussion with staff, the center failed to ensure that the documentation of monthly evacuation drills contains all of the required components as required by the standards.

“Evidence: The emergency evacuation drill for January and February 2022 did not contain the following information: method used for notification of the drill; the number of staff participating; any special conditions simulated; problems encountered, if any; and weather conditions (for emergency evacuation drills only).”

Rule 8VAC20-780-550-G.