Young Men’s Christian Association of Greater Richmond-Manchester

A tuberculosis (TB) screening is required every two years from the last screening..

“Staff #9 updated screening was due over 1 month ago and had not yet been completed.”

Rule 8VAC20-780-160-C.

All staff who work directly with children shall have within 90 days of the date of employment or 90 days from subsidy vendor approval: 1. Current certification in CPR appropriate to the ages of children in care.

“Staff #1 most recent CPR certification expired over 3 months ago.”

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

All staff who work directly with children shall have within 90 days of the date of employment or 90 days from subsidy vendor approval: 2. Current certification in first aid appropriate to the ages of children in care.

“Staff #1 most recent first aid certification expired over 3 months ago.”

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

At least one staff in each classroom or area where children are present shall have current certification in both CPR and first aid.

“On July 6, 2026, Staff #1 was alone with approximately 17, school age children in the gym and was not certified in CPR or first aid.”

Rule 8VAC20-780-530-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 #5, who has been enrolled for over 5 months, has a diagnosed food allergy and did not have a written care plan in their file.”

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

Immunization records are required to be signed and dated by a physician, his designee, or an official of the local health department.

“The immunization record for child #3 was not signed.”

Rule 8VAC20-780-150-B.

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

“The record for child #11 did not contain a medication authorization for one over-the-counter medication stored for the child on-site.”

Rule 8VAC20-780-510-F.

**REPEAT VIOLATION** 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 #10 was onsite, but the medication authorization had expired over 3 weeks 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 #3, enrolled for 4 days, was missing the following required components: the name, address, and phone number of two designated people to call in an emergency and the work phone number and place of employment of each parent.”

Rule 8VAC20-780-60-A.

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 #2, enrolled for over one week, was missing the following required components: the name, address, and phone number of two designated people to call in an emergency.”

Rule 8VAC20-780-60-A.

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

“Medication for child #2 was on site, but there was no completed medication authorization in the child’s record.”

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 #3 was onsite, but the medication authorization had expired over 21 days 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.

When staff are supervising children, they shall always ensure their care, protection, and guidance.

“On 4/28/2025, Staff #1 transported 42 school-age children from three different schools to the center while under the influence of alcohol and being intoxicated approximately three times the legal limit for operating a motor vehicle.”

Rule 8VAC20-780-340-A.

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

“Staff #1, employed for more than 1 year and 11 months, did not have documentation of a completed central registry check from one state.”

Rule 22.1-289.035-B-4.

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 4 months, has a diagnosed food allergy and did not have a written care plan in their file.”

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

The license and any other documents required shall be posted in a conspicuous place on the licensed premises.

“The findings from the most recent inspection, dated 7/24/2024, were not posted on the premises.”

Rule 22.1-289.011-F.

For staff hired before July 1, 2024, providers must obtain the results of a central registry search for an employee, within 30 days of service.

“Staff #3 had central registry results dated over 30 days after being employed.”

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

Staff are required to 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.

“Staff #2 and staff #5 completed orientation training more than 10 days after their first date of employment.”

Rule 8VAC20-780-240-B.

**Repeat Violation** Based on interviews and review of video footage, the center failed to ensure that when staff are supervising children, they shall always ensure their care, protection, and guidance.

Rule 8VAC20-780-340-A. From a complaint.

Based on interviews and review of video footage, the center failed to ensure when time is used as a behavior guidance technique it shall be used sparingly and shall not exceed one minute for each year of the child’s age.

Rule 8VAC20-780-400-B. From a complaint.

Based on review of staff records, the center did not ensure each staff member completed a sworn statement prior to their date of employment.

“Evidence: 1. The record for staff #3 (DOH: 10/22/2021) contained a sworn statement signed and dated on 10/25/2021.”

Rule 22.1-289.035-B-1.

Based on review of staff records, the center did not obtain the results of a national fingerprint-based criminal history record check prior to employment for each staff.

“Evidence: 1. The record for staff #3 (DOH 10/22/2021) contained a fingerprint background check dated 4/12/2022.”

Rule 22.1-289.035-B-2.

Based on interviews, the center failed to ensure that when staff are supervising children, they shall always ensure their care, protection, and guidance.

Rule 8VAC20-780-340-A.

Based on interviews, the center failed to ensure operational responsibilities that the center’s activities and services are maintained in compliance with the center’s own policies and procedures that are required by the standards.

“Evidence: 1. The YMCA Counselor Training Manual states that staff must maintain active supervision at all times to include, ?Be able to account for children in your care, always. Staff shall continuously scan the entire environment to know where someone is and what they are doing.? 2. Staff #3 stated they were unaware that child #2 was in the same restroom as child #1 until the children exited the restroom together.”

Rule 8VAC20-780-40-E.

8VAC20-780-510-F

“Based on a review of three medications and documentation review, the center did not ensure two medication authorizations were available to staff during the entire time the medication was effective for two children. Evidence: A prescription medication was observed at the center for Child #10. A medication authorization allowing the center to administer medication was not present at the center. Attendance rosters indicated Child #10 is currently attending the center.”

Rule 8VAC20-780-510-F.

8VAC20-780-510-G

“Based on observation and documentation review, the center did not ensure medication was labeled with the child’s name, the name of the medication, the dosage amount, and the time or times to be given. Evidence: A prescription medication for Child #10 was on site at the center. The medication was not labeled with the child’s name, the dosage amount and the time or times to be given. Attendance rosters indicated Child #10 is currently attending the center.”

Rule 8VAC20-780-510-G.

Based on review of five staff records, the center did not ensure two staff members completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.

“Evidence: 1. The record of staff #2, employed 09/20/2022, contained documentation of the completion of the Virginia Department of Education-sponsored orientation dated 03/16/2023, exceeding 90 days from the date of employment. 2. The record of staff #4, employed 03/14/2023, contained documentation of the completion of the Virginia Department of Education-sponsored orientation dated 07/01/2023, exceeding 90 days from the date of employment.”

Rule 8VAC20-780-240-A.

Based on review of staff records and interview, the center did not ensure staff obtained in addition to preservice and orientation training, at least 16 hours of training to include the department’s health and safety update course annually.

“Evidence: 1. The record of staff #2, employed 11/18/2021, did not contained documentation of the department’s annual health and safety update course. 3. A member of management stated staff #2 had not completed the annual health and safety update training.”

Rule 8VAC20-780-600-B.

Based on a review of four staff records, the center did not obtain the results of a search of the child abuse and neglect registry and an out of state criminal history name check from any state in which one staff member had resided in the preceding five years within the required time frame.

“Evidence: 1. The record for Staff #2, employed 11/18/2021, indicated the staff had resided in another state outside of Virginia within the last five years. 2.The record did not contain the results of a search of the child abuse and neglect registry from that state. There was no documentation of a follow up within 45 days requesting the status of the request.”

Rule 22.1-289.035-B-4.

Based on a review of four staff records and interviews, the center did not ensure that three staff member had a central registry finding within 30 days of employment.

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

Based on review of six children’s records and interview, the center did not obtain documentation of immunizations required by the State Board of Health before the child attended the center.

“Evidence: 1.The record of child #6, enrolled 08/22/2022, did not contain documentation of immunizations exceeding the first day of attendance. 2. The director stated the record did not have documentation of immunizations.”

Rule 8VAC20-780-130-A.

Based on revied of six children’s records and interview, the center did not obtain documentation of a physical examination for one child’s record before the child’s attendance or within 30 days after the first day of attendance.

“Evidence: 1. The record of child #6. Enrolled 08/22/2022, did not contain documentation of a physical examination exceeding 30 days from the first day of attendance. 2. The director stated the child’s record did not contain documentation of a physical.”

Rule 8VAC20-780-140-A.

Based on review of staff records and interview, the center did not ensure the assigned program director met program director qualifications.

“Evidence: 1. The record of staff #1, identified as the center’s program director, contained documentation of completing 62 college credits of which 11 semester hours were in a child related subject when 48 semester hours of college credits of which 12 semester hours are in a child related subject is required. 2. A member of management acknowledged staff #1 did not have any additional credits hours in a child related subject and did not meet director qualifications.”

Rule 8VAC20-780-190-A-3.

Based on observation and interview, the center did not ensure when a medication authorization expired, the parent was notified that the medication needs to be picked up within 14 days or the parent must renew the authorization. Medications not picked up by the parent within 14 days will be disposed of by the center.

“Evidence: 1. The medication authorization for child #8 expired on 06/30/2022 and the medication was still on site. The director stated the parent had not been notified that the authorization had expired. 2. The medication authorization for child #11 had a duration date of 09/02/2022 through 09/02/2023. The authorization was only signed by the parent and did not have a physician’s signature; therefore, the authorization was only valid for 10 days. The authorization expired on 09/12/2023 and the medication was still on site exceeding 14 days.”

Rule 8VAC20-780-510-P.

Based on review of the drill log and interview, the center did not implement a monthly practice evacuation drill.

“Evidence: The drill log did not have any practice evacuation drills documented. The director stated that evacuation drills had not been conducted this school year and that there was no documentation of conducted drill for the past 12 months.”

Rule 8VAC20-780-550-D.

Based on review of the drill log and interview, the center did not practice a minimum of two shelter in place drill in the past year.

“Evidence: The drill log did not have documentation of any shelter in place drills in the past 12 months. The director stated that they had not conducted any shelter-in-place drill in the past 12 months.”

Rule 8VAC20-780-550-E.

Based on review of the drill log and interview, the center did not ensure lockdown procedures were practiced at least annually.

“Evidence: The drill log did not have documentation of a lockdown drill in the past 12 months. The director stated a lockdown drill had not been conducted in the past 12 months.”

Rule 8VAC20-780-550-F.

Based on review of six children’s records, the center did not obtain all required documentation for four children’s records.

Rule 8VAC20-780-60-A.

Based on review of children’s records, 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 of child #1, with a diagnosed food allergy, did not have a written allergy care plan. 2. The record of child #4, with a diagnosed food allergy, did not have a written allergy care plan.”

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

Based on interviews and documentation review, the center did not notify the department within two business days of a serious injury to a child that required outside medical attention while under the center’s supervision.

Rule 8VAC20-780-80-B-2.

Based on a review of seven staff records and interviews, the center did not ensure that one staff member had a central registry finding within 30 days of employment.

“Evidence: The record for Staff #7, employed on 09/14/2021, contained the results of a central registry finding dated 05/04/2022 exceeding 30 days from the date of employment. The record did not contain documentation of any further contact or follow up as to the status of the request and the staff has been continuously employed.”

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

Based on review of seven staff records, the center did not obtain documentation of a negative tuberculosis screening for two staff members at the time of employment and prior to coming into contact with children.

“Evidence: 1. The record of staff #4, employed 06/02/2022, did not contain documentation of a TB screening. 2. The record of staff #5, employed 06/02/2022, did not contain documentation of a TB screening.”

Rule 8VAC20-780-160-A.

Based on review of documentation, the center did not obtain an annual fire inspection report from the appropriate fire official having jurisdiction.

“Evidence: The most recent fire inspection report was dated 02/26/2021 exceeding the annual requirement.”

Rule 8VAC20-780-260-A.

Based on review of documentation, the center did not obtain an annual approval from the health department.

“Evidence: The most recent health inspection report was dated 02/27/2020 exceeding the annual requirement.”

Rule 8VAC20-780-260-B.

Based on interview, the center did not implement a monthly practice evacuation drill.

“Evidence: The director stated that evacuation drills had not been conducted and that a drill log could not be located.”

Rule 8VAC20-780-550-D.

Based on interview, the center did not practice a minimum of two shelter in place drill in the past year.

“Evidence: The director stated that they had not conducted any shelter-in-place drill and that a drill log could not be located.”

Rule 8VAC20-780-550-E.

Based on interview, the center did not ensure lockdown procedures were practiced at least annually.

“Evidence: The director stated a lockdown drill had not been conducted and that a drill log could not be located.”

Rule 8VAC20-780-550-F.

Based on review of children’s records, 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: The record of child #8, with a diagnosed food allergy, did not have a written allergy care plan.”

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