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

8VAC20-780-60-A · 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 #5, enrolled for over six months, was missing the work phone number and place of employment of each parent who has custody, two designated emergency contact addresses, and previous daycares and schools attended by the child. Administration acknowledged that the child's health and history intake form which contained the information was missing from the record.

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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 #1, enrolled for 1 day, was missing 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, enrolled for 29 days, was missing 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 3 months, was missing the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.

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8VAC20-780-245-A · Based on a review of four staff records and interview, the center did not ensure that one staff annually completed a minimum of 16 hours of training appropriate to the age of children in care as required.

Evidence: 1. The record of staff #3 (date of employment: 9/3/2020) contained documentation of approximately six hours of annual training between 9/3/2023 and 9/3/2024. 2. Administration acknowledged that staff #3 had not completed 16 hours of annual training.

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8VAC20-780-60-A · REPEAT VIOLATION

Based on a review of five child records and interview, the center did not ensure that one record was kept that contained the required information. Evidence: 1. The record of child #4 (date of enrollment: 8/21/2023) did not contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached. 2. Administration acknowledged that the information was missing.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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22VAC40-185-420-A · Based on review of the center's policies and procedures and interview, the center did not ensure that the information provided to parents in writing contained all of the required components.

Evidence: 1. The center's policies for the arrival and departure of children did not include procedures for when a child is not picked up in emergency situations including but not limited to inclement weather or natural disasters. 2. Administration acknowledged that this policy was missing.

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