Effingham Street Family YMCA

8VAC20-770-60-C-2 · Based on a review of four staff records, it was determined that the facility did not deny continued employment of a staff who did not have a search of the central registry finding within 30 days of employment.

Evidence: 1. The record for staff #1 (date of hire 7/14/21) did not contain documentation of a completed search of the central registry finding. 2. Staff #4 (Program Director) reviewed the record for the staff #1, and confirmed that the search of the central registry finding has not been received.

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8VAC20-780-245-A · Staff shall complete annually a minimum of 16 hours of training appropriate to the age of children in care. There was no documentation to show that Staff #1 completed 16 hours of annual training in 2025.

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8VAC20-790-600-D-1 · All staff who work directly with children shall have current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care.

The record for Staff #1 did not contain an up to date CPR certification; the CPR certification reviewed was expired. The record for Staff #2 did not contain documentation of CPR certification.

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8VAC20-780-150-B · Repeat Violation

Each immunization report shall be signed by a physician, his designee, or an official of a local health department. The immunization reports for Child #1 and Child #2 were not signed by a physician, his designee, or an official of a local health department, which is required.

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22.1-289.011-F · The license and any other documents required by the Superintendent shall be posted in a conspicuous place on the licensed premises.

The license and most recent inspection findings were not posted in a conspicuous place on the licensed premises, which is required.

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8VAC20-790-600-D-1 · All staff who work directly with children shall have cardiopulmonary resuscitation (CPR) training within 90 days of the date of employment.

1.There is no documentation to show that Staff #1 and Staff #2 (both employed for 2 and a half years) have completed CPR training. 2. The documentation of CPR training for Staff #3 (employed for seven months) show that the staff member did not complete CPR training within 90 days of employment, which is required.

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22.1-289.035-B-3 · Centers must request central registry results for all staff members.

There is no documentation of a central registry search in the record of Staff #1 (employed for 2 and a half years). In the record of Staff #2 (employed for seven months), the documentation for the central registry search shows that the search results were not received until six months after the staff member's hire date.

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22.1-289.035-B-4 · Based on a review of six staff records, it was determined that the facility did not ensure that all staff who had lived out of state within the past five years had a sex offender registry check, and a child abuse and neglect registry check on file from the state the staff member had lived.

Evidence: Staff #5 indicated on her sworn statement that she had lived out of state in the past five years. The state participates in the National Fingerprint File however, there was no documentation in the record that the required out of state sex offender registry check, or a search of the child abuse and neglect registry had been completed.

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8VAC20-780-160-A · Based on a review of six staff records, it was determined that the facility did not ensure that each staff member had a tuberculosis (Tb) screening within 30 days prior to coming into contact with children.

Evidence: 1. Staff #1 (date of hire 6/7/22) had a Tb screening on file dated 1/16/23 which was not within the prescribed time frame. 2. Staff #2 (date of hire 12/15/22) had a Tb screening on file dated 9/2/21 which was not within the prescribed time frame. 3. Staff #5 (date of hire 6/22/22) had a Tb screening on file dated 7/21/22 which was not within the prescribed time frame. 4. Staff #6 (date of hire 6/10/22) had a Tb screening on file dated 1/16/23 which was not within the prescribed time frame.

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8VAC20-770-60-C-2 · Based on a review of eleven staff records, it was determined that the facility did not deny continued employment of a staff who did not have a search of the central registry finding

within 30 days of employment. Evidence: 1. The record for staff #1 (date of hire 6/10/22) did not contain documentation of a completed search of the central registry finding. 2. The record for staff #2 (date of hire 6/7/22) did not contain documentation of a completed search of the central registry finding. 3. The record for staff #4 (date of hire 5/17/22) did not contain documentation of a completed search of the central registry finding. 4. The record for staff #5 (date of hire 6/14/22) did not contain documentation of a completed search of the central registry finding. 5. The record for staff #6 (date of hire 6/10/22) did not contain documentation of a completed search of the central registry finding. 6. The record for staff #7 (date of hire 6/10/22) did not contain documentation of a completed search of the central registry finding. 7. The record for staff #8 (date of hire 6/15/22) did not contain documentation of a completed search of the central registry finding. 8. The record for staff #9 (date of hire 6/13/22) did not contain documentation of a completed search of the central registry finding. 9. The record for staff #10 (date of hire 6/10/22) did not contain documentation of a completed search of the central registry finding. 10. Staff #p11 (Program Director) reviewed the records for the staff listed above, and confirmed that the search of the central registry finding has not been received.

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