Brenda L Upsher Family Child Care Home

Regulation: 3290.117(c)

Description: Vet's certificate required

Noncompliance Area: Documentation of a current rabies immunization was not on file for the dog at the facility.

Correction Required: A veterinarian's certificate of current rabies immunization is required for a cat or dog at the facility. The certificate shall be on file when the cat or dog is present.

Regulation: 3290.151(a)(2)/3290.192(2)

Description: 12 months prior to service and every 24 months thereafter/Health assessment, TB test

Noncompliance Area: The health assessment on file for Staff #1 was dated 8/22/2022. Previous health assessments including one dated 6/1/2024, which was previously observed, were not part of Staff #1's file.

Correction Required: A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

Regulation: 3290.24(d)

Description: Emergency plan

Noncompliance Area: After a discussion with Staff #1, though annual emergency drills are conducted, they are documented on the fire drill log and does not include any special accommodations, if any, which were made or any problems encountered of observations during the emergency drill.

Correction Required: Emergency drills shall be conducted annually. Annual emergency drills shall be documented and on file at the facility.

Regulation: 3290.32(a)

Description: Comply with CPSL

Noncompliance Area: Staff person #1 has not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter training on file being dated 9/12/2020.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to Child Protective Services). Until such time as the required training has been completed, staff person #1 must be supervised, when interacting with children at a minimum by, a family child care home staff person who has completed all preservice trainings and has all qualifications to care for children unsupervised. If there are no staff person(s) available to supervise staff person #1, staff person #1 may not work in a child-care position at the facility.

Regulation: 3290.32(a)/3290.192(3)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file of Staff #1 did not contain documentation of a current of previous PA criminal history clearances and NSOR verification certificates. The file of household member #2 did not contain documentation of a PA criminal history clearance or NSOR verification certificate.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person #1 may not work in a child care position at the facility.

Regulation: 3290.94(a)(5)

Description: Evacuation routes posted

Noncompliance Area: An evacuation route was not posted in a conspicuous location in the basement.

Correction Required: Evacuation routes are posted in a conspicuous location on each floor of the facility.

Regulation: 3290.95(a)/3290.95(b)

Description: System in compliance/Operator or designated staff responsibility

Noncompliance Area: One of the devices to interconnected fire detection system was not on the second floor of the facility, but was located on the cubby in the hallway on the first floor of the home.

Correction Required: Fire detection devices or systems must be in compliance with standards established under section 1016(c) of the act (62 P.S. § 1016(c)). The operator or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in subsection (a) are met.

Regulation: 3290.95(a)/3290.95(b)

Description: System in compliance/Operator or designated staff responsibility

Noncompliance Area: During a review of the fire drill log, the area to document the testing of the fire detection system contained the initials of Staff #1 and lacked specific calendar dates for when the tests were performed making it unable to verify if they were conducted at least every 30-days.

Correction Required: Fire detection devices or systems must be in compliance with standards established under section 1016(c) of the act (62 P.S. § 1016(c)). The operator or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in subsection (a) are met.

Regulation: 3290.94(a)(9)

Description: Written record

Noncompliance Area: Based on review of the fire drill log, the last fire drill conducted was dated 8/4/2024, 10 months prior to the date of the inspection.

Correction Required: The operator or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that a written record is maintained on file at the facility indicating the specific time of day of the drill, the hypothetical location of the fire, the evacuation time, and the names of the facility persons and the number of children who participate in the fire drill.

Regulation: 3290.95(a)/3290.95(b)

Description: System in compliance/Operator or designated staff responsibility

Noncompliance Area: Based on documentation on the fire drill log, documentation of the most recent testing of the fire detection system was dated 8/2024, 10 months prior to the date of the inspection. Based on documentation on the fire drill log, documentation of the most recent testing of the fire detection system was dated 8/2024, 10 months prior to the date of the inspection. When demonstrating the fire detection system, the detector on the second floor did not operate in conjunction with the detectors in the basement and first floor. Though the detector did function as a standalone, it would not reconnect via Bluetooth with the other 2 detectors.

Correction Required: Fire detection devices or systems must be in compliance with standards established under section 1016(c) of the act (62 P.S. § 1016(c)). The operator or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in § 3290.95(a) are met.

Regulation: 3290.113(d)

Description: No harsh language

Noncompliance Area: At the time of inspection, while discipling a related child, staff #1 screamed at said child threatening to beat his butt in the presence of a childcare child.

Correction Required: A facility person may not use harsh, demeaning or abusive language in the presence of children.

Regulation: 3290.117(c)

Description: Vet's certificate required

Noncompliance Area: A certificate documenting current rabies vaccination for the dog, who was present at the inspection, was not on file at the facility.

Correction Required: A veterinarian's certificate of current rabies immunization is required for a cat or dog at the facility. The certificate shall be on file when the cat or dog is present.

Regulation: 3290.123(a)(3)

Description: Services provided

Noncompliance Area: Documentation of a completed child service report was not on file for child #1, who has been enrolled for more than 6 months (see LIS code sheet).

Correction Required: An agreement shall specify the services to be provided to the family and the child, including the Department's approved form to provide information to the family about the child's growth and development in the context of the services being provided. the operator shall complete and update the form and provide a copy to the family in accordance with the updates regarding emergency contact information at § 3290.124(e).

Regulation: 3290.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: The emergency contact form of child #3 included the health insurance policy name but did not include the policy number for the child.

Correction Required: Emergency contact information must include health insurance coverage and policy number for a child under a family policy or Medical Assistance benefits, if applicable.

Regulation: 3290.124(d)

Description: Written emergency plan posted

Noncompliance Area: A written plan which identifies the means of transporting a child to emergency care and the facility staffing provisions in the event of an emergency was not posted in a conspicuous location at the facility.

Correction Required: A written plan shall be conspicuously posted which identifies the means of transporting a child to emergency care and the facility staffing provisions in the event of an emergency. The plan must accompany a staff person who leaves the facility on an excursion with children.

Regulation: 3290.131(b)(1)/3290.182(1)

Description: Updated infant health report: every 6 months/Initial and subsequent health assessments

Noncompliance Area: The file of child #1, identified as a young toddler (see LIS code sheet), contained a health assessment dated 8/10/2023, but did not contain documentation of a health assessment within the last 6 months.

Correction Required: The operator shall require the parent to provide an updated health report at least every 6 months for an infant or young toddler. A child's record must contain initial and subsequent health reports.

Regulation: 3290.131(d)(5)/3290.131(e)(3)

Description: Immunization record/Dismissal policy

Noncompliance Area: The file of child #1 contained an immunization record which did not contain 1 pneumococcal and 1 DTaP vaccination to meet the recommendations of the ACIP or acceptable documentation of an exemption.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in child care group settings).

Regulation: 3290.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: The file of child #1 and #2 contained an emergency contact form and financial agreement which has not been reviewed and/or updated within the past 6 months. The forms were dated 6/24/2023.

Correction Required: A parent is required to review and update the emergency contact information and the financial agreement at least once in a 6-month period or as soon as there is a change in the information.

Regulation: 3290.24(b)

Description: Emergency plan

Noncompliance Area: The facility did not have documentation the emergency plan was reviewed and/or updated within the last 12 months.

Correction Required: The operator shall review the emergency plan at least annually and update the plan as needed. Each review and update of the emergency plan shall be documented in writing and kept on file at the facility.

Regulation: 3290.24(d)

Description: Emergency plan

Noncompliance Area: Though the facility documented emergency drills on the fire drill log, the information did not include if special accommodations were used for any of the children, or any problems or observations during the drill.

Correction Required: Emergency drills shall be conducted annually. Annual emergency drills shall be documented and on file at the facility.

Regulation: 3290.24(g)

Description: Emergency plan

Noncompliance Area: Staff #1 did not have documentation the emergency plan was sent to the local and county emergency management agencies at the time of the inspection.

Correction Required: The operator shall send a copy of the emergency plan and subsequent plan updates to the local municipality and to the county emergency management agency.

Regulation: 3290.64(a)

Description: Locked or inaccessible - in original container

Noncompliance Area: Carpet deodorizer was observed on a table in the living room and disinfecting wipes were on a shelf above the toilet. Both items were accessible to children in care and labeled "keep out of the reach of children."

Correction Required: Cleaning materials and other toxic materials shall be stored in an original labeled container or in a container that specifies the content. Toxics shall be kept in a locked area or in an area inaccessible to children, and shall be stored away from food, food preparation areas and child care spaces.

Regulation: 3290.95(a)/3290.95(b)

Description: System in compliance/Operator or designated staff responsibility

Noncompliance Area: The facility did not have the proof of purchase of the interconnected fire detection system.

Correction Required: Fire detection devices or systems must be in compliance with standards established under section 1016(c) of the act (62 P.S. § 1016(c)). The operator or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in § 3290.95(a) are met.

Regulation: 3290.105(a)

Description: Clean, age appropriate

Noncompliance Area: The sleep equipment of child #1 was not labeled with their name.

Correction Required: (a) Individual, clean, age-appropriate rest equipment shall be provided for preschool, toddler and infant children as agreed between the parent and the operator. The rest equipment must be labeled with the child's name and used only by the named child while enrolled in the program.

Regulation: 3290.117(c)

Description: Vet's certificate required

Noncompliance Area: Documentation of a current rabies immunization was not presented at the time of the inspection.

Correction Required: A veterinarian's certificate of current rabies immunization is required for a cat or dog at the facility. The certificate shall be on file when the cat or dog is present.

Regulation: 3290.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: The emergency contact form of child #1 and #2 did not contain the work address and work telephone number of the enrolling parent or documentation this is not applicable.

Correction Required: Emergency contact information must include the home and work addresses and telephone numbers of the enrolling parent.

Regulation: 3290.124(b)(5)

Description: Information re: disability

Noncompliance Area: The emergency contact form of child #1 and #2 did not contain information on the child's special needs, as specified by the child's parent, physician, physician's assistant or CRNP, which is needed in an emergency situation or documentation this is not applicable to the child.

Correction Required: Emergency contact information must include information on the child's special needs, as specified by the child's parent, physician, physician's assistant of CRNP, which is needed in an emergency situation.

Regulation: 3290.18

Description: General Health and Safety

Noncompliance Area: The emergency plan did not contain a contingency plan/contingency fund which can help strategize how to pay for repairs, pay staff, and continue to run the business after a disaster or emergency. The facility did not have a policy on the prevention of shaken baby syndrome, abusive head trauma, and child maltreatment. Documentation of the health and safety topics of facility person #1 were dated 7/31/2021, which would require the additional 1-hour Pennsylvania Update 2022 to be completed by 12/30/2022. Facility person #1 did not have documentation of this training.

Correction Required: Conditions at the facility may not pose a threat to the health or safety of the children.

Regulation: 3290.22(b)

Description: Availability of certificate of compliance and applicable regulations

Noncompliance Area: The facility did not provide the parents with information on how to access the regulations electronically.

Correction Required: The operator shall provide the parent of each child enrolled in the facility with information on how to access the regulations in this chapter electronically and with instructions for contacting the appropriate regional child care office.

Regulation: 3290.31(f)

Description: Age and training

Noncompliance Area: The record of facility person #1 contained documentation of 11 of the 12 annual hours of professional development.

Correction Required: A staff person shall obtain an annual minimum of 12 clock hours of child care training.

Regulation: 3290.95(a)/3290.95(b)

Description: System in compliance/Operator or designated staff responsibility

Noncompliance Area: Documentation of the testing of the fire detection system exceeded 30 days on the following occasions: 1/16/2023 to 2/28/2023 to 3/30/2023 and 4/22/2023 to 5/26/2023 to 6/28/2023.

Correction Required: Fire detection devices or systems must be in compliance with standards established under section 1016(c) of the act (62 P.S. § 1016(c)). The operator or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in § 3290.95(a) are met.

Regulation: 3290.31(f)(4)(i)

Description: Age and training

Noncompliance Area: The first aid and CPR training of facility person #1 expired on 9/18/2021 and was not renewed. Documentation of the on-line portion dated 6/3/2022 was presented, however the hands-on skills portion of the class has not yet been completed to make the training acceptable.

Correction Required: Competence is the completion of training by a professional in the field of first-aid and CPR. All staff persons shall renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification.

Regulation: 3290.151(a)(2)/3290.192(2)

Description: 12 months prior to service and every 24 months thereafter/Health assessment, TB test

Noncompliance Area: Documentation of the most current health assessment of facility person #1 is dated 11/27/2019 and lacked documentation of an current updated health assessment within 24 months of the prior.

Correction Required: A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem.A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

Regulation: 3290.24(a)(5)

Description: Emergency plan

Noncompliance Area: The emergency plan did not provide for accommodations of infants and toddlers, children with disabilities, and children with chronic medical conditions in an emergency situation.

Correction Required: The facility shall have an emergency plan that provides for accommodations of infants and toddlers, children with disabilities, and children with chronic medical conditions.

Regulation: 3290.31(f)(4)(i)

Description: Age and training

Noncompliance Area: Documentation of pediatric first aid and pediatric first aid of facility person #1 exceeded the expiration date of the previous training.

Correction Required: Competence is the completion of training by a professional in the field of first-aid and CPR. All staff persons shall renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification.

Regulation: 3290.31(f)/3290.192(4)

Description: Age and training/Required training

Noncompliance Area: Documentation of 10 hours of training between 12/19/2020 and 12/19/2021 was presented for facility person #1, but they lacked 2 hours to meet the required 12 annual hours of professional development.

Correction Required: A staff person shall obtain an annual minimum of 12 clock hours of child care training .A facility person's record shall include records of training required by the Department.

Regulation: 3290.73(c)

Description: Has all items

Noncompliance Area: The first aid kit did not contain gloves.

Correction Required: A first-aid kit must contain the following: soap, an assortment of adhesive bandages, sterile gauze pads, tweezers, tape, scissors and disposable, nonporous gloves.

Regulation: 3290.91(a)

Description: Stairs, exits, etc. unobstructed

Noncompliance Area: In the front room child care space, the doorway to the hall and front door was obstructed by the cubbies for the children.

Correction Required: Stairways, hallways, exits from rooms, exits from the facility and other means of egress serving as an exit shall be unobstructed.

Regulation: 3290.95(a)/3290.95(b)

Description: System in compliance/Operator or designated staff responsibility

Noncompliance Area: Documentation of testing the fire detection system exceeded 30 days on the following occasions: 10/30/2021 to 11/30/2021 and 2/20/2022 to 3/30/2022.

Correction Required: Fire detection devices or systems must be in compliance with standards established under section 1016(c) of the act (62 P.S. § 1016(c))The operator or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in § 3290.95(a) are met.

Noncompliance Area: The agreement on file for child #1 did not include the arrival and departure times.

Correction Required: An agreement shall specify the child's arrival and departure times.

Noncompliance Area: The agreement on file for child #1 was the original.

Correction Required: A parent shall receive the original agreement. The facility shall retain a copy of the agreement.

Noncompliance Area: The emergency contact form on file for child #1 did not include the physician's information.

Correction Required: Emergency contact information must include the name, address and telephone number of the child's physician or source of medical care.

Noncompliance Area: The emergency contact form on file for child #1 did not include the health insurance information.

Correction Required: Emergency contact information must include health insurance coverage and policy number for a child under a family policy or Medical Assistance benefits, if applicable.

Noncompliance Area: The only health assessment on file for Facility Person #1 was more than 24 months old.

Correction Required: A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment on file at the facility.A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem.

Noncompliance Area: The annual review of the emergency plan was not documented.

Correction Required: The operator shall review the emergency plan at least annually and update the plan as needed. The operator shall document in writing each review and update of the emergency plan.

Noncompliance Area: The criminal history and child abuse clearances on file for Facility Person #1 were more than 60 months old. There was no NSOR clearance on file for Facility Person #1.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person #1 may not work in a child care position at the facility without completed criminal history, state police and NSOR clearances from within the last 60 months.

Noncompliance Area: The only mandated reporter training completed and documented on file for Facility Person #1 was more than 60 months old.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include records of training required by the Department.

Noncompliance Area: The emergency phone numbers were not posted.

Correction Required: The telephone number of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephone in the facility.

Noncompliance Area: There were no tweezers in the first aid kit.

Correction Required: A first-aid kit must contain the following: soap, an assortment of adhesive bandages, sterile gauze pads, tweezers, tape, scissors and disposable, nonporous gloves.

Noncompliance Area: There was no current documentation of rabies immunization on file for the operator's dog at the facility.

Correction Required: A veterinarian's certificate of current rabies immunization is required for a cat or dog at the facility. The certificate shall be on file when the cat or dog is present.

Noncompliance Area: The health assessment on file for Facility Person #1 was more than 24 months old.

Correction Required: A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment on file at the facility.

Noncompliance Area: There was no documentation of current first aid training on file for Facility Person #1, the operator and only staff person.

Correction Required: One or more persons competent in first-aid techniques shall be at the facility when day care children are in care.

Noncompliance Area: There was no child service report completed in the last 6 months on file for child #1.

Correction Required: An agreement shall specify the services to be provided to the family and the child, including the Department's approved form to provide information to the family about the child's growth and development in the context of the services being provided. the operator shall complete and update the form and provide a copy to the family in accordance with the updates regarding emergency contact information at 3290.124(e).

Noncompliance Area: There was no agreement on file for child #2.

Correction Required: An agreement shall be signed by the operator and the parent.A child's record must contain a copy of the initial agreement and subsequent written agreements between the parent and the operator. The parent receives the original agreement.

Noncompliance Area: There was no emergency contact form on file for child #2.

Correction Required: Emergency contact information is required for each enrolled child. Emergency contact information must reference who shall be contacted in an emergency.

Noncompliance Area: There was no health insurance information on the emergency contact form on file for child #1.

Correction Required: Emergency contact information must include health insurance coverage and policy number for a child under a family policy or Medical Assistance benefits, if applicable.

Noncompliance Area: The emergency contact form and agreement on file for child #1 were not reviewed and updated by a parent in writing in the last 6 months.

Correction Required: The parent shall update in writing emergency contact information once in a 6-month period or as soon as there is a change in the informationA parent is required to review and update the emergency contact information and the financial agreement at least once in a 6-month period or as soon as there is a change in the information.

Noncompliance Area: The health assessment on file for child #1, a young toddler, was completed more than 6 months prior.

Correction Required: The operator shall require the parent to provide an updated health report at least every 6 months for an infant or young toddler

Noncompliance Area: The trash can used to dispose of diapers was not a hands-free lidded trash can.

Correction Required: If disposable diapers are provided by a parent or by a facility, a soiled diaper shall be discarded by immediately placing the diaper into a plastic-lined, hands-free covered can.

Noncompliance Area: There was a disinfectant spray on the table near the entrance, within reach of children.

Correction Required: Cleaning materials and other toxic materials shall be stored in an original labeled container or in a container that specifies the content. Toxics shall be kept in a locked area or in an area inaccessible to children, and shall be stored away from food, food preparation areas and child care spaces.

Noncompliance Area: Child #1 had an emergency contact form that lacked the child's health insurance name and policy number. Child #2 had an emergency contact form that lacked the child's health insurance policy number.

Correction Required: Emergency contact information must include health insurance coverage and policy number for a child under a family policy or Medical Assistance benefits, if applicable.

Noncompliance Area: Child #1, child #2 and child #3 had emergency contact forms that lacked the addresses of individuals designated by the parent to whom the child may be released.

Correction Required: Emergency contact information must include the name, address and telephone number of the individual designated by the parent to whom the child may be released.

Noncompliance Area: Child #2 had a most recent health assessment dated 5-2-16. Child #3 had a most recent health assessment dated 6-10-15.

Correction Required: The operator shall require the parent to provide an updated health report at least every 12 months for an older toddler or preschool child.

Noncompliance Area: There was hydrogren peroxide in the first aid kit that was not labeled for individual use.

Correction Required: The label of a medication container shall identify the name of the medication and the name of the child for whom the medication is intended. Medication shall be administered to only the child whose name appears on the container.

Noncompliance Area: Child #2 and child #3 had emergency contact forms and agreements that had not been updated within a 6 month time period.

Correction Required: A parent is required to review and update the emergency contact information and the financial agreement at least once in a 6-month period or as soon as there is a change in the information.

Noncompliance Area: There were uncovered outlets on the wall in the entryway.

Correction Required: Protective receptacle covers shall be placed in electrical outlets accessible to children 5 years of age or younger.

Noncompliance Area: There was peeling and chipping paint on the outside doors that lead to the basement of the facility. The doors are accessible to the children on the outside play area.

Correction Required: Peeled or damaged paint or damaged plaster is not permitted on indoor or outdoor surfaces in the child care facility.