Galaxy Beyond Walls Childcare

Regulation: 3280.103

Description: Small Toys and Objects

Noncompliance Area: In the main room in the clear 3 drawer art drawers were Styrofoam eggs and plastic beads less than an inch in diameter accessible to children who are still placing objects in their mouths.

Correction Required: Toys and objects with a diameter of less than 1 inch, objects with removable parts that have a diameter of less than 1 inch, plastic bags and styrofoam objects may not be accessible to children who are still placing objects in their mouths.

Regulation: 3280.192(5)

Description: Two written references

Noncompliance Area: Staff persons #1 and 2's files did not contain 2 written nonfamily letters of reference.

Correction Required: A facility person's record shall include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

Regulation: 3280.31(e)(4)(i)

Description: Age and training

Noncompliance Area: Staff person #3 has not completed Pediatric first aid and CPR training on or before expiration of the most current certification. This is evidenced by the previously documented Pediatric first aid and CPR training on file expiring 1/2026. Documentation of updated Pediatric first aid and CPR training is not on file.

Correction Required: Competence is the completion of training by a professional in the field of first-aid and cardiopulmonary resuscitation (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. Until such time as the required training has been completed, staff person #3 must be supervised, when interacting with children at a minimum by, a primary 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 #3, staff person #3 may not work in a child-care position at the facility.

Regulation: 3280.32(a)

Description: Comply with CPSL

Noncompliance Area: Staff person #3 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 2/10/21.

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 #3 must be supervised, when interacting with children at a minimum by, an primary 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 #3, staff person #3 may not work in a child- care position at the facility.

Regulation: 3280.32(a)/3280.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: Staff #1's file did not contain DHS FBI Clearance nor did it contain documentation of application of DHS FBI clearance prior to date of hire (See LIS CODE SHEET) required for provisional hiring under the CPSL.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Facility Person # 1 may not work in a child care position at the facility.

Regulation: 3280.35(1)/3280.192(2)(ii)

Description: HS/GED/Exp, educ., training prior to facility

Noncompliance Area: The file for staff person #1, who is classified as a secondary staff person, does not include a high school diploma or a general educational development certificate; or a minimum of an 8th grade education and 2 years of experience with children.

Correction Required: A secondary staff person shall have obtained a high school diploma or a general educational development certificate. A facility person's record shall include verification of child care experience, education and training prior to service at the facility.

Regulation: 3280.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: It was observed that 1 outlet in the main room and 2 outlets in the back room did not contain protective outlet covers.

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

Regulation: 3280.76

Description: Building Surfaces

Noncompliance Area: In the main room next to the window air conditioning unit was an outlet that did not have an outlet wall plate cover.

Correction Required: Floors, walls, ceilings and other surfaces, including the facility's outdoor play space surfaces shall be kept clean, in good repair and free from visible hazards.

Regulation: 3280.77(a)

Description: No peeling paint or plaster

Noncompliance Area: In the bathroom next to the sink was peeling paint.

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

Regulation: 3280.94(a)(9)

Description: Written record

Noncompliance Area: The facility did not have written proof of completing fire drills every 60 days.

Correction Required: 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: 3280.95(a)/3280.95(b)

Description: FIRE DETECTION/Staff responsibility

Noncompliance Area: The facility did not have written proof of completing fire alarm testing 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 primary staff person or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in subsection (a) are met

Regulation: 3280.104

Description: High Chairs

Noncompliance Area: At approximately 10am it was observed that an older toddler age child was in a highchair without the t-strap being used. The child was observed trying to climb out the top of the highchair.

Correction Required: High chairs shall have a wide base and a T-shaped safety strap.

Regulation: 3280.123(a)(3)

Description: Services proceeded

Noncompliance Area: The files for child #1 and 3 did not contain child service reports for children that have 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 § 3280.124(f).

Regulation: 3280.123(a)(6)/3280.182(2)

Description: Admission date/Application, admission, withdrawal dates

Noncompliance Area: Child #2's financial agreement did not contain the date of the child's admission.

Correction Required: An agreement shall specify the date of the child's admission. A child's record must contain the dates of application, admission and withdrawal of the child.

Regulation: 3280.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: Child #1's file did not contain 2 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.

Regulation: 3280.131(b)(2)/3280.182(1)

Description: Toddler/preschool: updated health report every 12 months/Initial and subsequent health assessments

Noncompliance Area: Child #2's, a preschool age child(See LIS Code Sheet), most recent health assessment is dated 6/20/24 which is more than 12 months ago. Child #3's, a preschool age child(See LIS Code Sheet), most recent health assessment is dated 8/20/24 which is more than 12 months ago.

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. A child's record must contain initial and subsequent health reports.

Regulation: 3280.131(d)(5)/3280.131(e)(1)

Description: Immunization record/Exemption documentation from parent/guardian

Noncompliance Area: The immunization record on file for Child #3, a preschool age child(See LIS Code Sheet), includes 4 of 4 DTAP vaccines recommended by the ACIP for a child this age; 2 of 4 HIB vaccines recommended by the ACIP for a child this age; 2 of 4 Pneumococcal vaccines recommended by the ACIP for a child this age ; and 2 of 3 Polio vaccines recommended by the ACIP for a child this age.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall require the parent to provide updated written verification from a physician, physician's assistant, CRNP, the Department of Health or a local health department of ongoing vaccines administered to an infant, toddler or preschool child in accordance with the schedule recommended by the ACIP.

Regulation: 3280.131(d)(7)

Description: Free from contagious/communicable disease

Noncompliance Area: Child #3's most recent health assessment dated 8/20/24 does not state that the child is able to participate in child care and appears to be free from contagious or communicable disease.

Correction Required: A health report shall include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease.

Regulation: 3280.14/3280.20

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: The facility was not able to produce the written policies that address: recognition of potential signs/symptoms of shaken baby syndrome and abusive head trauma, strategies for coping with a crying, fussing, or distraught child, and the prevention and identification of child maltreatment.

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children.

Regulation: 3280.14/3280.20

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: Staff person #1 was observed to be caring for children unsupervised. Staff person #1 has not completed the following pre- service training required prior to caring for children unsupervised: PA Required Health and Safety Training

Correction Required: 20 A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. Until such time as the required pre- service trainings are completed, staff person #1 must be supervised, when interacting with children at a minimum by, an primary 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: 3280.151(a)/3280.192(3)

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

Noncompliance Area: Staff #1's initial health assessment is dated 5/22/25 which is after date of hire(See LIS Code Sheet).

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 conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. 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: 3280.151(c)(2)/3280.192(3)

Description: Mantoux TB /Health assessment, TB test

Noncompliance Area: Staff #1's TB test is dated 5/22/25 which is after date of hire(See LIS Code Sheet).

Correction Required: An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department. 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: 3280.17

Description: Liability Insurance

Noncompliance Area: The facility did not have proof of Liability insurance.

Correction Required: The legal entity shall have comprehensive general liability insurance to cover all persons who are on the premises. A current copy of the insurance policy shall be on file at the facility.

Regulation: 3280.26(b)

Description: Emergency plan

Noncompliance Area: The facility did not have proof that the emergency plan has been reviewed annually.

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: 3280.26(c)

Description: Training regarding plan

Noncompliance Area: The file for staff #1 did not contain proof of initial emergency plan training within 90 days of hire. The files for staff 2 and 3 did not contain proof of annual emergency plan training.

Correction Required: The operator shall assure that each facility person receives training regarding the emergency plan at the time of initial employment, on an annual basis and at the time of each plan update. The operator shall document the date of each training and the names of all facility persons who received the training.

Regulation: 3280.32(a)

Description: Comply with CPSL

Noncompliance Area: Staff #1's mandated reporter is dated 11/12/25 which is more than 90 days after date of hire(See LIS Code Sheet).

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services).

Regulation: 3280.32(a)/3280.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file for staff #1 was observed to contain a state police clearance dated 11/10/25, child abuse clearance dated 5/5/25, DHS FBI clearance dated 5/2/25 all after the staff's date of hire(See LIS Code Sheet). Staff #2's two most recent NSOR certificates were dated 7/16/20 and 10/22/25 which are more than 60 months apart.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services).

Regulation: 3280.34(b)(5)/3280.192(2)(ii)

Description: HS/GED + 2 yrs/Exp, educ., training prior to facility

Noncompliance Area: The file for staff #1, identified as a primary staff person, did not contain proof of education.

Correction Required: A primary staff person shall have attained a high school diploma or a general educational development certificate and 2 years of experience with children. A facility person's record shall include verification of child care experience, education and training prior to service at the facility.

Regulation: 3280.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: In the infant room there was a protective outlet cover missing next to the entrance.

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

Regulation: 3280.75(c)

Description: Has all items

Noncompliance Area: The first aid kit in the book bag was missing tape.

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: 3280.77(a)

Description: No peeling paint or plaster

Noncompliance Area: In the infant room the window on the right side of the room had peeling paint along the windowsill and frame. Behind the main entrance door was a hole in the wall with exposed damaged plaster.

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

Regulation: 3280.94(a)(1)

Description: Every 60 days

Noncompliance Area: The facility did not have proof of fire drills being conducted before 10/2025.

Correction Required: Fire drills are conducted at least once every 60 days.

Regulation: 3280.95(a)/3280.95(b)

Description: FIRE DETECTION/Staff responsibility

Noncompliance Area: The facility did not have proof of fire alarm testing being conducted before 10/2025.

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 primary staff person or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in subsection (a) are met

Regulation: 3280.123(a)(3)

Description: Services proceeded

Noncompliance Area: The file for child #4, who have been enrolled for more than 6 months(See LIS Code Sheet), did not contain a child service report.

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 § 3280.124(f).

Regulation: 3280.123(a)(6)/3280.182(2)

Description: Admission date/Application, admission, withdrawal dates

Noncompliance Area: Child #2's financial agreement did not contain the date of the child's admission.

Correction Required: An agreement shall specify the date of the child's admission. A child's record must contain the dates of application, admission and withdrawal of the child.

Regulation: 3280.131(a)/3280.182(1)

Description: Health Information/Initial and subsequent health assessments

Noncompliance Area: The file for child #1, who enrolled more than 60 days ago(See LIS Code Sheet), did not contain a health assessment. Child #3's initial health assessment was dated 1/24/23 which was more than 60 days after enrollment(See LIS Code Sheet).

Correction Required: The operator shall require the parent of an enrolled child, including a child, a foster child and a relative of an operator or a facility person, to provide an initial health report no later than 60 days following the first day of attendance at the facility. A child's record must contain initial and subsequent health reports.

Regulation: 3280.131(d)(7)

Description: Free from contagious/communicable disease

Noncompliance Area: The health assessment on file for Child #4 does not indicate if the child is free from contagious disease and may participate in child care.

Correction Required: A health report shall include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease.

Regulation: 3280.14/3280.20

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: The emergency plan did not address the continuity of operations in the event of an emergency.

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children.

Regulation: 3280.14/3280.20

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: Staff person #1 and 5 was observed to be caring for children unsupervised. Staff person #1 and 5 does not have current pediatric first-aid/CPR training.

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. Until such time as the required trainings are completed, staff person #1 and 5 must be supervised, when interacting with children, by a primary staff person who has completed the required training related to this citation. If there are no staff person(s) available to supervise staff person #1 and 5, staff person #1 and 5 may not work in a child care position at the facility.

Regulation: 3280.151(a)/3280.192(3)

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

Noncompliance Area: Staff #6 two most recent health assessments are dated 4/6/21 and 9/3/24 which are more than 24 months apart.

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 conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. 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: 3280.24(a)

Description: Availability of certificate of compliance and applicable regulations

Noncompliance Area: The certificate of compliance that was posted was expired on 2/1/23.

Correction Required: The facility's current certificate of compliance shall be posted in a conspicuous location used by parents. The operator shall provide the parent of each child enrolled with information on how to access the regulations in this chapter electronically and with instructions for contacting the appropriate regional child care office.

Regulation: 3280.26(c)

Description: Training regarding plan

Noncompliance Area: Staff #2's two most recent emergency plan trainings are dated 10/1/21 and 9/16/24 which are more than 12 months apart. Staff #3's most recent emergency plan training is dated 10/21/23 which in more than 12 months prior.

Correction Required: The operator shall assure that each facility person receives training regarding the emergency plan at the time of initial employment, on an annual basis and at the time of each plan update. The operator shall document the date of each training and the names of all facility persons who received the training.

Regulation: 3280.31(e)

Description: Age and training

Noncompliance Area: Staff file #1 lacked 2 of the 12 hours of annual child care training required from 7/2023 to 7/2024. Staff file #2 lacked 7 of the 12 hours of annual child care training required from 9/2023 to 9/2024. Staff file #3 lacked 2 of the 12 hours of annual child care training required from 2/2023 to 2/2024. Staff file #6 lacked 12 of the 12 hours of annual child care training required from 12/2022 to 12/2023.

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

Regulation: 3280.31(e)(4)(i)

Description: Age and training

Noncompliance Area: Staff #3 most current pediatric CPR and first aid training is dated 10/25/22 which is more than 24 months prior. Staff #6 2 most recent pediatric CPR and first aid training are dated 3/22/21 and 1/26/24 which are more than 24 months apart.

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: 3280.31(f)

Description: Age and training

Noncompliance Area: Staff person # 1, 4, and 5 has CPR training in a non-approved curriculum and the trainer has not provided documentation that they are PQAS-certified.

Correction Required: Staff persons shall complete professional development in the topics of 3270.31(f)(10), 3280.31(f) (10), or 3290.31(g) (10) within 90 days of hire. Staff person #1, 4, and 5 must receive pediatric first-aid/CPR training in an approved curriculum by a PQAS-certified trainer. Until such time as the correction is implemented, staff person #1, 4, and 5 must be supervised, when interacting with children, by a primary staff person who has completed the required training related to this citation. If there are no staff available to supervise staff person #1, 4, and 5, staff person #1, 4, and 5 may not work in a child-care position at the facility.

Regulation: 3280.32(a)/3280.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: Staff #2 two most recent DHS FBI clearances are dated 4/11/18 and 9/3/24 which are more than 60 months apart. Staff #5 contained a Department of Aging FBI clearance which is not acceptable and did not have a receipt that they completed their DHS FBI fingerprints. Staff #5 file contained a state police clearance that did not contain a dissemination date which makes it an unacceptable clearance.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). PROVISIONAL HIRE UNSUPERVISED: A provisional employee may not be permitted to work alone with children and must work within the vicinity of a permanent employee. 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 #5 may not work in a child care position at the facility.

Regulation: 3280.35(3)/3280.192(2)(ii)

Description: 8th grade + 2 yrs/Exp, educ., training prior to facility

Noncompliance Area: The files for staff #4 and 5 did not contain verification of education.

Correction Required: A secondary staff person shall have a minimum of an 8th grade education and 2 years of experience with children. A facility person's record shall include verification of child care experience, education and training prior to service at the facility.

Regulation: 3280.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: In the main room a protective outlet cover was missing from the outlet near the printer.

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

Regulation: 3280.66(a)

Description: Locked or inaccessible - in original container

Noncompliance Area: The tall cabinet in the kitchen area was unlocked it contained bleach which stated keep out of reach of children was accessible to 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: 3280.77(a)

Description: No peeling paint or plaster

Noncompliance Area: In the infant room there was peeling paint around the window to the right.

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

Regulation: 3280.95(a)/3280.95(b)

Description: FIRE DETECTION/Staff responsibility

Noncompliance Area: The fire alarm testing log contained the following dates 10/10/24-11/20/24 which is more than 30 days apart.

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 primary staff person or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in subsection (a) are met.

Regulation: 3280.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: The Emergency Contact form, in the file for Child #1, did not contain the enrolling parent's work address.

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

Regulation: 3280.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The Emergency Contact form, in the file for Child #2, did not contain the release person's phone number.

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.

Regulation: 3280.26(c)/3280.192(2)(iii)

Description: Training regarding plan/Exp, educ., training at facility

Noncompliance Area: The files for Staff #1, Staff #2, Staff #4, and Staff #5 did not contain documentation of Emergency Plan Training in 2023, which exceeded the annual requirement.

Correction Required: The operator shall assure that each facility person receives training regarding the emergency plan at the time of initial employment, on an annual basis and at the time of each plan update. The operator shall document the date of each training and the names of all facility persons who received the training. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3280.31(e)(4)(i)/3280.192(2)(iii)

Description: Age and training/Exp, educ., training at facility

Noncompliance Area: The file for Staff #5 contained documentation of Pediatric First-Aid/CPR on 5.22.21, which has expired, and none thereafter.

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. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility. Until such time as the required trainings are completed, Staff #5 must be supervised, when interacting with child by a primary staff person who has completed the required training related to this citation. If there are no staff person(s) available to supervise Staff #5, Staff #5 may not work in a child care position at the facility.

Regulation: 3280.32(a)

Description: Comply with CPSL

Noncompliance Area: The file for Staff #3 (see IS Code Sheet) contained a State Police Clearance dated 11.26.23, with no application available, which was after the start date with children. The file for Staff #4 contained FBI Clearances dated 4.11.18 and 11.8.23, which exceeded the 60-month renewal requirement.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services).

Regulation: 3280.105(a)

Description: Clean, age appropriate

Noncompliance Area: The rest equipment was not labeled for the use of specific children.

Correction Required: Individual, clean, age-appropriate rest equipment shall be provided for preschool, toddler and infant children as agreed between the child's parent and the operator. The rest equipment shall be labeled for the use of a specific child and used only by the specified child.

Regulation: 3280.106

Description: Refrigerator

Noncompliance Area: A thermometer was not located in the refrigerator in the Infant Room.

Correction Required: A facility shall have an operable, clean refrigerator used to store potentially hazardous foods. The refrigerator shall be capable of maintaining food at 45° F or below. An operating thermometer shall be placed in the refrigerator.

Regulation: 3280.124(b)(2)

Description: Physician name, address, phone

Noncompliance Area: The Emergency Contact form, in the file for Child #3, did not contain the phone number of the physician or source of medical care.

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

Regulation: 3280.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The Emergency Contact form, in the file for Child #4, did not contain the release person's address.

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.

Regulation: 3280.124(f)/3280.181(c)

Description: Updated every 6 months/Emergency info/agreement updated 6 mos

Noncompliance Area: The files of Child #1, Child #2, Child #4, and Child #5 did not contain documentation that the parent reviewed and updated the Emergency Contact information and the Financial Agreement once in a 6-month period or as soon as there was a change in the information.

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 information. 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: 3280.131(d)(5)/3280.131(e)(1)

Description: Immunization record/Exemption documentation from parent/guardian

Noncompliance Area: The Immunization Record, in the file for Child #2, did not contain documentation of the following vaccinations in accordance with the schedule recommended by the ACIP: Rotavirus, DTAP, HIB, Pneumococcal, Polio, Influenza, MMR, Varicella, and Hepatitis A.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall require the parent to provide updated written verification from a physician, physician's assistant, CRNP, the Department of Health or a local health department of ongoing vaccines administered to an infant, toddler or preschool child in accordance with the schedule recommended by the ACIP.

Regulation: 3280.14/3280.20

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: Based on a conversation with the operator, a Shaken Baby Policy was not created or implemented.

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children.

Regulation: 3280.151(a)/3280.192(3)

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

Noncompliance Area: The file for Staff #1 (see IS Code Sheet), contained Health Assessments dated 7.20.22 & and 11.4.22, and a tuberculin skin test on 11.4.22, which exceeded the start date. The files for Staff #2 (see IS Code Sheet) and Staff #3 (see IS Code Sheet), contained a Health Assessment and tuberculin test dated 10.27.22, which exceeded the start dates. The file for Staff #5, contained Health Assessments dated 8.10.20 and 11.4.22, which exceeded the 60 -month renewal requirement.

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 conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. 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: 3280.192(2)(ii)/3280.192(2)(iv)

Description: Exp, educ., training prior to facility/Transcript, diploma and letters

Noncompliance Area: The files for Staff #1, Staff #2, and Staff #4 did not contain verification of education.

Correction Required: A facility person's record shall include verification of child care experience, education and training prior to service at the facility. A facility person's record shall include acceptable verification of experience, education or training is a transcript or a diploma or a letter signed by a representative of the experiential, educational or training entity.

Regulation: 3280.26(a)(6)

Description: Emergency plan

Noncompliance Area: Based on a conversation with the operator, an Emergency Drill had not been conducted.

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

Regulation: 3280.26(f)

Description: Emergency plan

Noncompliance Area: Documentation was not present that the Emergency Plan was sent to the local municipality and the county emergency management agency.

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: 3280.31(f)

Description: Age and training

Noncompliance Area: The files for Staff #3, Staff #4, and Staff #5 did not have documentation of the completion of the following required pre-service training within 90 days of their date of hire (see IS Code Sheet): Pediatric First Aid/CPR. The file for Staff #5 did not have documentation of the completion of the following required pre-service training within 90 days of the date of hire (see IS Code Sheet): Health & Safety Basics.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10.

Regulation: 3280.32(a)

Description: Comply with CPSL

Noncompliance Area: The files for Staff #2 and Staff #3 did not contain documentation of completion of the Mandated Reporter training within 90 days of their date of hire (see IS Code Sheet).

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services).

Regulation: 3280.32(a)/3280.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file for Staff #2 (see IS Code Sheet) contained an NSOR Clearance dated 6.27.22, and did not have proof of applying for this clearance prior to the start date. The file for Staff #3 (see IS Code Sheet) contained: State Police Clearances dated 5.1.17 and 10.27.22, which exceeded the 60-month renewal requirement, no Child Abuse Clearance, an FBI Clearance dated 4.4.17, which has expired.

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. Staff #3 may not work in a child care position at the facility.

Regulation: 3280.76

Description: Building Surfaces

Noncompliance Area: An unattached floor grate was present in the main room, creating a tripping/scraping hazard for children in care.

Correction Required: Floors, walls, ceilings and other surfaces, including the facility's outdoor play space surfaces shall be kept clean, in good repair and free from visible hazards.

Regulation: 3280.77(a)

Description: No peeling paint or plaster

Noncompliance Area: Peeling plaster/paint was present on the white wall, to the left of the window in the main room, and was accessible to children in care.

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

Regulation: 3280.32(c)

Description: Convicted or awaiting trial

Noncompliance Area: Upon a second review of the file for Staff #1, who was employed from 11.12.21 to 07.21.22, it was determined that Staff #1 should not have been employed due to felony convictions observed on the State Police clearance. These felony convictions represent crimes of physical violence or moral corruptness.

Correction Required: The operator may not allow an individual to enter the facility if the operator knows that the individual has been convicted or is awaiting trial on charges involving a crime of child abuse, child neglect, physical violence or moral corruptness.

Regulation: 3280.123(a)(4)

Description: Arrival/departure times

Noncompliance Area: The Fee Agreement in the file for Child #1 did not specify the child's departure time. The Fee Agreement in the file for Child #3 did not specify the child's arrival and departure times.

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

Regulation: 3280.123(a)(5)/3280.123(a)(6)

Description: Designated release persons/Admission date

Noncompliance Area: The Fee Agreements in the files for the five children reviewed did not specify the release persons or the dates of admission.

Correction Required: An agreement shall specify the persons designated by a parent to whom the child may be released. An agreement shall specify the date of the child's admission.

Regulation: 3280.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: The Emergency Contact Forms in the files for Child #1 and Child #5 did not include the work addresses and telephone numbers of the enrolling parent.

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

Regulation: 3280.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: The Emergency Contact Forms in the files for Child #2 and #3 did not include the insurance policy numbers.

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: 3280.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The Emergency Contact Form in the file for Child #1 did not include the name, address and telephone number of the release persons. The Emergency Contact Forms in the files for Child #4 and #5 did not include the addresses of the release persons.

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.

Regulation: 3280.124(c)

Description: Each child care space

Noncompliance Area: Emergency Contact Forms were not present in the child care spaces where children were receiving care.

Correction Required: When children are in the facility, emergency contact information shall be present in a child care space for children receiving care in the space.

Regulation: 3280.124(e)

Description: Written emergency plan posted

Noncompliance Area: The Emergency Transportation Plan was not posted in the Infant Room.

Correction Required: A written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency shall be displayed conspicuously in every child care space and shall accompany a staff person who leaves on an excursion with children.

Regulation: 3280.171(a)

Description: Pick up and drop off points

Noncompliance Area: The operator had not notified local traffic safety authorities in writing of the location of the facility and about the program's use of pedestrian and vehicular routes around the group child care facility.

Correction Required: The operator shall notify local traffic safety authorities in writing of the location of the facility and about the program's use of pedestrian and vehicular routes around the group child care facility.

Regulation: 3280.171(c)

Description: Safe routes posted

Noncompliance Area: Safe routes (pickup and drop-off procedures) were not posted at the facility.

Correction Required: Written notification of safe routes shall be posted by the operator at a conspicuous location in the child care facility.

Regulation: 3280.182(3)/3280.182(5)

Description: Consent for emergency medical care required prior to admission/Consent for administration of minor first-aid required prior to admission

Noncompliance Area: The Emergency Contact Form in the file for Child #4 did not contain signed parental consent for emergency medical care for the child or signed parental consent for administration of minor first-aid procedures by facility staff.

Correction Required: A child's record must contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission. A child's record must contain signed parental consent for administration of minor first-aid procedures by facility staff. Written consent is required prior to admission.

Regulation: 3280.182(8)

Description: Copy of initial and subsequent agreements. Parent receives original.

Noncompliance Area: The fee agreements in the files for the five children reviewed were the original agreements.

Correction Required: 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.

Regulation: 3280.192(2)(ii)/3280.192(2)(iv)

Description: Exp, educ., training prior to facility/Transcript, diploma and letters

Noncompliance Area: The file for Staff Person #2 did not include verification of education and child care experience.

Correction Required: A facility person's record shall include verification of child care experience, education and training prior to service at the facility. A facility person's record shall include acceptable verification of experience, education or training is a transcript or a diploma or a letter signed by a representative of the experiential, educational or training entity.

Regulation: 3280.32(a)/3280.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file for Staff Person #1 did not include an FBI Clearance. The file for Staff Person #1 also lacked out of state clearances for Washington and West Virginia, where Staff Person #1 has lived during the past five years.

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: 3280.75(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: 3280.77(a)

Description: No peeling paint or plaster

Noncompliance Area: Observed damaged paint/plaster in the following areas: Peeling paint on the wall behind the toilet in the bathroom. Damaged plaster on the wall of the main room by the smoke detector and on the ceiling in the hall by the smoke detector.

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

Regulation: 3280.94(a)(4)

Description: Hypothetical locations

Noncompliance Area: The evacuation point, rather than the hypothetical location, was listed as the hypothetical location on the fire drill log.

Correction Required: The primary staff person or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that the hypothetical locations of the fire are rotated around the facility for each drill such that the hypothetical location is never the same for consecutive drills.

Regulation: 3280.26(a)(5)

Description: Emergency plan

Noncompliance Area: The facility's emergency plan does not provide for accommodations for infants, toddlers, children with disabilities and children with chronic medical conditions.

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

Regulation: 3280.26(e)

Description: Letter to parents

Noncompliance Area: The letter to be provided to parents explaining the emergency procedures did not include the procedures for a lockdown.

Correction Required: The operator shall provide to the parent of each enrolled child a letter explaining the emergency procedures. The operator shall also provide to the parent of each enrolled child a letter explaining any subsequent update to the plan.

Regulation: 3280.32(a)

Description: Comply with CPSL

Noncompliance Area: There was no signed disclosure statement on file for Facility Person #1.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services).

Regulation: 3280.61(e)

Description: Halls, etc. not included

Noncompliance Area: The main room to be used for child care included a gated off kitchen area at one end that included a stove.

Correction Required: Measured indoor space excludes space occupied by halls, bathrooms, offices, kitchens and locker rooms.

Regulation: 3280.95(a)/3280.95(b)

Description: FIRE DETECTION/Staff responsibility

Noncompliance Area: The operator did not have on file proof of purchase for the interconnect smoke detectors.

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

Regulation: 3280.95(a)/3280.95(b)

Description: FIRE DETECTION/Staff responsibility

Noncompliance Area: Two of the smoke detectors at the facility were not interconnected with the other three smoke detectors.

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