Donegal Primary School

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: The record for staff person #1 included just one written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person. A second reference was on file, but it was from a relative.

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: 3270.36(b)/3270.192(2)(ii)

Description: Assistant Group Supervisor qualifications/Exp, educ., training prior to facility

Noncompliance Area: Staff person #1 serves as an assistant group supervisor at the facility. The staff person's record included documentation of a high school diploma, but did not include documentation of 2,500 hours of child care experience. Documentation of babysitting was on file, but it was from when the staff person was under 16 and still a child.

Correction Required: An assistant group supervisor shall have attained one of the qualification levels specified at § 3270.36(b)(1-5). (1) A high school diploma or a general educational development certificate and 30 credit hours from an accredited college or university in early childhood education, child development, special education, elementary education or the human services field. (2) A high school diploma or a general educational development certificate, including 600 or more hours of secondary training described in § 3270.31(c) (relating to age and training). (3) A high school diploma or a general educational development certificate, 15 credit hours from an accredited college or university in early childhood education, child development, special education, elementary education or the human services field and 1 year of experience with children. (4) A high school diploma or a general education development certificate and completion of a post-secondary training curriculum described in § 3270.31(c). (5) A high school diploma or a general educational development certificate and 2 years 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: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: A liner was not available in the lidded trash can, which contained trash.

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: 3270.75(c)

Description: Has all items

Noncompliance Area: Scissors were not available in the first aid kit. Corrected on site by adding scissors to the 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.

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: At the time of inspection, release person addresses were missing for child #1 and child #2

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: 3270.124(e)

Description: Written emergency plan posted

Noncompliance Area: At the time of the inspection, the transportation plan was not posted in the gym, which is the main area where the afterschool program operates for children in grades 1 & 2.

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: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: At the time of inspection, documentation of emergency plan training for Staff #1 at the time of initial employment was not available.

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 and kept on file at the facility.

Regulation: 3270.133(4)

Description: Locked

Noncompliance Area: At the time of the renewal inspection follow up visit to verify corrections, the plan of corrections for the violation citing 3270.133.4 on SIN-00251413 had not been fully implemented. On 10/25/24, an unlocked medication bag was observed to be stored in a backpack within reach of children. (CORRECTED ON SITE)

Correction Required: Medication shall be stored in a locked area of the facility or in an area that is out of the reach of children.

Regulation: 3270.123(a)(6)

Description: Admission date

Noncompliance Area: The agreement on file for child 1 did not specify the date of the child's admission.

Correction Required: An agreement shall specify the date of the child's admission.

Regulation: 3270.124(b)(2)/3270.124(b)(7)

Description: Physician name, address, phone/Name/address/phone release person

Noncompliance Area: The emergency contact forms on file for children 1, 2 and 3 did not include complete contact information for the following information: Child 1 - The emergency contact form did not include an address for the child's physician or source of medical care. The form also did not include an address for a listed release person. Child 2 - The emergency contact form did not include a phone number for a listed release person. Child 3 - The emergency contact form did not include an address for the child's physician or source of medical care. The form also did not include an address for a listed release person.

Correction Required: Emergency contact information must include the name, address and telephone number of the child's physician or source of medical care. 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: 3270.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: The emergency contact information on file for child 1 did not include 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.

Regulation: 3270.124(c)

Description: Each child care space

Noncompliance Area: Emergency contact forms were not present with the group in the gym.

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: 3270.133(4)

Description: Locked

Noncompliance Area: Medications (inhalers, epi-pens, liquid allergy medicine) were stored in a backpack within reach of the children. The medications were individually stored in bags that could lock, but they were all unlocked.

Correction Required: Medication shall be stored in a locked area of the facility or in an area that is out of the reach of children.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: Staff person #7 has been employed with the company for over two years. The staff person's record did not include documentation that the 1-hour Pennsylvania health and safety update training had been completed. The old 10-hour training was on file.

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations. Conditions at the facility may not pose a threat to the health or safety of the children.

Regulation: 3270.152

Description: Adult Hygiene

Noncompliance Area: A staff person was observed using gloves in-lieu of handwashing when preparing breakfast for children.

Correction Required: A facility person shall wash his hands before meals and snacks, and after toileting and after diapering a child.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: The record for staff person 3 included just one written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

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: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: According to documentation on file at the time of inspection, staff person #5 was trained on the emergency plan in October of 2022, and then more than a year later in September of 2024. According to documentation on file at the time of inspection, staff person #6 was trained on the emergency plan in June of 2023, and then more than a year later in September of 2024. According to documentation on file at the time of inspection, staff person #7 was trained on the emergency plan in January of 2023, and then more than a year later in September of 2024.

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 and kept on file at the facility.

Regulation: 3270.31(e)(4)(i)

Description: Age and Training

Noncompliance Area: Staff person #7's pediatric first aid and CPR training expired in August of 2022. An updated training was 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.

Regulation: 3270.31(e)(4)(ii)

Description: Fire safety - 1 yr.

Noncompliance Area: Staff person #7 has been employed for more than 12 months. The staff person's record did not include documentation of having received fire safety training.

Correction Required: Staff persons shall participate, at least annually, in firesafety training conducted by a fire protection professional. Staff persons and volunteers shall receive training in maintenance of smoke detectors, the duties of facility persons during a fire drill and during a fire and the use of the facility's fire extinguishers, not including discharge of the fire suppressant agent.

Regulation: 3270.31(e)/3270.192(2)(iii)

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

Noncompliance Area: The record for staff person #7 did not include 12 clock hours of annual training from the previous year.

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 verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person 1 did not complete the 10 hour health and safety training (topics (f)1-9) within 90 days of hire. The training was dated 206 days after the date of hire. Staff person 3 did not complete Pediatric first aid and CPR training (topic (f)10) within 90 days of hire. The only training on file was dated 14 months after the staff person's start date.

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

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: According to documentation on file at the time of inspection, staff person 1 worked beyond a 45 day provisional hire period with incomplete clearances on file. The sole NSOR on file was dated 310 days after start date. The record for staff person 2 did not include a completed disclosure statement (not signed by a witness). Staff person #4's mandated reporter training expired 9/16/24, but was not updated until 9/21/24. Staff person #4's DHS FBI clearance expired 9/16/24, but was not updated until 9/19/24.

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

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: Staff person #3's 1st written staff evaluation was due in May of 2024. The only staff evaluation on file was dated in August of 2024. The record for staff person #7 did not include a written evaluation of the staff person. The staff person has been employed by the company for more than a year.

Correction Required: A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months.

Regulation: 3270.36(b)(3)/3270.192(2)(ii)

Description: HS/GED, 15 credits + 1 yr/Exp, educ., training prior to facility

Noncompliance Area: Staff person 2 is serving as an assistant group supervisor at the facility. The staff person's record includes documentation of 15 credit hours in the fields listed. The record includes documentation of 865 hours of child care experience, short of the 1,250 hours (1 year) needed.

Correction Required: An assistant group supervisor shall have a high school diploma or a general educational development certificate, 15 credit hours from an accredited college or university in early childhood education, child development, special education, elementary education or the human services field and 1 year 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: 3270.51

Description: Similar Age Level

Noncompliance Area: Thirty young school-age children were present in the childcare room with 2 staff. A 3rd staff person was out in the hallway watching children walk down to the restroom. The third staff person was standing approximately 8-10 feet from the doorway and was unable to supervise the children in the room.

Correction Required: When children are grouped in similar age levels, the following maximum child group sizes and ratios of staff persons apply: Young school-age children 1:12 with a maximum group size of 24.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: Staff person #1 was caring for children unsupervised on 9/14/24 when the child fell and received an injury. At the time of inspection, the facility did not have documentation on file showing that staff person #1 had completed the following pre-service training required prior to caring for children unsupervised: Pediatric first aid and CPR.

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations. 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, by an AGS who has completed the required training related to this citation. 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: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: According to documentation on file at the time of inspection, when staff person #1 began working with children at the facility the staff record did not contain a completed employment child abuse clearance as required under the CPSL. The clearance was dated 10 days after the person's first day working with children. In addition, staff person #1 worked alone with a group of children on 9/4/24 without complete clearances on file. A volunteer child abuse clearance was on file, in lieu of the required employment clearance.

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

Regulation: 3270.113(a)/3270.113(a)(1)

Description: Supervised at all times /Staff assigned to specific children

Noncompliance Area: Staff #1 and #2 left a child outside on the playground for approximately 5-6 minutes. During this time, the child was alone and unsupervised.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Children must be supervised at all times. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

Regulation: 3270.113(a)/3270.113(a)(1)

Description: Supervised at all times /Staff assigned to specific children

Noncompliance Area: Staff #1 and #2 left a child outside on the playground for approximately 5-6 minutes. During this time, the child was alone and unsupervised.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. The legal entity must arrange for all facility staff to receive a minimum of two hours of training regarding supervision of children. The legal entity must receive DHS approval of the training content prior to scheduling the training. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

Regulation: 3270.113(a)/3270.113(a)(1)

Description: Supervised at all times /Staff assigned to specific children

Noncompliance Area: Staff #1 and #2 left a child outside on the playground for approximately 5-6 minutes. During this time, the child was alone and unsupervised.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. The legal entity must submit documentation in a format approved by DHS proving that the facility procedure for counting children is followed at all times e.g., a checklist. The legal entity will confirm continuing compliance by sending copies of the documentation to the Regional Office of Child Development and Early Learning on a weekly basis for a period of three months after DHS approves the documentation format. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: Staff did not have assigned supervision groups during the before school program. Staff were asked to identify the names of the children in their group and reported that they did not have supervision groups int he morning.

Correction Required: Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: Staff #1 had a child abuse clearance dated 6/4/18 and did not have an updated clearance on file. Staff #1 may not be on the facility premises until clearance is obtained.

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 be on the facility premises until clearance is obtained and on file.

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: The agreement on file for child 2 did not specify the services to be provided to the family and the child. (CORRECTED ON SITE)

Correction Required: An agreement signed by the operator and the parent must specify the following: 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 in § 3270.124(f) (relating to emergency contact information).

Regulation: 3270.124(b)(3)/3270.124(b)(7)

Description: Parent home/work address, phone/Name/address/phone release person

Noncompliance Area: The emergency contact information on file for child 1 did not include a complete address for the enrolling parent's work address, nor for 2 of the listed release persons. (CORRECTED ON SITE)

Correction Required: Emergency contact information must include the home and work addresses and telephone numbers of the enrolling parent. 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: 3270.151(c)(3)/3270.151(c)(5)

Description: Exam communicable disease/Physician/CRNP assessment

Noncompliance Area: The adult health assessment on file for staff person 2 did not include an examination for communicable diseases and the results of that examination. The health assessment also did not include the physician's or CRNP's assessment of the person's suitability to provide child care.

Correction Required: An adult health assessment must include an examination for communicable diseases and the results of that examination. An adult health assessment must include the physician's or CRNP's assessment of the person's suitability to provide child care.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: The record for staff person 1 did not include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

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: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: Staff person 1 did not have a signed disclosure statement on file prior to working with children. The disclosure on file was signed/dated 23 days after start date.

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

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: Staff person 2 has been employed for more than 12 months and did not have a completed staff evaluation on file.

Correction Required: A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months.

Regulation: 3270.34(c)/3270.241(c)(1)(iii)

Description: Employed and present 30 hrs/wk/46 or more hours a week, director or director/GS present as described at §3270.34(c) and (d).

Noncompliance Area: At the time of inspection on 12/2/22, the director was not present at the facility site at least 30 hours per week.

Correction Required: A director shall be employed by a facility and be present at the facility site a minimum of 30 hours per week. In a program operating 46 or more hours a week, a director or director/group supervisor shall be present at a facility site as described at §3270.34(c) and (d).