St Lukes Hospital Grand View Campus

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: On 6/25/26, at time of renewal, Staff #1 file did not contain two letters of written references.

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

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

Noncompliance Area: Continued noncompliance from inspection conducted on 2/3/26: On 2/20/26, at time of inspection, Child #1 was observed unsupervised asleep on a rest mat on the floor in the back half of the infant room, positioned in the corner directly behind a half wall. Child #2 was also observed unsupervised asleep in a crib behind a half wall. Staff #1 and Staff #2 were located in the front half of the room, preventing proper supervision of Child #1 and Child #2.

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. 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: On 2/3/26, at time of inspection, an infant was observed asleep on a rest mat on the floor in the back half of the infant room, positioned behind a half wall, while Staff #2, #3 and #4 were located in the front half of the room, preventing proper supervision of the infant. Additionally, the staff in Room 5 and Room 6 were not able to identify the children assigned to their group for the purpose of supervision.

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. 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: 3270.133(4)

Description: Locked

Noncompliance Area: On 2/3/26, at time of inspection, medication (inhaler) was observed accessible to children in an open backpack located in the older toddler room.

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: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: On 2/3/26, at time of inspection, Staff #1 file contained a PA Criminal clearance and NSOR clearance dated more than 60 months. The PA Criminal clearance was dated 10/10/19 and the NSOR clearance was dated 9/1/20.

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: 3270.82(i)

Description: Lidded waste receptacles

Noncompliance Area: On 2/3/26, at time of inspection, lidded waste receptacles were not observed by the toilet/sink area located in the K room and PS rooms.

Correction Required: A toilet area, training chair area, diapering area and sink area shall be equipped with a clean, lidded waste receptacle.

Regulation: 3270.91(a)

Description: Stairs, exits, etc. unobstructed

Noncompliance Area: On 2/3/26, at time of inspection, the exit door located in the back of the facility was obstructed by snow and not able to be opened in case of emergency.

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

Regulation: 3270.94(a)(1)/3270.94(a)(9)

Description: Every 60 days/Written record

Noncompliance Area: On 2/3/26, upon review of the fire drill log, the last fire drill conducted at the facility was dated 10/7/25.

Correction Required: The Director or designated staff person who is responsible for compliance with this chapter ensure fire drills are conducted at least once every 60 days. The Director or designated staff person who is responsible for compliance with this chapter ensure 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: 3270.95(a)/3270.95(b)

Description: Devices must be compliant/Director or designated staff person ensure compliance

Noncompliance Area: On 2/3/26, the fire alarm was not tested at least every 30 days as required by Panic and Fire Act 82. The last test was dated 10/7/25.

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

Regulation: 3270.131(d)(6)/3270.133(1)

Description: Diagnosis and treatment for emergency/Original container

Noncompliance Area: On 6/26/25, at time of inspection, the EpiPens belonging to Child #1 and Child #2 were not stored in the original box. A prescription was not on file for Child #1 EpiPen. Additionally, medical action plans pertinent to diagnosis and treatment in case of emergency were not on file for Child #1, Child #2 and Child #3.

Correction Required: A health report shall include a statement of the child's medical information pertinent to diagnosis and treatment in case of emergency. A prescription or nonprescription medication may be accepted only in an original container. The medication shall remain in the container in which it was received.

Regulation: 3270.133(5)

Description: Original label

Noncompliance Area: On 6/26/25, at time of inspection, the EpiPen belonging to Child #1 was expired.

Correction Required: Medication shall be stored in accordance with the manufacturer's or health professional's instructions on the original label.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: On 6/26/25, at time of inspection, Facility person #1 file did not contain a NSOR clearance as required by CPSL. Additionally, facility person #2 file did not contain a PA Criminal Clearance and NSOR clearance dated within 60 months as required by CPSL. The PA Criminal clearance was dated 10/9/19 and the NSOR clearance was dated 4/30/20.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Facility Person # 1 and #2- may not work in a child care position at the facility.

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: On 7/16/24, at time of renewal, 5 PS children were observed with Individual #1 unsupervised by a staff person while participating in "gym instruction" in the first room on the right.

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.

Regulation: 3270.133(5)

Description: Original label

Noncompliance Area: On 7/16/24, at time of renewal, the EpiPen belonging to Child #2 was expired (6/2024).

Correction Required: Medication shall be stored in accordance with the manufacturer's or health professional's instructions on the original label.

Regulation: 3270.31(f)/3270.31(f)(10)

Description: Health and Safety Training/Health and Safety Training - Pediatric First Aid and CPR

Noncompliance Area: On 7/16/24, at time of renewal, Staff person #1 and #2 have not completed the following required pre-service training within 90 days of their date of hire: Pediatric First Aid/CPR. Additionally, Staff person #3 have not completed the following required pre-service training within 90 days of their date of hire: Health & Safety Training.

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

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: On 7/16/24, at time of renewal, Staff #4 and Staff #5 FBI clearance were expired. The FBI clearance in Staff #4 file was dated 5/18/19. The FBI clearance in Staff #5 file was dated 6/28/17.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). SAFETY PLAN: The operator is required to submit to the Children and Youth Agency a plan of supervision or alternate arrangement as required by the Child Protective Services Law. LACKING REQUIRED HIRING DOCUMENTS: Facility Person # -- may not work in a child care position at the facility. 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.

Regulation: 3270.61

Description: Measurement and use of indoor child care space

Noncompliance Area: On 7/16/24, at time of renewal, children were observed participating in "gym instruction" in a room not measured for the use of childcare or indoor play space. Staff #6 stated that the room is used by children on rainy days.

Correction Required: Measurement and use of inodoor child care space.

Regulation: 3270.123(a)(5)

Description: Designated release persons

Noncompliance Area: During renewal inspection certification rep reviewed children's files. Fee agreement for child 4 did not the persons designated by a parent to whom the child may be released.

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

Regulation: 3270.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: During renewal inspection certification rep reviewed child Files. Child 2 was missing 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(b)(7)

Description: Name/address/phone release person

Noncompliance Area: During renewal inspection certification rep reviewed children's file. Emergency contact for child 1 was missing the full address of the individual 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: 3270.131(d)(5)/3270.131(e)(3)

Description: Immunization record/Dismissal policy

Noncompliance Area: During renewal inspection certification rep reviewed children's file. The file of child 3, 5,6,7 and 8 were enrolled more than 60 days at the facility, did not contain documentation of an influenza vaccination within the past year, as required per the ACIP recommended schedule.

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: 3270.192(5)

Description: Two written references

Noncompliance Area: During renewal inspection certification rep reviewed staff files. Staff 1 had one reference from a family member in their file.

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)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During renewal inspection certification rep reviewed staff files. Staff 1 was missing child abuse clearance from her file.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). SAFETY PLAN: The operator is required to submit to the Children and Youth Agency a plan of supervision or alternate arrangement as required by the Child Protective Services Law. LACKING REQUIRED HIRING DOCUMENTS: Facility Person # -1- may not work in a child care position at the facility. 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 #-1-- may not work in a child care position at the facility.

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: During renewal inspection certification rep observed soft mat with fringes exposing the foam

Correction Required: Toys, play equipment and other indoor and outdoor equipment used by the children shall be clean, in good repair and free from rough edges, sharp corners, pinch and crush points, splinters and exposed bolts.

Regulation: 3270.133(6)/3270.133(7)

Description: Written consent/Medication log

Noncompliance Area: During renewal inspection, certification rep reviewed medications for child 1. Child 1 did not have written consent for administration of medication completed or medication log signed by the parent

Correction Required: A parent shall provide written consent for administration of medication or a special diet. An operator is responsible to establish and maintain a medication log if prescription or nonprescription medication is administered.

Regulation: 3270.27(a)(6)

Description: Emergency plan

Noncompliance Area: During renewal inspection certification rep asked to see the emergency drill log. Provider did not have an emergency drill documented.

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

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: During renewal inspection, certification rep observed disinfectant wipes and disinfectant spray in an area accessible to children in classrooms 2

Correction Required: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During renewal inspection on 8/23/21, while reviewing staff files, Staff # 26 whose hire date 4/13/21 did not have NSOR clearance and a rap sheet attached to the FBI

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Facility Person # --26 may not work in a child care position at the facility. 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 #---26 may not work in a child care position at the facility.