Susan E Mcgivern Family Child Care Home

Regulation: 3290.106

Description: Refrigerator

Noncompliance Area: The thermometer placed in the refrigerator storing potentially hazardous foods was observed showing temperatures well below freezing while no items in the refrigerator were frozen. The thermometer was taken out and put back into the refrigerator and observed a second time still showing temperatures below freezing. With the thermometer, it was not possible to determine if the refrigerator was maintaining food at a temperature of 45 degrees or below.

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: 3290.114

Description: Outdoor Activity

Noncompliance Area: During the entirety of the visit, the weather was appropriate for outdoor play, and the children were never taken out of doors. Staff indicated that the children do not go out doors daily.

Correction Required: Weather permitting, children shall be taken out doors daily.

Regulation: 3290.121(a)

Description: Review policies and procedures

Noncompliance Area: Written health policies and supervision policies did not include policies addressing recognition of potential signs/symptoms of shaken baby syndrome and abusive head trauma, strategies for coping with a crying, fussing, or distraught child, or the prevention and identification of child maltreatment.

Correction Required: The operator shall review with the parent, at the time of application, the facility's general daily schedule, hours for which care is provided, fees, responsibilities for meals, clothing, health policies, supervision policies, night care policies, dismissal policies, transportation and pick-up arrangements.

Regulation: 3290.123(a)(3)

Description: Services provided

Noncompliance Area: Child #4's file contained no department approved Child Service Report form with information about the child's growth and development in the context of the services being provided. Child #4 has a date of admission of 08/26/2024 and has been enrolled more than 6 months at the date of inspection.

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

Regulation: 3290.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: Emergency contact information for child #5 was missing the work address and work phone number of the enrolling parent.

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

Regulation: 3290.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: Emergency contact information for child #5 did not include the health insurance coverage, 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: 3290.124(e)

Description: Updated every 6 months

Noncompliance Area: There was no written evidence of a parent update of emergency contact information once in a 6-month period or as soon as there is a change in the information observed in the files for child #1, #2, or #4.

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.

Regulation: 3290.131(d)(1)

Description: Child's health history

Noncompliance Area: There was no health report including a review of the child's health history observable for child #5.

Correction Required: A health report shall include a review of the child's health history.

Regulation: 3290.18

Description: General Health and Safety

Noncompliance Area: Children have access to the kitchen where there is a gas stove with the gas dials able to be turned on.

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

Regulation: 3290.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: There was no evidence of a parent review or update the financial agreement at least once in a 6-month period or as soon as there is a change in the information for child #1, #2, and #4.

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

Regulation: 3290.24(a)(5)

Description: Emergency plan

Noncompliance Area: The facility emergency plan letter to parents did not include provisions for accommodations of infants and toddlers, children with disabilities, and children with chronic medical conditions.

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

Regulation: 3290.74(a)/3290.75(a)

Description: Requirements/No peeling paint or plaster

Noncompliance Area: Peeling paint was observed on the outdoor deck railings and floor of the deck that is intended to be used as child care outdoor play space. Additionally, one of the corners of the deck railing was observed to contain rotting wood.

Correction Required: Floors, walls, ceilings and other surfaces, including the facility's outdoor play area, shall be kept clean, in good repair and free from visible hazards. Peeled or damaged paint or damaged plaster is not permitted on indoor or outdoor surfaces in the child care facility.

Regulation: 3290.94(a)(5)

Description: Evacuation routes posted

Noncompliance Area: No evacuation routes were posted in a conspicuous location on the lower level of the facility.

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

Regulation: 3290.105(a)

Description: Clean, age appropriate

Noncompliance Area: A pack 'n play was not labeled with the name of the child for whom it was intended.

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

Regulation: 3290.123(a)

Description: Signed

Noncompliance Area: The financial agreement of child #2 was not signed by the operator.

Correction Required: An agreement shall be signed by the operator and the parent.

Regulation: 3290.123(a)(3)

Description: Services provided

Noncompliance Area: Documentation of the last completed child service report of #1 was dated 9/22/2022 and child #4 was dated 9/21/2022, lacking documentation of child service reports completed every 6 months since. Child #5 enrolled for more than 6 months (see LIS code sheet) did not contain documentation of 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 § 3290.124(e).

Regulation: 3290.123(a)(6)

Description: Admission date

Noncompliance Area: The financial agreements of child #2 and #5 did not contain their dates of admission.

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

Regulation: 3290.123(b)

Description: Parent receives original

Noncompliance Area: The file of child #2 contained the original financial agreement.

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

Regulation: 3290.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: The emergency contact form of child #3 did not contain the work address of the enrolling parent.

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

Regulation: 3290.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The emergency contact form of child #2 did not contain a telephone number of a person 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: 3290.131(b)(2)/3290.182(1)

Description: Updated toddler/preschool health report: every 12 months/Initial and subsequent health assessments

Noncompliance Area: The file of child #1 and #2, both identified as preschool age children (see coded LIS sheet), contained documentation of health assessments which were updated more than 12 months apart.

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: 3290.135(b)

Description: Surfaces cleaned

Noncompliance Area: The changing mat used to change a child's diapers was not sanitized prior to changing another child.

Correction Required: Diaper changing surfaces shall be cleaned after each use by wiping the surface with a sanitizing solution or by changing a pad or other surface covering.

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

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

Noncompliance Area: The file of staff #1 did not contain a current health assessment within the past 24 months with the last being dated 12/13/2021.

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

Regulation: 3290.166(4)

Description: Bottles labeled

Noncompliance Area: In the refrigerator, 3 bags of infant breast milk were in the kitchen refrigerator and not labeld with the name of the child for which they are intended.

Correction Required: Disposable nursers and bottles shall be labeled with the child's name.

Regulation: 3290.18

Description: General Health and Safety

Noncompliance Area: The emergency plan did not include a continuity of operations plan which may include, backing up or retrieving health and other key records/files and managing financial issues such as paying employees and bills during the aftermath of the disaster.

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

Regulation: 3290.181(c)/3290.181(d)

Description: Emergency info/agreement updated 6 mos/Dated signature affixed

Noncompliance Area: Based on the signed and dated forms, the emergency contact forms and financial agreements of child #4 and #5 were updated more than 6 months apart.

Correction Required: A parent is required to review and update the emergency contact information and the financial agreement at least once in a 6-month period or as soon as there is a change in the information. Following review, a parent shall attest to the accuracy of information in the emergency contact information and the financial agreement at each review by affixing a dated signature to the record.

Regulation: 3290.182(8)

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

Noncompliance Area: The file of child #3 did not contain a financial agreement.

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: 3290.24(b)

Description: Emergency plan

Noncompliance Area: The last documentation of a review and/or update to the facilities emergency plan was dated 9/2021, lacking documentation of a review and/or update in the past 12 months.

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

Regulation: 3290.24(d)

Description: Emergency plan

Noncompliance Area: The facility did not have documentation of an emergency drill conducted in the last 12 months.

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

Regulation: 3290.31(f)/3290.192(4)

Description: Age and training/Required training

Noncompliance Area: The file of staff #1 contained documentation of 1 hour of professional development during their annual training period between 12/2022 and 12/2023, lacking 11 hours.

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

Regulation: 3290.64(a)

Description: Locked or inaccessible - in original container

Noncompliance Area: A & D Ointment labeled "keep out of the reach of children" was on a desk in the family room 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: 3290.95(a)/3290.95(b)

Description: System in compliance/Operator or designated staff responsibility

Noncompliance Area: Based on documentation on the fire drill log, the testing of the fire detection system exceeded 30 days on the following occasions: 12/30/2023 to 1/30/2024 to 3/1/2024 to 4/1/2024 and 6/28/2024 to 8/25/2024.

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

Regulation: 3290.102(a)

Description: Clean and good repair

Noncompliance Area: In the basement child care space, there was a small circular trampoline that was on the back of the couch with the legs sticking out from the wall on the top of the couch that was a visible hazard.

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: 3290.113(a)

Description: Supervised at all times

Noncompliance Area: At approximately 9:50 a.m. upon entry to the facility on the 1st floor, staff person #1 was observed walking up from the basement and stated that there was one child, an infant, that was sleeping alone in a pack 'n play without staff supervision in the dining room on the 1st floor. When the staff person walked upstairs to get the infant that was sleeping in the dining room, there were three children, two young toddlers and an older toddler, that were left alone for approximately 30 seconds in the basement until staff person #1 returned with the infant.

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 requirement for supervision on and off the facility premises includes compliance with the staff:child ratio requirements in §§ 3290.51-3290.52 (relating to maximum number of children; and staff:child ratio).

Regulation: 3290.123(a)(3)

Description: Services provided

Noncompliance Area: Child #1 and #2 lacked current child service reports updated within the last 6 months.

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

Regulation: 3290.123(a)(5)

Description: Designated release persons

Noncompliance Area: The files for child #3 and #4 had an agreement that lacked 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: 3290.123(a)(6)

Description: Admission date

Noncompliance Area: The files for child #1, #2, #3, #4, and #5 had an agreement that lacked the date of the child's admission.

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

Regulation: 3290.124(b)(1)

Description: Child's name, birth date

Noncompliance Area: The file for child #2 had an emergency contact form that lacked the child's birthdate.

Correction Required: Emergency contact information must include the name and birth date of the child.

Regulation: 3290.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The file for child #2 had an emergency contact form that lacked the 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: 3290.131(b)(2)/3290.182(1)

Description: Updated toddler/preschool health report: every 12 months/Initial and subsequent health assessments

Noncompliance Area: The file for child #2, a preschooler, had a health assessment that exceeded 12 months between assessments.

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

Description: Immunization record/Dismissal policy

Noncompliance Area: The file for child #1, a 22 month old, had an immunization record that lacked verification of the Influenza vaccination being administered within the last calendar year in accordance with the schedule recommended by the ACIP and lacked exemption documentation. The file for child #1, a 22 month old, had an immunization record that lacked documentation of the 4th dose of the DTAP vaccination by age 18 months being administered in accordance with the schedule recommended by the ACIP and lacked exemption documentation.

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). Child #1 must be dismissed from care by close of business on 9-28-23 and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

Regulation: 3290.18

Description: General Health and Safety

Noncompliance Area: Staff person #1, with health and safety training completed prior to 10-4-22, had the Pennsylvania Health and Safety Update 2022 Training dated 1-21-23 that was not completed by 12-30-22 as required.

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

Regulation: 3290.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: The files for child #1 and #2 lacked a current emergency contact form and agreement updated within the last 6 months.

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

Regulation: 3290.182(3)/3290.182(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 file for child #4 had an emergency contact form that lacked signed parental consent for emergency medical care for the child and 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: 3290.192(3)

Description: CPSL information

Noncompliance Area: The file for staff person #1 lacked a copy of the current state police and child abuse clearances.

Correction Required: 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.

Regulation: 3290.31(f)

Description: Age and training

Noncompliance Area: The file for staff person #1 had 10 of the 12 required child care training hours that were not completed within the last year.

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

Regulation: 3290.74(a)

Description: Requirements

Noncompliance Area: On the back porch, there were multiple poles on the ground for an awning that had sharp edges and metal pieces protruding out from the poles that were a visible hazard.

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

Regulation: 3290.94(a)(1)

Description: Every 60 days

Noncompliance Area: According to the fire drill log, a fire drill was not conducted at least once within the last 60 days with the last fire drill being conducted on 7-6-23.

Correction Required: The operator or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that fire drills are conducted at least once every 60 days.

Regulation: 3290.95(a)/3290.95(b)

Description: System in compliance/Operator or designated staff responsibility

Noncompliance Area: During the renewal inspection on 9-28-23, there were three smoke detectors that the operator identified as interconnected smoke detectors, with one detector each on the 2nd floor, 1st floor, and basement. The smoke detectors were not functioning as an interconnected fire detection system as required. The smoke detectors on the 1st and 2nd floors were observed to be operating as interconnected detectors, however the smoke detector in the basement was not sounding and operating as interconnected with the other two detectors. The smoke detector in the basement was observed to audibly sound and operate as a stand-alone detector. The operator stated that the basement detector had previously been interconnected with the other two detectors. According to the log, the operator did not manually test the interconnected fire detection system in the facility at least once within the last 30 days with the last test being conducted on 8-2-23.

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

Regulation: 3290.124(b)(2)

Description: Physician name, address, phone

Noncompliance Area: The file for child #3 had an emergency contact form that lacked the telephone number of the child's physician.

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

Regulation: 3290.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: The file for child #3 had an emergency contact form that lacked the name of the health insurance and the 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: 3290.131(e)(1)/3290.182(1)

Description: Parent written verification from Doctor./Initial and subsequent health assessments

Noncompliance Area: The file for child #1, a 3 year old, and child #2, a 3 year old, had an immunization record that lacked verification of the Influenza vaccination being administered within the last calendar year in accordance with the schedule recommended by the ACIP and lacked exemption documentation.

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

Regulation: 3290.134(b)/3290.134(c)

Description: Towels labeled and laundered/Paper towels discarded

Noncompliance Area: In the downstairs bathroom, according to the provider, after washing their hands the children were using the same cloth towels to dry their hands. There were no paper towels observed in the bathroom.

Correction Required: Cloth towels and washcloths shall be labeled with the child's name, used by only the named child and laundered weekly. The operator shall arrange a laundry schedule with the parent. Paper towels may be used as towels and washcloths. Paper towels shall be discarded after each use.

Regulation: 3290.166(1)

Description: Written statement

Noncompliance Area: Child #4, an infant, lacked an infant feeding schedule obtained from the parent.

Correction Required: A written statement giving the formula and feeding schedule for an infant shall be obtained from the parent.

Regulation: 3290.18

Description: General Health and Safety

Noncompliance Area: In the kitchen in an unlocked drawer, there was an Exacto knife with sharp edges that was accessible to children.

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

Regulation: 3290.18

Description: General Health and Safety

Noncompliance Area: The facility lacked a policy and procedure to identify the prevention of shaken baby syndrome, abusive head trauma, and child maltreatment to comply with 45 CFR 98.41(a)(1)(vi). The emergency plan lacked requirements for practice drills and continuity of operations according to federal requirements at 45 CFR § 98.41(a)(1)(vii).

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

Regulation: 3290.192(2)

Description: Health assessment, TB test

Noncompliance Area: The file for staff person #1 lacked documentation of a current health assessment updated within the last 24 months.

Correction Required: A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

Regulation: 3290.192(4)

Description: Required training

Noncompliance Area: The file for staff person #1 lacked documentation of current mandated reporter training completed within the last 5 years.

Correction Required: A facility person's record shall include records of training required by the Department.

Regulation: 3290.24(a)(5)

Description: Emergency plan

Noncompliance Area: The facility's emergency plan lacked a plan that provides for accommodations of infants and toddlers.

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

Regulation: 3290.24(d)

Description: Emergency plan

Noncompliance Area: The facility lacked documentation on file of an emergency drill being conducted within the last year.

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

Regulation: 3290.24(g)

Description: Emergency plan

Noncompliance Area: The operator lacked documentation of sending a copy of the updated emergency plan to the local municipality and to 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: 3290.31(f)(4)(i)

Description: Age and training

Noncompliance Area: The file for staff person #1 had current pediatric first-aid and CPR training with a completion date of 9-5-22 that was after the November 2021 expiration of the prior training.

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

Regulation: 3290.32(a)/3290.192(3)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The files for staff person #1 and household member #2 lacked current state police, child abuse, and FBI clearances updated within the last 60 months.

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 Person #1 and Household Member #2 may not work at the facility.

Regulation: 3290.64(a)

Description: Locked or inaccessible - in original container

Noncompliance Area: In the kitchen, there was Gorilla glue labeled "Keep out of reach of children" and was in an unlocked drawer that 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: 3290.95(a)/3290.95(b)

Description: System in compliance/Operator or designated staff responsibility

Noncompliance Area: The facility lacked proof of purchase of the interconnected fire detection system in accordance with 62 P.S. 1016(c)(3).

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