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Regulation: 3270.151(c)(2)/3270.192(3)

Description: Mantoux TB/Health assessment, TB test

Noncompliance Area: During the initial inspection, certification representative reviewed 2 staff files and the file for staff #1 did not have an updated physical.

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: 3270.27(a)(2)

Description: Emergency plan

Noncompliance Area: During the initial inspection, certification representative reviewed the facility files and the emergency plan did not include information on how staff are to respond in the event of an evacuation.

Correction Required: The facility shall have an emergency plan that provides for accommodations for evacuation of children from the facility building and evacuation of children to a location away from the facility premises. The evacuation routes and evacuation plans to exit the building may be the same as those required by §3270.94 (relating to fire drills).

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: During the initial inspection, certification representative reviewed 2 staff files and the file for staff #1 and staff #2 did not contain a record of 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 and kept on file at the facility.

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

Description: Fire safety - 1 yr.

Noncompliance Area: During the initiall inspection, certification representative reviewed25 staff files and the files for staff #1 did not include fire safety training.

Correction Required: Staff persons shall participate, at least annually, in fire safety 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: 3270.63

Description: Unsafe Areas in Outdoor Space

Noncompliance Area: During the initiall inspection, certification representative conducted a facility walkthrough and there was access to the central air units and a toxic plant in the outdoor play space.

Correction Required: If unsafe areas or conditions are in or near an outdoor play space, fencing or natural barriers are required to restrict children from those unsafe areas or conditions.

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: During the initial inspection, certification representative conducted a facility walk through and there was a hole behind the kitchen door on 2nd floor and in the pink room there was visible trim on the walls with sharp edges.

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.