Wilkes-barre Family Ymca Early Learning Center

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

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

Noncompliance Area: Staff #1 and #2 admitted to the director during an internal investigation that they that placed blankets over the heads of infants #1 and #2 while sleeping in bounce chairs, mats, and cribs rendering the infants from being seen, heard, and accessed.

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. TIERED LIS: 1. Children must be supervised at all times. The correction date for this must be immediate. 2 The legal entity must arrange for staff #1 and #2 to receive a minimum of four hours of training specific to supervision and care of infants. The legal entity must receive DHS approval of the training content prior to scheduling the trainings. The operator shall provide a date for when these trainings are completed. 3. The facility will be subject to three unannounced monitoring visits by DHS following the conclusion of the four hours of required staff trainings. These unannounced monitoring visits will be conducted to ensure that both supervision and care of infants are being adhered to and that no further instances of noncompliance are observed. The correction date should reflect a date that allows for at least 6 weeks from the completion of the required trainings for DHS to complete.

Regulation: 3270.119

Description: Infant sleep position

Noncompliance Area: Staff #1 and #2 admitted to the director during an internal investigation that they allowed infants #1 and #2 to sleep in bounce chairs. Bounce chairs are not a recommended sleeping position by the American Academy of Pediatrics and there are no medical reasons documented by a physician on file at the facility recommending a bounce chair sleeping position.

Correction Required: Infants shall be placed in the sleeping position recommended by the American Academy of Pediatrics unless there is a medical reason an infant should not sleep in this position. The medical reason shall be documented in a statement signed by a physician, physician's assistant or CRNP and placed in the child's record at the facility.

Regulation: 3270.151(a)/3270.151(c)(2)

Description: 12 months prior to service and every 24 months thereafter/Mantoux TB

Noncompliance Area: While at the facility unannounced the inspector observed the file for staff #1 (see LIS Code Sheet for DOH) and found that this staff was missing a health assessment and TB screening and has been working in direct care with children.

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. 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.

Regulation: 3270.166(5)

Description: Six-months-old held

Noncompliance Area: Staff #1 and #2 admitted to the director during an internal investigation that they did not hold infant #1 and #2 (see LIS Code for DOB) while being fed instead staff #1 and #2 propped infant #1 and #2 bottles while the infants were in bounce chairs, cribs, and mats until they fell asleep.

Correction Required: An infant 6 months of age or younger shall be held while being bottle fed.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: While at the facility unannounced the inspector observed the file for staff #1 and found that it was missing the 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)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: While at the facility unannounced the inspector observed the file for staff #2 (see LIS Code Sheet for DOH) and found that the Pa State Police on file was incomplete.

Correction Required: Staff Person # 1 may not work in a childcare position at the facility. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). The CPSL was revised to include a requirement that all clearances be updated and on file at least every 60 months. As of 2/1/25 If staff are going to be hired under the 45-day provisional hire basis, the following conditions must be met; facility received the results of the applicant's PA Child Abuse History Clearance, NSOR Clearance, completed out-of-state clearances (if applicable), a signed disclosure statement, prior to employment and have received the result of the applicant's Pennsylvania State Police OR the FBI finger-print results prior to employment. Proof of submission must be on file for either the FBI or PA State Police Clearance. The employer, administrator, supervisor or other person responsible for employment decisions has no knowledge of information pertaining to the applicant which would disqualify him from employment based on CPSL.

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

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

Noncompliance Area: The facility self-reported that on 9/9/25 staff #1 was observed to be sleeping while in a seated position, holding an infant in the infant room. As a result of this staff #1 was terminated from employment on 9/11/25.

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 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: During the course of the renewal the inspector observed the file for staff #1 and fund that this staff did not update their Pa Child Abuse clearance every 60 months as evidenced by the previous Pa Child Abuse dated 03/26/20 and the most current dated 9/19/25.

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.

Regulation: 3270.151(a)/3270.151(c)(2)

Description: 12 months prior to service and every 24 months thereafter/Mantoux TB

Noncompliance Area: The inspector found that staff #1 was hired with a health assessment and TB screening dated for 9/01/23, both of which were conducted over 12 months prior to providing initial service in a childcare setting.

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. 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.

Regulation: 3270.113(a)(1)/3270.177(a)

Description: Staff assigned to specific children/Not unattended in vehicle

Noncompliance Area: On 1/2/25 staff #1 did, in fact, leave child #1, #2, #3, and #4 (see DOB's on LIS Code Sheet) alone and unsupervised, on a facility van, while staff #1 went into another facility to pick up another child.

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. Children may not be left unattended in a vehicle.

Regulation: 3270.113(a)(1)/3270.177(a)

Description: Staff assigned to specific children/Not unattended in vehicle

Noncompliance Area: On 1/2/25 staff #1 did, in fact, leave child #1, #2, #3, and #4 (see DOB's on LIS Code Sheet) alone and unsupervised, on a facility van, while staff #1 went into another facility to pick up another child.

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. Children may not be left unattended in a vehicle. The facility director will implement a transportation supervision policy that will ensure all staff fully understand their roles and responsibilities regarding the supervision of children during and following transportation. This transportation policy must be submitted to DHS prior to implementation for approval. Once this transportation policy is accepted by DHS the director will ensure all staff and facility persons are trained on this policy and sign off on this policy.

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: During the annual unannounced inspection on 9/19 and 9/26/24 the inspector observed the ceiling tiles in the multipurpose room to be in disrepair.

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: 3270.91(a)

Description: Stairs, exits, etc. unobstructed

Noncompliance Area: During the annual unannounced inspection on 9/19 and 9/26/24 the inspector observed the exit from the multipurpose room to be housing two large children's strollers.

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

Regulation: 3270.182(7)

Description: Reports of accidents, injuries and illnesses. Original report - parent same day Copy - facility accident file. Copy - child's file

Noncompliance Area: On 6/19/24 child #1 fell into a chair at the center causing an injury to their lip. Upon pick up the parent of child #2 was not told of the incident by staff #1 nor #2. The parent of child #1 was not provided with an incident report until the following day, 6/20/24.

Correction Required: A child's record shall contain reports of accidents, injuries and illnesses involving a child in care at the facility. The original report shall be given to the parent on the day of the incident. The second copy of the report shall be retained at the facility in an accident file. The third copy of the report shall be retained at the facility in the child's file.

Regulation: 3270.151(a)/3270.151(c)(2)

Description: 12 months prior to service and every 24 months thereafter/Mantoux TB

Noncompliance Area: An unannounced inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the dates of hire. Staff #1 does not have a valid tuberculosis screening on file that was dated with 12 months prior to hire. Staff #2 did not have a health assessment conducted until 12/27/23. Staff #3 did not have a health assessment or tuberculosis screening on file at the time of his inspection.

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. 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.

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the date of hire. Regulation requires health assessments to be updated every 24 months. Staff # 5 had a health assessment dated 5/8/21 and this health assessment was not updated until 6/28/23. This staff did not update their health assessment every 24 months as required by regulation. Regulation requires staff to have a health assessment completed prior to working in childcare. Staff # 6 did not have a health assessment completed until 8/31/23. Staff # 9 did not have a health assessment completed until 9/12/23. Staff # 10 did not have a health assessment completed until 9/19/23. These health assessments were completed after these staff began working in a childcare position at the facility.

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

Description: Mantoux TB/Health assessment, TB test

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the date of hire. Regulation requires tuberculosis screening to be completed prior to staff working in a childcare position at the facility. Staff # 3 did not have a tuberculosis screening completed until 7/26/23. Staff # 6 did not have a tuberculosis screening completed until 8/31/23. Staff # 9 did not have a health assessment completed until 9/14/23. Staff # 10 did not have a health assessment completed until 9/22/23. These staff did not have a tuberculosis screening completed prior to working in a childcare position at the facility.

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: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. Staff person # 7 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): health and safety topics.

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: A renewal inspection occurred at the facility. A review of staff files was conducted. Staff # 8 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 4/12/18. Staff # 8 completed the training on 9/8/23.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the date of hire. The CPSL requires staff to update their clearances every 60 months. The following staff did not update their clearances as appropriate to the CPSL: Staff # 2 had a state police clearance dated for 8/21/18 and this clearance was not updated until 8/25/23. Staff # 4 had a child abuse clearance dated for 6/28/18 and this clearance was not updated until 8/30/23. This staff also had an FBI clearance dated for 7/2/18 and this clearance was not updated until 8/31/23. Staff # 8 had a child abuse clearance dated for 3/15/18 and this clearance was not updated until 8/7/23. This staff also had an FBI clearance dated for 3/14/18 and this clearance was not updated until 8/8/23.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the date of hire of Staff # 5, # 7, # 9, 21 # 22, # 24, and # 25. Staff # 5 was working in child care and the file did not contain an NSOR clearance. Staff # 7 began working in child care before applying for an NSOR clearance. Staff # 7 did not receive an NSOR clearance until 2/14/22. Staff # 9 did not have an FBI clearance. Staff # 9 did not apply for an FBI clearance before working in child care. The file of Staff # 21 indicated they had lived out of state within the last 5 years. Those states clearances were not in the file at the time of the inspection. Staff # 22 did not have an FBI clearance. Staff # 22 did not apply for an FBI clearance before working in child care. Staff # 24 began working in child care before applying for an NSOR clearance. Staff # 24 did not receive an NSOR clearance until 1/31/22. Staff # 25 began working in child care before applying for a state police clearance. Staff # 25 did not receive a state police clearance until 9/15/22. The file of Staff # 25 also indicated that this staff had lived out of state within the last 5 years and the clearances of that state were not in the staff's file at the time of this inspection. An acceptable plan of correction was received on 10/20/22. An unannounced inspection occurred on 10/21/22. The file of Staff # 22 still did not contain an FBI clearance or proof that a clearance was applied for. Staff # 22 has worked in child care without having an FBI clearance on file. The file of Staff # 25 still did not contain out of state clearances. Staff # 25 was working unsupervised with children during this inspection.

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 # 22 and # 25 may not work in a child care position at the facility. The Legal Entity, Director and any other staff involved with maintaining staff files will schedule ( 1-800-222-2108) and participate in the next Existing Provider Orientation on November 30, 2022.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the date of hire of Staff # 5, # 7, # 9, 21 # 22, # 24, and # 25. Staff # 5 was working in child care and the file did not contain an NSOR clearance. Staff # 7 began working in child care before applying for an NSOR clearance. Staff # 7 did not receive an NSOR clearance until 2/14/22. Staff # 9 did not have an FBI clearance. Staff # 9 did not apply for an FBI clearance before working in child care. The file of Staff # 21 indicated they had lived out of state within the last 5 years. Those states clearances were not in the file at the time of the inspection. Staff # 22 did not have an FBI clearance. Staff # 22 did not apply for an FBI clearance before working in child care. Staff # 24 began working in child care before applying for an NSOR clearance. Staff # 24 did not receive an NSOR clearance until 1/31/22. Staff # 25 began working in child care before applying for a state police clearance. Staff # 25 did not receive a state police clearance until 9/15/22. The file of Staff # 25 also indicated that this staff had lived out of state within the last 5 years and the clearances of that state were not in the staff's file at the time of this inspection. An acceptable plan of correction was received on 10/20/22. An unannounced inspection occurred on 10/21/22. The file of Staff # 22 still did not contain an FBI clearance or proof that a clearance was applied for. Staff # 22 has worked in child care without having an FBI clearance on file. The file of Staff # 25 still did not contain out of state clearances. Staff # 25 was working unsupervised with children during this inspection.

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 # 22 and # 25 may not work in a child care position at the facility.

Regulation: 3270.106(j)

Description: Prohibit items in crib

Noncompliance Area: A renewal inspection occurred at the facility. A physical site review was conducted. In the infant room, an infant was found sleeping. In the crib, with the sleeping infant, a pacifier was found that had a clip attached to it with a string hanging from the clip.

Correction Required: Toys, bumper pads, or pillows may not be present in a crib while an infant is sleeping in the crib.

Regulation: 3270.119

Description: Infant sleep position

Noncompliance Area: A renewal inspection occurred at the facility. A physical site review was conducted. Staff # 25 was working in the infant room and when asked the sleeping position of infants, this staff responded on their belly. The appropriate sleeping position per the American Academy of Pediatrics is on their backs.

Correction Required: Infants shall be placed in the sleeping position recommended by the American Academy of Pediatrics unless there is a medical reason an infant should not sleep in this position. The medical reason shall be documented in a statement signed by a physician, physician's assistant or CRNP and placed in the child's record at the facility. The legal entity must arrange for Staff # 25 to receive a minimum of two hours of PQAS-approved training, regarding infant safe sleep.

Regulation: 3270.119

Description: Infant sleep position

Noncompliance Area: A renewal inspection occurred at the facility. A physical site review was conducted. Staff # 25 was working in the infant room and when asked the sleeping position of infants, this staff responded on their belly. The appropriate sleeping position per the American Academy of Pediatrics is on their backs.

Correction Required: Infants shall be placed in the sleeping position recommended by the American Academy of Pediatrics unless there is a medical reason an infant should not sleep in this position. The medical reason shall be documented in a statement signed by a physician, physician's assistant or CRNP and placed in the child's record at the facility.

Regulation: 3270.123(a)(6)

Description: Admission date

Noncompliance Area: A renewal inspection occurred at the facility. A review of children's files was conducted. Child file # 1 did not contain a date of admission.

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

Regulation: 3270.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: A renewal inspection was conducted at the facility. A review of children's files was conducted. Child file # 2 did not contain documentation of their health insurance coverage including 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: 3270.124(f)/3270.181(c)

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

Noncompliance Area: A renewal inspection occurred at the facility. A review of children's files was conducted. The emergency contact of Child # 1 has not been updated since 5/13/19. The emergency contact and agreement forms of Child # 2 were not updated every 6-month period. The documents were reviewed on 3/17/22 and again on 8/22/22. The emergency contact and agreement forms of Child # 8 were not updated every 6-month period. The documents were reviewed on 2/24/22 (emergency contact) and 9/6/22 and 9/23/22 (agreement). The agreement of Child # 9 was not updated every 6-month period. The document was reviewed on 5/28/21 and 9/22/22. The emergency contact and agreement forms of Child # 10 were not updated every 6-month period. The documents were reviewed on 7/13/20 and 9/26/22 (emergency contact) and 12/15/20 and 9/26/22 (agreement).

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: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: Staff person # 21 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): pediatric first aid/CPR and health and safety topics. Staff person # 24 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): pediatric first aid/CPR. Staff person # 12, and # 25 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): health and safety topics. Staff person # 12, # 21, # 24 and # 25 was observed to be caring for children unsupervised.

Correction Required: Staff person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10), 3280.31(f) (1-10), or 3290.31(g) (1-10) within 90 days of hire. Staff person# 12, # 21, # 24 and # 25 will have until 10/19/22 to complete the required training. Until such time as the required training has been completed, staff person # 12, # 21, # 24 and # 25 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 available to supervise staff person # 12, # 21, # 24 and # 25; staff person # 12, # 21, # 24, and # 25 may not work in a child-care position at the facility. 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 # 12, # 21, # 24 and # 25 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 # 12, # 21, # 24 and # 25; staff person # 12, # 21, # 24 and # 25 may not work in a child-care position at the facility.

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the listed staff's dates of hire. Staff # 1 did not receive a health assessment or TB screening until 3/17/22 and 3/19/22. Staff # 2 did not receive a health assessment or TB screening until 10/30/21 and 10/27/21. Staff # 5 did not have a health assessment or TB on file. Staff # 7 did not have a health assessment or TB on file. Staff # 8 did not have a TB screening completed until 2/19/21. Staff # 9 did not have a health assessment and TB screening completed until 3/12/22 and 3/11/22. Staff # 10 did not have a health assessment on file and did not receive a TB screening until 8/15/22. Staff # 17 had a health assessment dated for 8/24/19 and this health assessment was not updated until 9/22/22. Staff # 18 did not have a health assessment or TB screening completed until 9/21/21. Staff # 23 did not have a health assessment or TB screening on file. Staff # 24 did not have a health assessment or TB screening on file until 1/31/22. Staff # 26 did not have a health assessment or TB screening on file until 8/21/21. Staff # 28 had a health assessment completed on 8/4/20 and and updated health assessment has not yet been obtained. These staff have either not participated in a health assessment and TB prior to working in child care or have not updated their health assessments every 24 months as required by regulation. Staff have worked in child care without the proper documentation in their file.

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: 3270.151(c)(1)/3270.151(c)(2)

Description: Physical examination/Mantoux TB

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the listed staff's dates of hire. Staff # 1 did not receive a health assessment or TB screening until 3/17/22 and 3/19/22. Staff # 2 did not receive a health assessment or TB screening until 10/30/21 and 10/27/21. Staff # 5 did not have a health assessment or TB on file. Staff # 7 did not have a health assessment or TB on file. Staff # 8 did not have a TB screening completed until 2/19/21. Staff # 9 did not have a health assessment and TB screening completed until 3/12/22 and 3/11/22. Staff # 10 did not have a health assessment on file and did not receive a TB screening until 8/15/22. Staff # 17 had a health assessment dated for 8/24/19 and this health assessment was not updated until 9/22/22. Staff # 18 did not have a health assessment or TB screening completed until 9/21/21. Staff # 23 did not have a health assessment or TB screening on file. Staff # 24 did not have a health assessment or TB screening on file until 1/31/22. Staff # 26 did not have a health assessment or TB screening on file until 8/21/21. Staff # 28 had a health assessment completed on 8/4/20 and and updated health assessment has not yet been obtained. These staff have either not participated in a health assessment and TB prior to working in child care or have not updated their health assessments every 24 months as required by regulation. Staff have worked in child care without the proper documentation in their file.

Correction Required: An adult health assessment must include a physical examination. 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.

Regulation: 3270.151(c)(3)

Description: Exam communicable disease

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. The health assessment of Staff # 24 did not include an exam for communicable diseases and the results of that examination.

Correction Required: An adult health assessment must include an examination for communicable diseases and the results of that examination.

Regulation: 3270.161(d)

Description: Potentially hazardous food refrigerated

Noncompliance Area: A renewal inspection occurred at the facility. A physical site review was conducted. Lunchboxes were found on the third floor that contained dairy and meats. These lunchboxes required refrigeration but were not refrigerated.

Correction Required: Potentially hazardous food brought from the child's home or provided by the facility shall be refrigerated.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the date of hire of the following staff. Staff # 25 was missing 1 letter of written reference. This staff was working in child care without having a complete 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: 3270.27(a)(6)

Description: Emergency plan

Noncompliance Area: A renewal inspection occurred at the facility. The facility's emergency drill log was requested and the facility did not provided the emergency drill log for review.

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

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: A renewal inspection occurred at the facility. Staff # 26 did not review the emergency plan within 90 days of their hire date. See the code sheet for the date of hire. Staff # 27 has not reviewed the emergency plan since 7/5/21. The emergency plan is required to be reviewed on an annual basis.

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: A renewal inspection occurred at the facility. Staff # 13 has not participated in fire safety training since 8/17/21. Fire safety training is required on an annual basis. See the code sheet for the date of hire for Staff # 26 and # 27. Staff # 26 and # 27 have not yet participated in 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(f)

Description: Health and Safety Training

Noncompliance Area: Staff person # 6, # 19, # 21, # 24 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): pediatric first aid/CPR and health and safety topics. Staff person # 1, # 2, # 5, # 8, # 10, # 18, # 24, # 27 and # 29 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): pediatric first aid/CPR. Staff person # 25 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): health and safety topics. Staff person # 9 has acceptable pediatric first aid/CPR training in an approved curriculum; however, the trainer has not provided documentation that they are PQAS-certified in that training topic.

Correction Required: Staff person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10) within 90 days of hire. Staff person # 1, # 2, # 5, # 6, # 8, # 9, # 10, # 18, # 19, # 21, # 24, # 25, # 27, and # 29 will have until 10/15/22 to complete the required training. Until such time as the required training has been completed, staff person # 1, # 2, # 5, # 6, # 8, # 9, # 10, # 18, # 19, # 21, # 24, # 25, # 27, and # 29 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 available to supervise staff person # 1, # 2, # 5, # 6, # 8, # 9, # 10, # 18, # 19, # 21, # 24, # 25, # 27, and # 29; staff person # 1, # 2, # 5, # 6, # 8, # 9, # 10, # 18, # 19, # 21, # 24, # 25, # 27, and # 29 may not work in a child-care position at the facility Staff persons shall complete professional development in the topics of 3270.31(f)(10)within 90 days of hire. Staff person # 9 must do one of the following: provide documentation that the trainer has become PQAS-certified or at least is on the waiting list, request the instructor provide documentation, such as their Pediatric First-Aid/CPR Instructor Card from the PQAS-approved organization or the approved curriculum organization, that the instructor is approved to offer Pediatric First-Aid/CPR training on behalf of their organization, or receive pediatric first-aid/CPR training in an approved curriculum by a PQAS-certified trainer.

Regulation: 3270.31(g)

Description: Professional development certificate

Noncompliance Area: A renewal inspection occurred at the facility. Staff # 12 has health and safety topic training dated for 9/18/16. Per regulation, this training no longer meets the requirements for the health and safety topic training.

Correction Required: Completion of professional development shall be documented by the signature and title of a representative of the professional development entity and include the date professional development was completed. Documentation shall be retained in the facility person's file or maintained in an electronic system as designated by the Department. Documentation of the completion of the professional development under subsection (f) taken from September 30, 2016, forward satisfies this requirement.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the date of hire of Staff # 5, # 7, # 9, 21 # 22, # 24, and # 25. Staff # 5 was working in child care and the file did not contain an NSOR clearance. Staff # 7 began working in child care before applying for an NSOR clearance. Staff # 7 did not receive an NSOR clearance until 2/14/22. Staff # 9 did not have an FBI clearance. Staff # 9 did not apply for an FBI clearance before working in child care. The file of Staff # 21 indicated they had lived out of state within the last 5 years. Those states clearances were not in the file at the time of the inspection. Staff # 22 did not have an FBI clearance. Staff # 22 did not apply for an FBI clearance before working in child care. Staff # 24 began working in child care before applying for an NSOR clearance. Staff # 7 did not receive an NSOR clearance until 1/31/22. Staff # 25 began working in child care before applying for a state police clearance. Staff # 25 did not receive a state police clearance until 9/15/22. The file of Staff # 25 also indicated that this staff had lived out of state within the last 5 years and the clearances of that state were not in the staff's file at the time of this inspection.

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 # 5, # 7, # 9, 21 # 22, # 24, and # 25 may not work in a child care position at the facility.

Regulation: 3270.33(a)/3270.192(2)(ii)

Description: Each staff person meets quals/Exp, educ., training prior to facility

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the date of hire for the listed staff. Staff # 8 did not have proof of education in their file. Staff # 8 has not been appropriately qualified before working in a child care role at the facility.

Correction Required: A staff person or a substitute staff person shall meet one of the applicable staff qualifications for the position in which the person is performing. A facility person's record shall include verification of child care experience, education and training prior to service at the facility.

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. The following staff evaluations did not occur on an annual basis but did have a current evaluation on file at the time of the inspection: Staff # 3, # 4, # 11, # 12, # 13, # 14, # 15, # 16, # 26, and # 27. The following staff did not have an annual evaluation completed at the time of this inspection: Staff # 8, # 17, and # 19.

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: 3270.76

Description: Building Surfaces

Noncompliance Area: A renewal inspection occurred at the facility. A physical site review was conducted. In the toddler classroom of Staff # 2, the sink had a strong odor when run. The smell was overpowering and the door needed to be opened to circulate fresh air. This sink was brought to the attention of maintenance during this inspection.

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: 3270.95(a)/3270.95(b)

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

Noncompliance Area: A renewal inspection occurred at the facility. At the time of the inspection, the facility was unable to provide the annual testing of the fire safety system that was conducted by a fire safety professional.

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: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. Staff # 1 had a date of hire prior to 9/30/19 and the file did not contain an NSOR clearance by 7/1/20 as required by the CPSL. Staff # 1 did not receive an NSOR until 10/9/20. Staff # 3 had mandated reporter training dated for 8/27/16 and this training was not updated until 8/30/21. Staff # 3 had mandated reporter training dated for 6/2/15 and this training was not updated until 7/31/20. These staff did not update their mandated reporter training every 60 months as required by the CPSL. The facility has an approved provisional hire waiver. Staff # 4 had a provisional date of hire of 8/16/21 and the file contained documentation that this staff has lived out of state. The file of Staff # 4 did not contain the appropriate clearances of this other state. Staff # 4 began working with children prior to applying for and receiving this other state's clearances. Staff # 4 was hired incorrectly as a provisional hire.

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 # 4 may not work in a child care position at the facility. The CPSL requires all clearances and mandated reporter training to be updated every 60 months. The CPSL requires all staff that have lived out of state to obtain all clearances appropriate to that state. Staff hired provisionally must apply for these clearances prior to working in child care. The Child Protective Services Law(CPSL) was revised to include the requirement for the National Sex Offender Registry(NSOR) clearance effective 9/30/2019. The CPSL also states that anyone hired before 9/30/19 had until 7/1/20 to obtain this clearance.

Regulation: 3270.63/3270.76

Description: Unsafe Areas in Outdoor Space/Building Surfaces

Noncompliance Area: A renewal inspection occurred at the facility. A physical site inspection was conducted. On the rooftop play area, a section of the fencing to the left when looking out of the facility's door, had come unfastened from the horizontal poles. This allowed for the fencing to be moved leaving a gap of 1-2 feet.

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. 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.