Good Shepherd Evangelical Lutheran Church

Regulation: 3270.151(a)

Description: 12 months prior to service and every 24 months thereafter

Noncompliance Area: During a renewal inspection on 6/24/26 Staff Person 1's most recent Staff Health assessment was dated 8/12/22 which is more than 12 months ago. Staff 1 was on leave from August 2024 until 6/9/25, and 8/21/25-until 6/8/26. Staff 1 was observed to be providing care to children on 6/24/26.

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.

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

Description: Fire safety - 1 yr.

Noncompliance Area: During a swimming inspection on 6/24/26 Cert rep noted that Staff person 1's most recent fire safety training was dated 5/20/25. Staff 1 was on leave from 8/21/25-6/8/26. Staff 1 was observed providing care to children on 6/24/26.

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: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During a swimming inspection on 6/24/26 Cert rep noted that Staff person 1 did not have a DHS FBI clearance certificate. Staff 1 had a Department of Education FBI clearance dated 11/18/22. Staff 1 was observed providing care to children on 6/24/26. Staff 1 has been employed for more than 45 days. See LIS code sheet for first day with children.

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. TIERED LIS 1. Staff person 1 may not work in a child care position for the facility or have direct contact with children at the facility or on facility activities until such time as the require missing clearance are on file at the facility. This portion of the plan shall have an immediate correction date. 2. The director and persons responsible for maintaining Staff, facility persons and volunteer files shall view the DHS Vodcast regarding staff's file with the Certification Representative. The director and persons responsible for maintaining Staff, facility persons and volunteer files will contact the Certification Representative to schedule an appointment to view a DHS Vodcast regarding staff files. The provider shall provide a date for when this viewing of the Vodcast with the Certification Representative shall be completed.

Regulation: 3270.37(c)

Description: Aides supervised all times

Noncompliance Area: During a swimming inspection on 6/24/26 Cert rep observed Staff 2 was unsupervised with 1 young school age child who was not swimming. Staff 2 was reported to be working as an aide.

Correction Required: An aide or a combination of aides shall be supervised at all times by a staff person qualified at minimum as an assistant group supervisor.

Regulation: 3270.124(b)(2)/3270.124(b)(3)

Description: Physician name, address, phone/Parent home/work address, phone

Noncompliance Area: During a renewal inspection on 4/15/26 Child 3's emergency contact form did not list the address and telephone number of the child's physician or source of medical care. Additionally Children 1-5'emergency contact forms were missing the following information regarding their parents: parent's home phone number(Child 5), parent's work address (Children 1, 2, &3), and parent's work phone number (Children 1, 2, 3, 4, & 5).

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

Regulation: 3270.151(c)(3)

Description: Exam communicable disease

Noncompliance Area: During a renewal inspection on 4/15/26 Staff 2 had a health assessment dated 5/14/25 which did not include information that an exam for communicable diseases was completed and the results of that examination. Staff 2 was observed providing care to children on 4/15/26.

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

Regulation: 3270.171(c)

Description: Safe routes posted

Noncompliance Area: During a renewal inspection on 4/15/26 the facility's safe routes were not posted at the facility.

Correction Required: Written notification of safe routes shall be posted by the operator at a conspicuous location in the child care facility.

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: During a renewal inspection on 4/15/26 Staff 1 did not have emergency plan training since previous documented training dated 4/12/23. Staff 1 was on leave from 6/1/24-6/16/25.

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: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During a renewal inspection on 4/15/26 Staff 1 has Child abuse clearances dated 1/6/21, and 3/7/26, which is more than 60 months between clearance certificate dates. Staff 1 was reported to have worked as staff between 1/6/21 and 3/7/26.

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. TIERED LIS: 1. The operator shall comply with the CPSL and with Chapter 3490 (related to protective Services. This portion of the plan shall have an immediate correction date. 2. The legal entity must create a checklist for staff and facility persons files that addresses all necessary staff and facility persons file paperwork and time frames for renewals of paperwork as appropriate. The staff and facility persons file paperwork that must be addressed in this checklist includes but is not limited to PA clearances, Out of State clearances and trainings as required by the CPSL and all documents required for staff and facility persons to be hired. The checklist must be submitted to the Regional Office for approval. Once approved this checklist shall be used by the person responsible for hiring and maintaining facility persons records. The provider shall provide a date for when this portion of the plan shall be completed.

Regulation: 3270.36(b)(5)/3270.192(2)(iv)

Description: HS/GED + 2 yrs/Transcript, diploma and letters

Noncompliance Area: During a renewal inspection on 4/15/26 Staff 2's file had a high school diploma and acceptable verification of 1125 hours of experience via a signed letter from the legal entity were the experience was obtained. Staff 2 reported they worked at least 1840 hours with children at a separate entity however Staff 2's file did not have acceptable verification of this experience. Staff 2 has been working as a Assistant Group supervisor.

Correction Required: An assistant group supervisor shall have a high school diploma or a general educational development certificate and 2 years experience with children. A facility person's record shall include acceptable verification of experience, education or training is a transcript or a diploma or a letter signed by a representative of the experiential, educational or training entity.

Regulation: 3270.151(a)

Description: 12 months prior to service and every 24 months thereafter

Noncompliance Area: During a swimming inspection on 7/30/25 Staff 3's health assessment was dated 6/10/25, which is after their first day with children. See LIS code sheet for 1st day 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.

Regulation: 3270.182(5)

Description: Consent for administration of minor first-aid required prior to admission

Noncompliance Area: During a swimming inspection on 7/30/25 Child 1's record did not contain signed parental consent for the administration of minor first aid by facility persons.

Correction Required: A child's record shall contain signed parental consent for administration of minor first-aid procedures by facility staff. Written consent is required prior to admission.

Regulation: 3270.192(2)(ii)/3270.192(2)(iv)

Description: Exp, educ., training prior to facility/Transcript, diploma and letters

Noncompliance Area: During a swimming inspection on 7/30/25 Staff 3 did not have verification of education or childcare experience in their staff file. It was reported Staff 3 worked at a local school and graduated high school.

Correction Required: A facility person's record shall include verification of child care experience, education and training prior to service at the facility. A facility person's record shall include acceptable verification of experience, education or training is a transcript or a diploma or a letter signed by a representative of the experiential, educational or training entity.

Regulation: 3270.192(4)

Description: CPSL information

Noncompliance Area: During a swimming inspection on 7/30/25 Facility person 2, and Staff 3 did not have a disclosure statement that was signed by the staff and a witness and dated. Facility person 2, and Staff 3 were not hired provisionally. See LIS code sheet for first day with children.

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. Facility Person 2 and Staff 3 may not work in a child care position or have direct contact with children at the facility until such time as the disclosure statement is signed, dated and has a witness signature.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: During a swimming inspection on 7/30/25 Staff 3 and 4 did not have 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: During a swimming inspection on 7/30/25 the following violations of the CPSL were noted: Facility Person 1 did not have an NSOR certificate. Staff 4's FBI clearance was dated 6/11/25 which is after their first day with children. There was no FBI request documented in the file. Staff 4's disclosure statement was dated 7/7/25 which is after their first day with children. Staff 4 was provisionally hired. See LIS code sheet for first day with children.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person 1 may not work in a child care position or have direct contact with children at the facility until the required clearance is on file at the facility.

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: During a swimming inspection on 7/30/25 Staff 5 and 6 did not have staff evaluations in their staff files. Director reported that staff evaluations were not being completed for seasonal staff.

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: 3270.75(d)

Description: On excursions

Noncompliance Area: During a swimming inspection on 7/30/25 Each staff had a first aid kit for their care group. Cert rep observed no first aid kit's present on the excursion to the pool had all of the required items: Staff 6's first aid kit did not have soap, tape, scissors, and a bottle of water. Staff 7's first aid kit did not have soap, an assortment of adhesive bandages, scissors, gloves and a bottle of water. The remaining first aid kits did not have soap, sterile gauze pads, tweezers, tape, scissors a bottle of water.

Correction Required: One first-aid kit per child care group must accompany children and facility persons on excursions from the facility. Each first aid kit taken on an excursion must contain a bottle of water in addition to the items specified at §3270.75(c).

Regulation: 3270.121(b)

Description: Given parents in writing

Noncompliance Area: During a renewal inspection on 4/23/25 Cert rep noted parent were not being provided information regarding Supervision policies and health policies in writing at the time of enrollment.

Correction Required: At the time of enrollment, a parent shall receive in writing 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: 3270.124(b)(2)

Description: Physician name, address, phone

Noncompliance Area: During a renewal inspection on 4/23/25 Cert rep noted Child 1's emergency contact form did not have the physician phone number and Child 2's form did not have the physician address.

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

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

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

Noncompliance Area: During a renewal inspection on 4/23/25 Cert rep noted Children 1, 2, 3, and 4's emergency contact form did not have the parent's work address, and Child 3's form did not have the parents work phone number. Child 4's emergency contact form did not have addresses for the release persons.

Correction Required: Emergency contact information must include the home and work addresses and telephone numbers of the enrolling parent. Emergency contact information must include the name, address and telephone number of the individual designated by the parent to whom the child may be released.

Regulation: 3270.131(d)(7)/3270.131(d)(8)

Description: Free from contagious/communicable disease/Age appropriate screenings complete

Noncompliance Area: During a renewal inspection on 4/23/25 Cert rep noted Child 4's DHS Health assessment form did not have an answer to the if child is able to participate in child care and appears to be free from contagious or communicable disease and if age-appropriate screenings recommended by the American Academy of Pediatrics.

Correction Required: A health report shall include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease. A health report shall include a statement that age-appropriate screenings recommended by the American Academy of Pediatrics were conducted since the time of the previous health report required by this section.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: During a renewal inspection on 4/23/25 Cert rep observed Expo cleaner, dish soap, and Lysol cleaner on an accessible shelf in an unlocked closest in the Centers Room, and Lysol spray and Mr. Clean Cleaner on an accessible shelf in the hallway on the way to the Game Room. All of these items were labeled "keep out of reach of children".

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations.State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. School aged only programs: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: During a renewal inspection on 4/23/25 Cert rep noted the facility's emergency plan did not address continuity of operations. Cert rep also noted the facility did not have a written policy to address the following: recognition of potential signs/symptoms of shaken baby syndrome and abusive head trauma, strategies for coping with a crying, fussing, or distraught child and the prevention and identification of child maltreatment

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. The facility's emergency plan must address continuity of operations. The facility must have a written policy which addresses the following: Written policy to address the following: 1. Recognition of potential signs/symptoms of shaken baby syndrome and abusive head trauma 2. Strategies for coping with a crying, fussing, or distraught child 3. The prevention and identification of child maltreatment

Regulation: 3270.151(a)

Description: 12 months prior to service and every 24 months thereafter

Noncompliance Area: During a renewal inspection on 4/23/25 Staff 1's health assessments were dated 1/8/23 and 2/12/25, Staff 2's were dated 3/29/22 and 4/3/24, and Staff 3's were dated 10/28/22 and 11/16/24. These time frames are more than 24 months. It was reported that these staff worked in childcare positions after the expiration of their previous health assessments.

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.

Regulation: 3270.27(a)(6)

Description: Emergency plan

Noncompliance Area: During a renewal inspection on 4/23/25 Cert rep noted Emergency drills took place on 3/11/24 and 4/11/25, which is more than 12 months between emergency drills.

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

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: During a renewal inspection on 4/23/25 Cert rep noted Staff 2 had mandated reporter training dated 2/19/20 and 4/1/25 which is more than 60 months between trainings.

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: During a renewal inspection on 4/23/25 Cert rep noted Staff 2 had PSP clearances dated 11/6/19 and 3/28/25, Child abuse clearances dated 11/13/19 and 4/3/25, and FBI clearances dated 11/8/19 and 3/31/25. These time frames are more than 60 months between the clearances. The director confirmed Staff 2 continued to work in a childcare position between 11/6/24-and 4/3/25.

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: 3270.51

Description: Similar Age Level

Noncompliance Area: During a renewal inspection on 4/23/25 Cert rep observed Staff 4 had 13 young school aged children in her assigned group. It was reported that Staff 1 originally had a group of 6 young school aged children, and Staff 4 had a group of 7 young school aged children. Staff 1 gave 5 of her children to Staff 4(resulting in Staff 4 having 12 children) so that Staff 1 could take 1 child to the bathroom. When Staff 1 returned, she gave her last child to Staff 4(resulting in Staff 4 having 13 children) so that Staff 2 could complete clean up tasks.

Correction Required: When children are grouped in similar age levels, the following maximum child group sizes and ratios of staff persons apply: Infants 1:4 with a maximum group size of 8; Young toddlers 1:5 with a maximum group size of 10; Older toddlers 1:6 with a maximum group size of 12; Preschool children 1:10 with a maximum group size of 20; Young school-age children 1:12 with a maximum group size of 24; Older school-age children 1:15 with a maximum group size of 30. TIERED LIS: 1. The required staff:child ratios must be maintained at all times. This portion of the plan shall have an immediate correction date. 2. The operator shall create a Ratio Policy that must include procedures to maintain ratio during times of transition such as bathroom trips or staff transitions. This policy will be submitted to the Northeast regional office for approval and will be reviewed with all staff once approved by the Northeast regional office. Staff will sign acknowledgement of the updated policy which will be kept in their staff files. The operator shall provide a correction date for when this portion of the plan will be completed.

Regulation: 3270.94(a)(1)

Description: Every 60 days

Noncompliance Area: During a renewal inspection on 4/23/25 Cert rep noted more than 60 days between fire drills on one occasion(11/13/24-1/13/25).

Correction Required: The Director 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: 3270.95(a)/3270.95(b)

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

Noncompliance Area: During an unannounced inspection on 10/30/24 Fire detection testing log was reviewed and had one incident of more than 30 days between testing: 9/6/24-10/30/24.

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(a)

Description: Health information

Noncompliance Area: On 4/25/2024, Child #1 did not have an initial health report on file. See LIS code sheet.

Correction Required: The operator shall require the parent of an enrolled child, including a child, a foster child and a relative of an operator or a facility person, to provide an initial health report no later than 60 days following the first day of attendance at the facility.

Regulation: 3270.151(a)

Description: 12 months prior to service and every 24 months thereafter

Noncompliance Area: On 4/25/2024, both Staff #1 and #2 had current health assessments on file. However, the current health assessment for Staff #1 was dated 1/12/2024, while the previous health assessment that was on file for Staff #1 was dated 9/3/2021. The current health assessment for Staff #2 was dated 9/18/2023, while the previous health assessment that was on file for Staff #2 was dated 8/13/2021.

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.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: On 4/25/2024, Staff #3 did not have the required DHS FBI clearance on file. The most recent DHS FBI clearance on file was dated 9/11/2018. Staff #3 had an unofficial clearance from the Department of Education.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). 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 childcare position at the facility until the required DHS FBI clearance is on file.

Regulation: 3270.151(a)

Description: 12 months prior to service and every 24 months thereafter

Noncompliance Area: On 4/20/2023, the most recent health assessment on file for Staff #2 was dated 4/2/2021. See LIS code sheet. Staff #7 had updated health on file dated 1/8/2023, but the prior health assessment on file for Staff #7 was dated 9/2/2020.

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 childcare 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.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff #3, #4, #5, #6, #7, #8, #9 and #10 did not complete the required one-hour 2022 update to the health and safety training by 12/30/2022.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-9. Staff #3, #4, #5, #6, #7, #8, #9 and #10 shall complete the required one-hour 2022 update to the health and safety training by 5/5/2023.

Regulation: 3270.31(f)(10)

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

Noncompliance Area: Staff #1 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Professional development in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR)

Correction Required: Staff persons shall complete professional development in pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire. Staff person #1 will have until 1/28/2023 to complete the required training. Until such time as the required training has been completed, staff person #1 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff available to supervise staff persons #1, staff persons #1 may not work in a child-care position at the facility.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: Staff #9 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 3/11/2018.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Staff person #9 will have until 5/5/2023 to complete the mandated reporter training. Until such time as the required training has been completed, staff person #9 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 #9, staff person #9 may not work in a child-care position at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: On 4/20/2023, Staff #8 and Staff #9 had current clearances on file. However, the clearances were renewed as follows for Staff # 8: State police on 3/22/2023, child abuse on 3/27/2023 and the FBI on 4/4/2023. The previous clearances on file for Staff #8 were dated 1/1/2018 for the state police and child abuse and 1/12/2018 for the FBI. The current FBI clearance for Staff #9 was dated 4/4/2023. The previous FBI clearance on file for Staff #9 was dated 10/5/2017.

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. Each clearance for all facility persons must be renewed at least every 60 months.

Regulation: 3270.115(a)(6)

Description: Lifeguard training/supervision

Noncompliance Area: The operator disclosed that they have taken the children swimming this summer. The facility does not have anybody on staff that is certified in lifeguard training.

Correction Required: When children are swimming, supervision shall include one person certified in lifeguard training, as described in § 3270.31(e)(4)(iii) (relating to age and training).

Regulation: 3270.115(a)(8)

Description: Included in ratio/annual training

Noncompliance Area: The operator disclosed that they have taken the children swimming this summer. The facility does not have any staff that have completed annual water safety training.

Correction Required: A facility person who is counted in the staff-child swimming ratio shall annually complete water safety instruction.

Regulation: 3270.133(6)/3270.133(7)

Description: Written consent/Medication log

Noncompliance Area: The operator confirmed that a child at the facility is prescribed insulin while in care this summer beginning in June 2022. The operator did not have parental consent for administering this medication and also did not have a medication log established until 7/11/2022.

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

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

Noncompliance Area: An unannounced inspection was conducted on 7/12/2022. Facility Person/Staff #1 had a tuberculosis screening by the Mantoux method within the previous 12 months of starting employment on file, but not have a completed health assessment on file. Facility Person/Staff #2 did not have a completed health assessment and tuberculosis screening by the Mantoux method within the previous 12 months of starting employment on file. Facility Person #3, #4 and #5, all volunteers did not have completed health assessments and tuberculosis screenings by the Mantoux method on file. Facility Person/Staff #6 and #7 both had tuberculosis screenings by the Mantoux method conducted within the previous 12 months prior to beginning employment on file, but Facility Person/Staff #6 and #7 did not complete health assessments on file. Facility Person/Staff #8 did not have a health assessment and tuberculosis screening by the Mantoux method on file. See LIS code sheet.

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: 3270.192(5)

Description: Two written references

Noncompliance Area: During an unannounced inspection on 7/12/2022, Facility Persons #1, #2, #3, #4, #5, #6, #7 and #8 did not have two written, nonfamily references on file. See LIS code sheet.

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: 3270.21/3270.66(c)

Description: General Health and Safety/Toxic use- no contamination

Noncompliance Area: An unannounced inspection was conducted on 7/12/2022. It was verified through staff interviews that while on an excursion away from the facility on 6/30/2022 that the diabetic lancet used by a child was not disposed of properly. The lancet was placed in a plastic bag that was then placed into a trash can.

Correction Required: Conditions at the facility may not pose a threat to the health or safety of the children. Cleaning materials and other toxic materials shall be used in a way that does not contaminate play surfaces, food, food preparation areas and does not constitute a hazard to the children.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: An unannounced inspection was conducted on 7/12/2022. The following was observed during the review of staff files: Facility Person/Staff #1 had an FBI clearance that was more than 60 months old (6/12/2017) on file, a volunteer state police clearance and did not have the National Sex Offender Registry (NSOR) clearance or request on file. Facility Person/Staff #2 did not have the FBI clearance or request on file and did not have the completed National Sex Offender Registry (NSOR) clearance on file. Facility Person #3, a volunteer did not have the clearances or requests on file for the FBI, child abuse, and National Sex Offender Registry (NSOR). Facility Person #4, a volunteer did not have the clearances or requests on file for the FBI or the National Sex Offender Registry (NSOR). Facility Person #5, a volunteer did not have the clearances or requests on file for the FBI, child abuse, and National Sex Offender Registry (NSOR). See LIS code sheet.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person #1, #2, #3, #4 and #5 may not work in a child care position at the facility. 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, #2, #3, #4 and #5 may not work in a child care position at the facility.

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: During the Renewal Inspection on 4/26/2022, the surface on the side of the 2nd step to the sliding board was cracked and sharp edges were exposed.

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: 3270.31(f)(10)

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

Noncompliance Area: During the Renewal Inspection on 4/26/2022, The files showed that Staff #1, Staff #2 and Staff #3 had not yet completed professional development in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR). Staff #1, Staff #2 and Staff #3 all have been working at the facility for longer than 90 days. See code sheet for dates of hire.

Correction Required: Staff persons shall complete professional development in pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During the Renewal Inspection on 4/26/2022, Staff #1 did not have a National Sex Offender Registry (NSOR) clearance on file. The file for Staff #2 showed that the National Sex Offender Registry (NSOR) clearance on file for Staff #2 was dated 9/24/2021. The file showed that the NSOR clearance was requested on 8/13/2021. The facility did not have a CPSL Provisional Hiring Waiver when Staff #1 and Staff #2 were hired. Staff #2 also did not complete the mandated reporter training until 2/27/2022. See code sheet for dates of hire.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Staff #1 may not work in a child care position at the facility until the completed National Sex Offender Registry (NSOR) clearance in on file. All staff must complete an approved mandated reporter training with 90 days of hire, On Feb. 17, 2022, Act 12 of 2022 on Provisional Hiring Practices was signed into law. Act 12 amended the Child Protective Services Law (CPSL) to allow most employers to hire an applicant on a provisional basis for up to 45 days. For certified child care operators, to do so, all the following conditions MUST be met: -The applicant has received the results of the National Sex Offender Registry (NSOR) and out of state clearances, if applicable, and submitted the results to the employer. -The employer, administrator, supervisor, or other person responsible for employment decisions received the result of the applicant's PA Child Abuse History Clearance AND either the Pennsylvania State Police Criminal Record Check OR the FBI Criminal History Background Check before the start of employment. The applicant must have applied for the outstanding check (Pennsylvania State Police Criminal Record Check or the FBI Criminal History Background Check) and submit proof of application to the employer, administrator, supervisor, or other person responsible for employment decisions. 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: 3270.95(a)/3270.95(b)

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

Noncompliance Area: During the Renewal Inspection on 4/26/2022, the Fire Drill and Fire Detection Log did not document that the fire detection system in the facility has been getting tested at least every 30 days.

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.