Brilliant Minds Llc

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: Several children's records did not contain a child service report that had been completed within the past 6 months. (#1, #2, #3, and #4)

Correction Required: The services to be provided to the family and the child, including the Department's approved form to provide information to the family about the child's growth and development in the context of the services being provided. The operator shall complete and update the form and provide a copy to the family in accordance with the updates regarding emergency contact information in § 3270.124(f) (relating to emergency contact information). Complete and submit a current up-to-date child service report for the indicated child. Ensure that child service reports are completed for all children as specified in this regulation.

Regulation: 3270.124(f)/3270.181(c)

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

Noncompliance Area: Emergency contact and financial agreement information in four children's records were not being updated every 6 months.(#1, #2, #3 and #4) Two children's records did not contain a financial agreement completed in the past 6 months.(#1 and #2)

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. Revise and submit written policies and procedures to ensure that children's emergency contact and financial agreement information is updated at least every 6 months or as soon as the information changes. Obtain and submit current up-to date financial agreement information for the two identified child.

Regulation: 3270.131(b)(2)

Description: Toddler/preschool: updated health report every 12 months

Noncompliance Area: One child's record did not contain a health report completed within the past 12 months as required for children older toddler age to preschool age. (#1- last completed on file 7/9/23)

Correction Required: The operator shall require the parent to provide an updated health report at least every 12 months for an older toddler or preschool child. Obtain and submit a current up-to-date health report for the indicated child. Ensure that an updated health report is obtained every 12 months for children older toddler to preschool age.

Regulation: 3270.182(3)/3270.182(5)

Description: Consent for emergency medical care required prior to admission/Consent for administration of minor first-aid required prior to admission

Noncompliance Area: One child's record did not contain written verification of signed parental consent for emergency medical care and for administration of minor first-aid procedures by facility staff prior to admission. (#5)

Correction Required: A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission. 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. Obtain and submit written verification of signed parental consent for emergency medical care and for administration of minor first-aid procedures by facility staff prior to admission for the indicated children. Ensure that this information is in all children's records.

Regulation: 3270.27(a)(6)

Description: Emergency plan

Noncompliance Area: There was no written record verifying that emergency drills were being conducted annually.

Correction Required: Emergency drills shall be conducted annually. Annual emergency drills shall be documented and on file at the facility. Conduct an emergency drill and ensure that an emergency drill is conducted annually. Submit a copy of the completed emergency drill form to verify compliance.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: One staff person's required CCDBG health and safety training was not completed within 90 days of employment. It was completed more than one year after initial date of hire. (#4- hired 2/1/24 completed 9/7/24)

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Revise facility practices to ensure that the required CCDBG health and safety training is completed within 90 days of employment.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The facility was not in compliance with the CPSL and with Chapter 3490 (relating to protective services): Several staff/facility person's record did not contain the required CPSL hiring documents. (#1-hired 8/7/24- STATE POLICE 1/22/25, FBI 1/24/25, NSOR 1/27/25- no proof of request prior to working with children and completed more than 45 days after hire; also outdated DISCLOSURE STATEMENT) (#2- hired 1/7/25- STATE POLICE 1/17/25, NSOR 1/9/25-no proof of request for STATE POLICE prior to working with children and no completed NSOR prior to working with children)(#3-hired 10/1/24-STATE POLICE 1/23/25, CHILD ABUSE 1/30/25, FBI 1/28/25, NSOR 10/4/24-no proof of requests for STATE POLICE or FBI prior to working with children and no completed CHILD ABUSE and NSOR prior to working with children (#4- hired 2/1/24- STATE POLICE 9/1/24, CHILD ABUSE 9/9/24, FBI 8/1/24- no completed CHILD ABUSE and no completed STATE POLICE or FBI prior to working with children; mandated reporter training not completed within

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: 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. Submit an updated DISCLOSURE STATEMENT using the new form for staff person #1. Revise and submit written policies and procedures regarding the CPSL hiring requirements to ensure that all staff/facility persons (new and existing) have the required CPSL clearance documents within the required timeframes in accordance with the CPSL.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: Operator lacked written documentation on file indicating that the fire alarm system has been tested every 30 days as required under Fire Act of July 14, 2020.

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. The fire alarm system must be tested every 30 days as required under Act 62. Submit written documentation verifying that the system has been tested as specified. Ensure that the system is tested, documented in writing and retained with the fire drill records as required in ACT 62.

Regulation: 3270.27(b)

Description: Plan reviewed/updated annually

Noncompliance Area: There was no written documentation indicating that the emergency plan had been reviewed and updated within the past 12 months in accordance with 55 PA CODE 3270 regulations. The posted plan was dated 2022 and the current plan was not presented at the time of the inspection.

Correction Required: The operator shall review the emergency plan at least annually and update the plan as needed. The operator shall document in writing each review and update of the emergency plan and kept on file at the facility. Submit a written copy of the updated emergency plan. Ensure that the plan is reviewed and documented in writing annually as specified.

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: On 1/22/26, the bus driver dropped a child off at home and left child with a stranger. The parent had not given permission for the child to be released to this person.

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: Children must be supervised at all times by2/20/25. The legal entity must arrange for all facility driver staff persons to receive 2 hours of DHS approved training in proper supervision of children, including transportation protocols for drivers to follow when dropping off children. Submit written verification of the completed training for all facility driver staff persons. Submit written documentation of the facility's transportation protocols by 3/20/25.

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: Several children's records did not contain a child service report that had been completed within the past 6 months. (child #2), (child #3) and (child #5)

Correction Required: The services to be provided to the family and the child, including the Department's approved form to provide information to the family about the child's growth and development in the context of the services being provided. The operator shall complete and update the form and provide a copy to the family in accordance with the updates regarding emergency contact information in § 3270.124(f) (relating to emergency contact information). Complete and submit a current up-to-date child service report for the indicated child. Ensure that child service reports are completed for all children as specified in this regulation.

Regulation: 3270.123(a)(5)

Description: Designated release persons

Noncompliance Area: Several children's records contained agreements that did not specify the persons designated by a parent to whom the child may be released. (child #1-corrected) (child #2-corrected) (child #3-corrected) (child #4- not corrected)

Correction Required: An agreement shall specify the persons designated by a parent to whom the child may be released. Update the agreements to specify the persons designated by a parent to whom the child may be released. Submit a copy of the updated agreements.

Regulation: 3270.123(a)/3270.123(a)(6)

Description: Signed /Admission date

Noncompliance Area: One child's agreement was not signed by the operator and did not contain the date of admission. (child #2)

Correction Required: An agreement shall be signed by the operator and the parent. An agreement shall specify the date of the child's admission. Obtain and submit a signed agreement for the indicated child that includes both the operator and parent's signature as specified. Specify the date of admission on the child's agreement and submit a copy of the properly completed agreement for verification of compliance. Ensure that all agreements are signed by the parent and include the date of the child's admission.as required.

Regulation: 3270.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: One child's emergency contact information did not include the health insurance policy number. (child #4)

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. Obtain and submit the health insurance policy number for the identified child. Ensure that all children's records include the health insurance information as specified in this regulation.

Regulation: 3270.124(f)/3270.181(c)

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

Noncompliance Area: Two children's records did not contain emergency contact and financial agreement information that had been reviewed and updated within the past 6 months. (child #2 and child #3)

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. Obtain and submit written verification of the updated emergency contact and financial agreement information for the identified children.

Regulation: 3270.131(b)(1)

Description: Infant: updated health report every 6 months

Noncompliance Area: One child's record did not contain a health report completed within the past 6 months as required for a child from infant to young toddler age. (child #2)

Correction Required: The operator shall require the parent to provide an updated health report at least every 6 months for an infant or young toddler. Obtain and submit a current up-to-date health report for the indicated child. Ensure that an updated health report is obtained every 6 months for children from infant to young age.

Regulation: 3270.27(a)(1)

Description: Emergency plan

Noncompliance Area: The facility's emergency plan did not provide for shelter of children during an emergency including lock down procedures.

Correction Required: The facility shall have an emergency plan that provides for accommodations for shelter of children during an emergency including lock-down, shelter in place at the facility and shelter at locations away from the facility premises. Amend the facility emergency plan to include lock down procedures. Submit a written copy of the amended emergency plan.

Regulation: 3270.27(a)(5)

Description: Emergency plan

Noncompliance Area: The facility's emergency plan did not include provide for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

Correction Required: The facility shall have an emergency plan that provides for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions. Amend the facility emergency plan to include accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions. Submit a written copy of the amended emergency plan.

Regulation: 3270.27(e)

Description: Letter to parents

Noncompliance Area: The letter given to parents regarding the emergency plan did not explain the emergency procedure /updates to the plan as required in 3270.27 subsection a. Revise the letter given to parents to ensure that it explains the emergency procedures/ and updates to the plan as required in 3270.27 subsection a.

Correction Required: The operator shall provide to the parent of each enrolled child a letter explaining the emergency procedures. The operator shall also provide to the parent of each enrolled child a letter explaining any subsequent update to the plan. Submit a copy of the revised letter.

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 2/2/24, a child sustained an injury to the eye while in care and the operator failed to provide the parent an injury report.

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. Ensure that parents are provided the original report on the day of the incident. Revise and submit written policies and procedures to ensure that parents are provided the original incident report on the date of the incident.

Regulation: 3270.20(a)(1)

Description: Inpatient hospitalization or ER treatment of child

Noncompliance Area: On 2/2/24, a child sustained an injury to the eye while in care and was taken to the emergency room for treatment. The operator failed to notify the Regional Office within 24 hours as required.

Correction Required: The operator shall immediately notify a child's parent and shall telephone notice to the appropriate regional office within 24 hours if a child in care at the facility is hospitalized or receives emergency room treatment. Revise policies and practices to ensure that telephone notice is made to the appropriate regional office within 24 hours if a child in care at the facility is hospitalized or receives emergency room treatment.

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: On 2/2/24, a child sustained an injury to the eye and staff persons were unaware of what caused the injury.

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: Children must be supervised at all times -corrected by 2/21/24 The legal entity must arrange for all facility staff persons to receive at least 2 hours of training in supervision of children. Submit written verification of the completed training for all staff persons. - correction by 3/21/24

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: Two staff persons were observed caring for a group of 14 school-age children and none had been assigned responsibility for supervision of specific children in the group. (#1, #2 and #3)

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. The legal entity must inform staff of these requirements and develop procedures for assigning staff the responsibility for supervision of specific children as well as for staff persons being physically present and knowing the names of the children in their assigned group. Submit written documentation of the facility's procedures for assigning supervision responsibility.

Regulation: 3270.119

Description: Infant sleep position

Noncompliance Area: An infant was observed in the infant room sleeping face down on a pillow on the floor. Staff acknowledged placing child face down to sleep. (child #6)

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 all facility staff persons to complete training in proper infant sleeping position and use of age-appropriate rest equipment. Submit written verification of the completed training for all facility staff.

Regulation: 3270.121(b)

Description: Given parents in writing

Noncompliance Area: Two children's agreement did not indicate that at the time of enrollment, a parent received 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. (#1 and #2)

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. Obtain and submit written verification that this information has been given to the parent. Ensure that the specified information is given to the parent in writing at the time of enrollment as specified in this regulation.

Regulation: 3270.123(a)(1)

Description: Amount of fee

Noncompliance Area: One child's record contained an agreement that did not specify the amount of the fee to be charged per day or per week. (#3)

Correction Required: An agreement shall specify the amount of the fee to be charged per day or per week. Update the agreement to specify the amount of the fee to be charged per day or per week. Submit a copy of the updated agreement. Ensure this information is completed for all children's files. T

Regulation: 3270.123(a)(5)

Description: Designated release persons

Noncompliance Area: Two children's records contained agreements that did not specify the persons designated by a parent to whom the child may be released. (#1 and #4)

Correction Required: An agreement shall specify the persons designated by a parent to whom the child may be released. Update the agreements to specify the persons designated by a parent to whom the child may be released. Submit a copy of the updated agreements.

Regulation: 3270.124(b)(2)

Description: Physician name, address, phone

Noncompliance Area: One child's emergency contact information did not include the telephone number of the child's physician or source of medical care. (#1)

Correction Required: Emergency contact information must include the name, address and telephone number of the child's physician or source of medical care. Obtain and submit the telephone number of the child's physician or source of medical care for the identified child. Ensure that all children's records include this information as specified in this regulation.

Regulation: 3270.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: One child's emergency contact information did not include the home and work addresses and telephone numbers of the enrolling parent. (#2)

Correction Required: Emergency contact information must include the home and work addresses and telephone numbers of the enrolling parent. Obtain and submit the missing required information. Ensure that the contact information includes the home and work addresses and telephone numbers of the enrolling parent.

Regulation: 3270.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: Several children's emergency contact information did not include health insurance coverage and policy number information. (#2, #4 and #5)

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. Obtain and submit a written copy of the missing health insurance information for the identified child. Ensure that all children's records contain emergency contact information as specified in these regulations.

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: One child's emergency contact information did not include the complete contact information- name, address and telephone number of the individual designated by the parent to whom the child may be released. (#1)

Correction Required: Emergency contact information must include the name, address and telephone number of the individual designated by the parent to whom the child may be released. Obtain and submit a written copy of this missing contact information for the identified child. Ensure that all children's records contain emergency contact information as specified in these regulations.

Regulation: 3270.151(a)

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

Noncompliance Area: One staff person's record/s did not contain a health assessment including negative TB skin testing completed within 12 months prior to the date of hire. (#3)

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. Obtain and submit a current up-to-date health assessment for the identified staff person including negative TB skin testing. Ensure that health assessments contain the required information and are completed within the required timeframes.

Regulation: 3270.151(c)(2)

Description: Mantoux TB

Noncompliance Area: Two staff person's records did not contain a health assessment including negative TB skin testing completed within 12 months prior to the date of hire. (#1and #4 )

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. Obtain and submit written verification of negative TB skin testing for the identified staff person. Ensure that facility persons' health assessments include written verification of tuberculosis screening by the Mantoux method.

Regulation: 3270.37(b)(3)

Description: 8th grade + 2 yrs

Noncompliance Area: One staff person's record did not contain written verification of education and experience for their aide position. (#3)

Correction Required: An aide shall have a minimum of an 8th grade education and 2 years of experience with children. Obtain and submit written verification of education and experience for the identified staff person. Ensure that all staff records have written verification of education and experience for their positions.