922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, two (2) staff members (DOH 09/05/23 and 10/14/20) did not have evidence of a negative tuberculin skin result, nor a physician’s statement clearing this individual of active tuberculosis. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Children's Records Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, two (2) children had immunization records that were outdated. Both had been enrolled longer than thirty (30) days.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, three (3) children’s files reviewed did not list a preferred hospital, and one (1) did not list a physician. Written Documentation In Compliance Posted Documentation In Compliance Animals Not Applicable

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:280 · 922 KAR 2:280. Section 4. Procedures and Payments.

General: Based on review of documentation, staff hired on 10/14/21, 2/02/20 and one staff without a hire date did not have the results of the required background check on file. The Kentucky National Background Service was reviewed. None of the staff were working alone at the time of the inspection. Supervision In Compliance Staffing Requirements In Compliance General Administration Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 6. License Issuance.

General: Based on review of documentation, the liability insurance for the after school program was not available for review. Director Requirements In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report Employee Records Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, there were two (2) staff files that did not have a hire date listed. The staff person in charge did not know either hire date.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, staff hired on 08/21/22 and one staff with hire date unknown did not have education documentation on file.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, staff hired 02/20/20, 10/14/21 and 07/20/20 did not have current documentation on file from a health care professional stating they were free of active tuberculosis.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 7. First Aid and Medicine.

General: Based on review of documentation, staff hired on 08/21/22, 10/14/21, 07/20/20, 10/08/21 and two (2) staff with hire dates unknown did not complete the required CPR/First Aid one hour training that is required by the Cabinet. The ECE-TRIS was reviewed.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, the following was found: 1) Staff hired on 08/21/22, 10/08/21 and 02/20/20 did not complete the required Orientation. The staff members have been employed for more than 3 months. 2) Staff hired on 02/20/20, 10/14/21, 12/02/21, 10/17/16 and 10/08/21 did not complete the required fifteen (15) hours of cabinet approved training on file. 3) Staff hired on 02/20/20, 12/02/21 and 10/08/21 did not complete the required PAHT training. The staff members have been employed for more than one year. 4). Staff hired 10/17/16 completed PAHT training on 10/24/16; however, the staff member did not renew the training due 10/24/21. The ECE-TRIS was reviewed. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Outdoor Play Area In Compliance Equipment In Compliance Transportation In Compliance Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, 3 children enrolled on 08/10/22 had immunization records on file but there was no expiration date listed on thier records. Written Documentation Not In Compliance

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, staff hired on 02/02/20, 12/02/21, 10/17/16 and 10/08/21 did not have a current professional development plan on file. Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:280 · 922 KAR 2:280 - Section 4. Procedures and Payments.

General: Based on review of documentation, this regulatory requirement was not met. The following was found: 1. One staff person (hire date: 2/2/20) had a completed child abuse/neglect check (CAN) and a completed criminal records check (CRC) in their file from September and October 2020. However, a review of the Kentucky National Background check service (KARES) found this staff person has not had a fingerprint-based background check processed; therefore, does not have the eligible for hire status. This staff person was observed working alone with a group of 13 children during the inspection. 2. One staff person (hire date: 10/14/20) had a completed child abuse/neglect check (CAN) and a completed criminal records check (CRC) in their file from October 2020. However, a review of the Kentucky National Background check service (KARES) found that the facility has yet to initiate the process for obtaining a fingerprint-based background check for this staff person; therefore, does not have the eligible for hire status. Supervision In Compliance Staffing Requirements In Compliance General Administration In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report Director Requirements Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 10. Director Requirements and Responsibilities.

General: Based on review of documentation, one staff eligible for an annual performance review did not have documentation on file at the facility. This staff person had a 10/14/20 hire date. Employee Records Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation and interview, this regulatory requirement was not met. A review of staff files during the inspection found two staff that did not have the date of employment listed in their file. The staff person in charge reviewed information on her computer and then verbally identified the dates 10/22/21 and 10/11/21, as the hire dates. However, the dates of hire were not maintained in the personnel files.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, this regulatory requirement was not met. Two staff (hire dates: 10/8/21 and 10/22/21) did not have educational documentation on file.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, this regulatory requirement was not met. Two staff (hire dates: 10/8/21 and 10/22/21) did not have T.B. documentation on file.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation and the Training Records Information System (TRIS), the following was found: 1. One staff person (hire date: 2/2/20) did not complete the required Orientation training, the required PAHT training, and did not complete the required 15 hours of cabinet-approved training hours between 7/1/2020 and 6/30/21. 2. One staff person (hire date: 10/17/16) completed PAHT training on 10/24/16; however, did not renew the training due by 10/24/21. This same staff person did not complete the required 15 hours of cabinet-approved training hours between 7/1/2020 and 6/30/21. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, this regulatory requirement was not met. The following was found: 1. One child (enrollment date: 8/12/21) had an immunization certificate on file that was no longer current as of 1/30/18. 2. One child’s file had an immunization certificate that did not have the required information (expiration date); therefore, it could not be determined whether or not the immunization certificate was current. Written Documentation In Compliance Posted Documentation Not In Compliance

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 8. General.

General: Based on review of documentation, information on the Kentucky Consumer Product Safety Program and the program’s website was not posed. Animals Not Applicable

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, staff hired on 09/25/2020, did not have education documentation on file. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Children's Records Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, two children did not have an immunization record on file.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, the following was found: 1) Out of the 10 children files reviewed, only one child had an enrollment date listed. Staff person in charge stated that she did not know the exact date each child was enrolled without looking up that information in the system. 2) All 10 children's files reviewed did not have an emergency medical care authorization signed by the parent/guardian. Written Documentation Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, one staff member did not have a current professional development plan on file. Posted Documentation In Compliance Animals Not Applicable Emergency Regulation In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, staff hired on 08/26/16 did not have education documenation on file.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, staff hired on 07/22/19 did not have education documentation on file. Programming In Compliance Premises In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance Children's Records Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, children enrolled on 08/15/19 did not have an immunization record on file.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, child enrolled on 08/15/19 did not have a physician's contact number or preferred hospital listed on file. Written Documentation Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 3. General Requirements.

General: Based on review of documentation, there was no documentation of the names of the children who participated in each monthly fire drill. Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, this regulatory requirement was not met. Surveyor review of the emergency drill log revealed that the detailed time of each practiced fire and tornado drill had not been documented. Posted Documentation In Compliance Animals Not Applicable

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 6. License Issuance.

General: Based on review of documentation, this regulatory requirement was not met. A review of the facility's liability insurance documentation on file found that the coverage dates were 7/1/17 through 8/1/18; therefore, the policy was not current. Director Requirements Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 10. Director Requirements and Responsibilities.

General: Based on review of documentation, this regulatory requirement was not met. Two (2) staff eligible for an annual performance review did not have documentation of a review on file in the facility. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report Employee Records Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, observation and interview, the facility failed to maintain staff files. A staff person with a 8/15/18 hire date was observed working with the children on the day of the survey. The staff person in charge stated that this person "floats between several different sites". A review of the facility files during the inspection found that this staff person did not have an employee file available for the surveyor to review. The staff person in charge stated that she thought it was in the file cabinet with the rest of the staff files; however, she was not able to locate it.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, this regulatory requirement was not met. Three (3) staff (hire dates: 9/5/18, 8/24/18 and 8/15/18) did not have educational documentation on file.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, this regulatory requirement was not met. Two (2) staff (hire dates: 11/17/17 and 8/15/18) did not have T.B. documentation on file.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation and the Training Records Information System (TRIS), one (1) staff file (hire date: 8/26/16) did not contain the required fifteen (15) hours of training. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Children's Records Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, this regulatory requirement was not met. At the time of the survey a review of ten (10) children's files found that eight (8) children (enrollment dates: 5/23/18, 7/24/18, 8/14/18, 7/23/18, 8/22/18, 8/4/18, 8/3/18 and 5/10/18) had no immunization record on file. Written Documentation Not In Compliance

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, this regulatory requirement was not met. The following was found: 1. One (1) staff person (hire date: 10/17/16) did not have evidence of a staff professional development plan on file in the facility. 2. One (1) staff person (hire date: 11/28/16) had a blank staff professional development plan in her file and a plan that was dated 11/2016; therefore, she did not have one that was current.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.

General: Based on Review of Documentation, an employee with a hire date of 08/08/2017 and an employee with a hire date of 11/28/2016 did not have proof of completing an orientation class within the required ninety (90) day time period. A review of ECE-TRIS supported this finding. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Children's Records Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, eight (8) out of the ten (10) children's files produced for review did not have proof of current immunization. Written Documentation In Compliance Posted Documentation In Compliance Animals Not Applicable

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Statement of Deficiency and Corrective Action Plans.

A PLAN OF CORRECTION WAS DUE ON 30 Nov 16 AND AS OF 09 Dec 16, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. Director Requirements In Compliance Employee Records Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.

General: Based on Review of Documentation, one (1) staff hired on 2/02/15 did not complete fifteen (15) hours of cabinet-approved early care and education training during the staff members completed training year. The staff member completed 12 hours of training. The ECE-TRIS system was reviewed as well as the staff member's file. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Equipment In Compliance Transportation Not Applicable Food Service In Compliance Children's Records Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, one (1) child's file did not have a preferred hospital listed in the enrollment paperwork. The enrollment form was marked with "no preference" under the preferred hospital. Written Documentation Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 5. Evacuation Plan.

General: Based on Observation, the facility did not have written evidence of the annual submission of the emergency evacuation plan in accordance with KRS 199.895. The last documented submission of the plan was 8/1/13.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 3. Records.

General: Based on Observation, during the relicensure survey there were thirty-seven (37) children signed into the after-school program and only thirty (30) children present in the cafeteria. Based on observation and interviews a group of students left the gym to attend an archery class sponsored by the school and there was not an employee of the after- school program present with the children. The children were not signed out; therefore, the daily attendance sheets did not match the number of children present in the after-school program. Posted Documentation In Compliance Animals Not Applicable

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Statement of Deficiency and Corrective Action Plans.

A PLAN OF CORRECTION WAS DUE ON 12 Oct 15 AND AS OF 10 Nov 15, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 4. Director Requirements and Responsibilities.

General: Based on Review of Documentation, there were no current staff evaluations on file for staff members hired on 08/22/13, 10/29/13 and 10/28/13.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.

General: Based on Review of Documentation, staff member hired on 08/14/15 did not have education documentation on file.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.

General: Based on Review of Documentation, staff hired on 08/12/15, 08/13/15, 08/14/15, 09/14/15 and 08/22/13 did not have current documentation on file from a health professional that they are free of active tuberculosis.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.

General: Based on Review of Documentation, staff member hired on 08/13/14 had only six (6) hours of cabinet approved training on file. Staff member hired on 08/22/13 had only six (6) hours of cabinet approved training on file. Staff member hired on 10/28/13 had no cabinet approved training hours on file.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, two (2) children enrolled on 08/12/15 did not have a current immunization record on file.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, there was not a written annual professional development plan on file for the staff.

Open Not marked corrected in the state record

Open / not marked corrected.