3280.26(c) · 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.

Emergency plan training for staff #1, #2, and #3 exceeded one year between previous training and current training. The date of the previous training was 5/21/23 and the current training is dated 6/18/24.

Corrected Corrected by Oct 25, 2024

Category: recordkeeping. Marked corrected in the state record.

3280.26(f) · The operator shall send a copy of the emergency plan and subsequent plan updates to the local municipality and to the county emergency management agency.

The facility did not have documentation showing that their emergency plan and plan updates have been sent to the local municipality and to the county emergency management agency.

Corrected Corrected by Oct 30, 2024

Category: physical safety. Marked corrected in the state record.

3280.32(a)/3280.192(4) · 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 #--- may not work in a child care position at the facility.

The disclosure statement for staff person #1 was not included in the staff person's file.

Corrected Corrected by Nov 2, 2024

Category: background checks. Marked corrected in the state record.

3280.123(a)(6) · An agreement shall specify the date of the child's admission.

The agreements for children #1 - #4 did not include the child's date of admission.

Corrected Corrected by Oct 26, 2024

Category: recordkeeping. Marked corrected in the state record.

3280.26(a)(6) · Emergency drills shall be conducted annually. Annual emergency drills shall be documented and on file at the facility.

The facility did not have documentation on file showing that annual emergency drills are conducted.

Corrected Corrected by Oct 25, 2024

Category: recordkeeping. Marked corrected in the state record.

3280.131(a) · 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.

Child #4 did not have an initial or updated health assessment on file. (See LIS code sheet for date of enrollment)

Corrected Corrected by Oct 26, 2024

Category: health medication. Marked corrected in the state record.

3280.171(a) · The operator shall notify local traffic safety authorities in writing of the location of the facility and about the program's use of pedestrian and vehicular routes around the group child care facility.

The facility did not have documentation of notification of local traffic authorities, in writing, of the location of the facility and about the programs' use of pedestrian and vehicular routes around the group childcare facility.

Corrected Corrected by Nov 10, 2024

Marked corrected in the state record.

3280.26(e) · 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.

The operator stated that they were providing parents of each enrolled child information explaining the emergency procedures but the proof could not be located during the inspection.

Corrected Corrected by Oct 27, 2023

Category: physical safety. Marked corrected in the state record.

3280.26(f) · The operator shall send a copy of the emergency plan and subsequent plan updates to the local municipality and to the county emergency management agency.

At the time of the inspection, there was not documentation showing that a copy of emergency plan updates from 2022 were sent to the local municipality and to the county emergency management agencies.

Corrected Corrected by Nov 3, 2023

Category: physical safety. Marked corrected in the state record.

3280.66(a) · Cleaning materials and other toxic materials shall be stored in an original labeled container or in a container that specifies the content. Toxics shall be kept in a locked area or in an area inaccessible to children, and shall be stored away from food, food preparation areas and child care spaces.

The following items were observed to be accessible to children in care at the time and included instructions to keep out of the reach of children: In a plastic bag in a child's cubby, there was Shine and Jam conditioning gel, Just for Me Curl Peace shampoo, Just for Me leave-in conditioner and a package of Member Mark's baby wipes. On the desk in the basement, there was a bottle of white out in a jar and next to the desk in the basement, there was an inhaler in an unlocked cabinet.

Corrected Corrected by Oct 18, 2023

Category: ratio. Marked corrected in the state record.

3280.102(a) · 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.

In the living room, there was a small tear in one of the floor pillows.

Corrected Corrected by Oct 18, 2023

Category: physical safety. Marked corrected in the state record.

3280.102(c) · Outdoor equipment that requires embedded mounting must be mounted over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission. The equipment must be anchored firmly and be in good repair.

The rubber mulch under the embedded swing set in the back yard measured a little over 4 inches.

Corrected Corrected by Nov 3, 2023

Category: physical safety. Marked corrected in the state record.

3280.123(a)(3) · An agreement shall specify 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 at § 3280.124(f).

The last two child service reports in the file for child #1 were dated 9/13/22 and 9/6/23. The last child service report in the file for child #2 was dated 4/8/23.

Corrected Corrected by Nov 3, 2023

Category: recordkeeping. Marked corrected in the state record.

3280.124(f)/3280.181(c) · 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.

The last update in writing by a parent on the emergency contact information and agreement form in the file for child #1 was dated 10/25/22. The last two updates in writing by a parent on the emergency contact information and agreement form in the file for child #2 were dated 9/8/22 and 4/8/23. The last update in writing by a parent on the emergency contact information and agreement form in the file for child #4 was dated 9/25/22 .

Corrected Corrected by Nov 3, 2023

Category: recordkeeping. Marked corrected in the state record.

3280.131(b)(2) · The operator shall require the parent to provide an updated health report at least every 12 months for an older toddler or preschool child.

The last two health reports in the file for child #3, a preschooler, were dated 5/2/22 and 6/20/23.

Corrected Corrected by Oct 18, 2023

Category: health medication. Marked corrected in the state record.

3280.26(a)(6) · Emergency drills shall be conducted annually. Annual emergency drills shall be documented and on file at the facility.

The operator stated that an emergency drill had been conducted in the last 12 months, but there was no documentation of the drill at the time of the inspection.

Corrected Corrected by Nov 3, 2023

Category: recordkeeping. Marked corrected in the state record.

3280.94(a)(1) · The primary staff person 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.

The following fire drills were conducted more than 60 days apart: 12/22/22 and 2/21/23; 4/4/23 and 6/20/23; 6/20/23 and 8/21/23.

Corrected Corrected by Oct 18, 2023

Category: recordkeeping. Marked corrected in the state record.

3280.94(a)(4) · The primary staff person or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that the hypothetical locations of the fire are rotated around the facility for each drill such that the hypothetical location is never the same for consecutive drills.

Based on review of the fire drill log, the hypothetical location was listed as "basement" for consecutive drills on 12/22/22 and 2/21/3

Corrected Corrected by Oct 18, 2023

Category: recordkeeping. Marked corrected in the state record.

3280.95(a)/3280.95(b) · 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 primary staff person or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in subsection (a) are met.

Based on conversation with the operator, the smoke detectors were being tested every 30 days, but were not documented.

Corrected Corrected by Oct 18, 2023

Category: recordkeeping. Marked corrected in the state record.

3280.24(a) · The facility's current certificate of compliance shall be posted in a conspicuous location used by parents. The operator shall provide the parent of each child enrolled with information on how to access the regulations in this chapter electronically and with instructions for contacting the appropriate regional child care office.

The operator stated that they were providing parents of each enrolled child the information on how to access the regulations electronically, but the proof could not be located during the inspection.

Corrected Corrected by Nov 3, 2023

Marked corrected in the state record.

3280.31(f) · Staff person(s) shall complete professional development in the topics of 3280.31(f) (1 -- 10) within 90 days of hire. Staff person #3 will have until 2/7/23 to complete the required training. Until such time as the required training has been completed, staff person #3 must be supervised, when interacting with children, by a primary staff person who has completed the required training related to this citation. If there are no staff person(s) available to supervise staff person #3, staff person #3 may not work in a child-care position at the facility.

Continued Non-Compliance: On 10/19/22, a renewal inspection was conducted at the facility. Staff person #3 had not completed the following required pre-service training within 90 days of their date of hire: Acceptable first aid/cpr. The facility's acceptable plan of correction indicated the correction would be implemented by 12/15/22. On 1/20/23, an unannounced inspection was conducted. Staff person #3 still has not completed the following required pre-service training: first aid/cpr

Corrected Corrected by Jan 23, 2023

Category: supervision. Marked corrected in the state record.

3280.31(f) · Staff persons shall complete professional development in the topics of 3280.31f (1-10) within 90 days of hire. Staff person #1 and #2 will have until 2/7/23 to complete the required training. Until such time as the required training has been completed, staff person #2 and #3 must be supervised, when interacting with children, by an assistant group supervisor who has completed the required training related to this citation. If there are no staff available to supervise staff person #1 and #2, staff person #1 and #2 may not work in a child-care position at the facility.

Staff person #1 and #2 has not completed the following required pre-service training within 90 days of their date of hire: first aid/cpr.

Corrected Corrected by Jan 23, 2023

Category: supervision. Marked corrected in the state record.

3280.14/3280.20 · 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 did not address volunteer emergency preparedness training or continuity of operations.

Corrected Corrected by Dec 29, 2022

Category: ratio. Marked corrected in the state record.

3280.14/3280.20 · 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 had a shaken baby policy, but it did not address the identification and prevention of child maltreatment (child abuse).

Corrected Corrected by Jan 2, 2023

Category: ratio. Marked corrected in the state record.

3280.26(c) · 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.

The last two emergency plan trainings in the file for staff person #2 and #3 were dated 4/28/21 and 5/21/22.

Corrected Corrected by Oct 19, 2022

Category: recordkeeping. Marked corrected in the state record.

3280.31(e) · A staff person shall obtain an annual 12 clock hours of child care training.

The file for staff person #1, #2 and #3, all working with children before 12/19/20, included 6 hours of child care training between 12/19/20 and 12/19/21.

Corrected Corrected by Oct 19, 2022

Category: recordkeeping. Marked corrected in the state record.

3280.32(a) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services).

The last mandated reporter training in the file for staff person #1 was dated 2/14/17.

Corrected Corrected by Dec 29, 2022

Category: recordkeeping. Marked corrected in the state record.

3280.32(a)/3280.192(4) · 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 and #2 may not work in a child care position at the facility.

The last child abuse clearance in the file for staff person #1 was dated 4/8/17 and last two state police clearances in the file were 8/4/16 and 10/22/21. The last state police clearance in the file for staff person #2 was dated 5/10/17.

Corrected Corrected by Jan 2, 2023

Category: background checks. Marked corrected in the state record.

3280.65 · Protective receptacle covers shall be placed in electrical outlets accessible to children 5 years of age or younger.

There was a power strip in the facility's kitchen that was uncovered. Children must pass through the kitchen to get to and from the basement child care space to the 1st floor child care space.

Corrected Corrected by Oct 19, 2022

Category: physical safety. Marked corrected in the state record.

3280.66(a) · Cleaning materials and other toxic materials shall be stored in an original labeled container or in a container that specifies the content. Toxics shall be kept in a locked area or in an area inaccessible to children, and shall be stored away from food, food preparation areas and child care spaces.

There was a bottle of Fabuloso on the kitchen floor. Staff and children must walk through the kitchen to move to and from the 1st floor and basement child care spaces. In the basement bathroom, there were toxics observed in an unlocked cabinet, including Windex, Lysol disinfecting wipes and other cleaning items. There were 3 bottles of hand sanitizer on cabinets in the basement child care space. All items were accessible to children in care and included instructions to keep out of the reach of children.

Corrected Corrected by Oct 19, 2022

Category: ratio. Marked corrected in the state record.

3280.67(d) · Trash that has been contaminated by human secretions or excrement shall be contained in closed, plastic-lined receptacles.

The garbage can in the basement bathroom was unlined.

Corrected Corrected by Oct 19, 2022

Marked corrected in the state record.

3280.103 · Toys and objects with a diameter of less than 1 inch, objects with removable parts that have a diameter of less than 1 inch, plastic bags and styrofoam objects may not be accessible to children who are still placing objects in their mouths.

There were boxes of staples and paper clips in an unlocked desk cabinet in the basement, making them accessible to the toddlers in care at the time. There was rubber mulch in the outdoor toddler gross motor area.

Corrected Corrected by Jan 13, 2023

Category: physical safety. Marked corrected in the state record.

3280.105(a) · Individual, clean, age-appropriate rest equipment shall be provided for preschool, toddler and infant children as agreed between the child's parent and the operator. The rest equipment shall be labeled for the use of a specific child and used only by the specified child.

Several pack n plays in the basement were unlabeled.

Corrected Corrected by Dec 29, 2022

Category: physical safety. Marked corrected in the state record.

3280.123(a)(5) · An agreement shall specify the persons designated by a parent to whom the child may be released.

The agreement in the file for child #2 did not specify the release persons.

Corrected Corrected by Jan 2, 2023

Category: recordkeeping. Marked corrected in the state record.

3280.124(b)(7) · 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.

The emergency contact information in the file for child #1didn't include a city or zip for one of the release persons. The emergency contact information in the file for child #2 didn't include a city or zip for one of the release persons and no phone number for one of them. The emergency contact information in the file for child #3 didn't include an address for two of the release persons.

Corrected Corrected by Jan 2, 2023

Category: recordkeeping. Marked corrected in the state record.

3280.124(f)/3280.181(c) · 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.

The only emergency contact information and agreement form in the file for child #1, enrolled 2/14/22, were signed and dated by a parent on 6/7/22. The only written update by a parent on the emergency contact information in the file for child #2, enrolled in 2020, was 9/25/22 and the last two written updates on the agreements in the file for child #2 were 7/2/20 and 9/25/22. The last written update by a parent on the emergency contact and agreement form in the file for child #4, enrolled 10/5/21 were dated 10/3/21.

Corrected Corrected by Jan 2, 2023

Category: recordkeeping. Marked corrected in the state record.

3280.131(e) · The facility may not accept or retain an infant 2 months of age or older, a toddler or a preschool child at the facility for more than 60 days following the first day of attendance at the facility unless the parent provides written verification from a physician, physician's assistant, CRNP, the Department of Health or a local health department of the dates (month, day and year) the child was administered immunizations in accordance with the recommendations of the ACIP.

The list of vaccinations in the file for child #1, enrolled 2/14/22, were attached to the health report dated 4/29/22.

Corrected Corrected by Oct 19, 2022

Category: health medication. Marked corrected in the state record.

3280.131(e)(1) · The facility shall require the parent to provide updated written verification from a physician, physician's assistant, CRNP, the Department of Health or a local health department of ongoing vaccines administered to an infant, toddler or preschool child in accordance with the schedule recommended by the ACIP.

The file for child #1, an older toddler, did not include evidence of a flu shot or a written exemption by a parent. The last flu shot in the file for child #3, an older toddler, was dated 2020 and there was no written exemption by a parent.

Corrected Corrected by Jan 2, 2023

Category: health medication. Marked corrected in the state record.

3280.151(a)/3280.192(3) · A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

The most recent health assessment in the file for staff person #2 was dated 11/6/19.

Corrected Corrected by Jan 2, 2023

Category: ratio. Marked corrected in the state record.

3280.151(c)(3) · An adult health assessment must include an examination for communicable diseases and the results of that examination.

The most recent health assessment in the file for staff person #1 did not include an examination for communicable disease and the results of that examination, as the second question was unanswered.

Corrected Corrected by Jan 2, 2023

Category: health medication. Marked corrected in the state record.

3280.161(d) · Fresh fruits and vegetables that are not used on the day of purchase shall be refrigerated.

There were apples and bananas observed in a basket on a counter in the basement. Based on conversation with the operator, the fruit was not purchased that day.

Corrected Corrected by Oct 19, 2022

Marked corrected in the state record.

3280.192(5) · 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.

The file for staff person #2 had 1 letter of reference.

Corrected Corrected by Jan 2, 2023

Category: recordkeeping. Marked corrected in the state record.

3280.94(a)(9) · The primary staff person or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that a written record is maintained on file at the facility indicating the specific time of day of the drill, the hypothetical location of the fire, the evacuation time, and the names of the facility persons and the number of children who participate in the fire drill.

The fire drills documented on the facility's fire drill log did not include all of the names of the facility persons who participated in the drill.

Corrected Corrected by Jan 2, 2023

Category: recordkeeping. Marked corrected in the state record.

3280.95(a)/3280.95(b) · 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 primary staff person or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in subsection (a) are met.

Since 12/1/21, there were four times that the testing was conducted between 31 and 33 days apart. The last testing documented was listed as 7/4/22.

Corrected Corrected by Oct 19, 2022

Category: recordkeeping. Marked corrected in the state record.

3280.24(a) · The facility's current certificate of compliance shall be posted in a conspicuous location used by parents. The operator shall provide the parent of each child enrolled with information on how to access the regulations in this chapter electronically and with instructions for contacting the appropriate regional child care office.

Based on conversation with the operator, they have not provided parents of enrolled children with information on how to access the regulations electronically.

Corrected Corrected by Oct 19, 2022

Marked corrected in the state record.

3280.31(f) · Staff person(s) shall complete professional development in the topics of 3280.31(f)(1 -- 10) within 90 days of hire. Staff person #3 will have until 12/28/22 to complete the required training. Until such time as the required training has been completed, staff person #3 must be supervised, when interacting with children, by a primary staff person who has completed the required training related to this citation. If there are no staff available to supervise staff person #3, staff person #3 may not work in a child-care position at the facility.

Staff person #3 has not completed the following required pre-service training within 90 days of their date of hire: Acceptable FA/CPR training.

Corrected Corrected by Dec 28, 2022

Category: supervision. Marked corrected in the state record.

3280.131(a) · 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.

The only health report in the file for child #1, enrolled 2/14/22, was dated 4/29/22.

Corrected Corrected by Oct 19, 2022

Category: health medication. Marked corrected in the state record.

3280.123(b) · A parent shall receive the original agreement. The facility shall retain a copy of the agreement.

The files for child #1, #2, #3, #4, and #5 all contained the original agreement.

Corrected Corrected by Nov 12, 2021

Category: recordkeeping. Marked corrected in the state record.

3280.32(a)/3280.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Facility Person #1 -- may not work in a child care position at the facility. 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 at the facility.

The file for facility person #1 contained a State Police clearance dated for 8/4/16, which is more than 60 months old and a FBI clearance dated for 7/28/16 and 8/26/21, which is more than 60 months apart. The file for facility person #2 contained a Child Abuse clearance dated for 6/24/15 and 10/29/20 and a FBI clearance dated for 7/21/15 and 8/26/21, which is more than 60 months apart.

Corrected Corrected by Oct 15, 2021

Category: background checks. Marked corrected in the state record.

3280.91(a) · Stairways, hallways, exits from rooms, exits from the facility and other means of egress serving as an exit shall be unobstructed.

In the basement, the door leading to the garage was blocked by a highchair.

Corrected Corrected by Oct 15, 2021

Marked corrected in the state record.

3280.124(b)(2) · Emergency contact information must include the name, address and telephone number of the child's physician or source of medical care.

The emergency contact form for child #5 lacked the physician's address.

Corrected Corrected by Nov 12, 2021

Category: health medication. Marked corrected in the state record.

3280.124(b)(7) · 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.

The emergency contact form for child #1, #2, #3, and #4 lacked the release person's address.

Corrected Corrected by Nov 12, 2021

Category: recordkeeping. Marked corrected in the state record.

3280.124(c) · When children are in the facility, emergency contact information shall be present in a child care space for children receiving care in the space.

Facility staff stated, school age children use the living and dinning room. Emergency contact information was not present in the living room or dinning room.

Corrected Corrected by Nov 12, 2021

Category: recordkeeping. Marked corrected in the state record.

3280.124(e) · A written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency shall be displayed conspicuously in every child care space and shall accompany a staff person who leaves on an excursion with children.

Transportation plan was not present in the living room or dinning room.

Corrected Corrected by Nov 12, 2021

Category: transportation. Marked corrected in the state record.

3280.151(a)/3280.192(3) · A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem.A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

The file for facility person #1 contained a health assessment completed on 6/22/19. The file for facility person #3 contained a health assessment completed on 9/25/19, which is more than 24 months ago.

Corrected Corrected by Nov 12, 2021

Category: ratio. Marked corrected in the state record.

3280.26(a)(5) · The facility shall have an emergency plan that provides for accommodations for infants, toddlers, children with disabilities and children with chronic medical conditions.

Facility lacked an emergency plan that provides for accommodations for infants, toddlers, children with disabilities and children with chronic medical conditions.

Corrected Corrected by Nov 12, 2021

Category: physical safety. Marked corrected in the state record.

3280.94(a)(4) · The primary staff person or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that the hypothetical locations of the fire are rotated around the facility for each drill such that the hypothetical location is never the same for consecutive drills.

The fire drill log listed the hypothetical location of the fire as the basement for the last year.

Corrected Corrected by Oct 15, 2021

Category: recordkeeping. Marked corrected in the state record.

3280.94(a)(5) · The primary staff person or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that evacuation routes are posted in a conspicuous location on each floor of the facility.

Primary staff person stated that the evacuation routes were not posted on the 2rd floor.

Corrected Corrected by Nov 12, 2021

Category: recordkeeping. Marked corrected in the state record.

3280.95(a)/3280.95(b) · (a) Fire detection devices or systems must be in compliance with standards established under section 1016(c) of the act (62 P.S. §  1016(c)).(b) The primary staff person or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in subsection (a) are met.

The facility lacked proof of purchase of the inter-connected smoke alarms and documentation of operability.

Corrected Corrected by Nov 12, 2021

Category: recordkeeping. Marked corrected in the state record.

3280.26(a)(1) · The facility shall have an emergency plan that provides 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.

Facility lacked an emergency plan that provides for shelter of children during an emergency lock-down.

Corrected Corrected by Nov 12, 2021

Category: physical safety. Marked corrected in the state record.