BRIGHT HORIZONS AT MOUNT JOY

Staff assigned to specific children (3270.113(a)(1))

Staff persons #1 and #2 were present with a group of 17 preschoolers. When the staff were asked to identify the names and whereabouts of the children in their care groups, only 16 of the 17 children were accounted for. Requirement: 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. This portion of the plan shall have an immediate correction date. TIERED LIS: The legal entity must arrange for staff persons #1 and #2 to receive a DHS approved 2 hour training on supervision. The legal entity must receive DHS approval of the training content prior to completion of the training. Documentation of completed training must be submitted to DHS and be kept on file at the facility. This portion of the plan shall have a correction date within 14 days. Correction: Staff persons #1 and #2 will receive two hours of additional training in supervision through Better Kid Care offerings. The DHS approved trainings for Staff persons #1 and #2 are: (1) Supervision: Teamwork and (2) Supervision: Counting Children. These trainings will be completed on July 2, 2026. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Supervised at all times /Staff assigned to specific children (3270.113(a)/3270.113(a)(1))

The facility self-reported the following incident: Staff persons #1 and #2 were caring for a group of preschoolers on the afternoon of Thursday, May 21st. Child #1 was able to exit the room without staff supervision, following along with a large group of other families that were picking up their children at the end of the day. Once they exited the building, a parent realized child #1 was not with a parent and returned child #1 to the office staff. Staff estimated that the child was without staff supervision for less than 2 minutes. Requirement: 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. 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. Correction: The center conducted a full investigation of the incident and followed our company protocol by including HR in progressive counseling, up to and including termination of Staff number 1. Inspection: Self-Reported Non Compliance. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Devices must be compliant (3270.95(a))

The proof and date of purchase of the interconnected fire detection device or system was not on file with the facility's fire drill logs. Requirement: Fire detection devices or systems must be in compliance with standards established under section 1016(c) of the act (62 P.S. § 1016(c)). A child care center shall keep the proof and date of purchase of an interconnected fire detection device or system with the facility's fire drill logs. Correction: We have contacted our business partner from which the facility rents from to obtain documentation showing proof and date of purchase for the interconnected fire detection system. If we are unable to obtain the proof of purchase, we will complete the attestation form. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Physician/CRNP assessment (3270.151(c)(5))

The health assessment on file for facility person #11 did not include the physician's or CRNP's assessment of the person's suitability to provide child care. Requirement: An adult health assessment must include the physician's or CRNP's assessment of the person's suitability to provide child care. Correction: Facility person #11, who served as a volunteer through our business partner program, will not be permitted to have contact with children until a completed health assessment, including the physician's determination of suitability to provide child care, is obtained and placed on file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Exam communicable disease (3270.151(c)(3))

The health assessment on file for staff person #7 did not include an examination for communicable diseases and the results of that examination. Requirement: An adult health assessment must include an examination for communicable diseases and the results of that examination. Correction: Staff person #7 will provide an updated health assessment including examination results for communicable diseases. It will be placed in the staff file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Staff assigned to specific children (3270.113(a)(1))

Staff persons #7 and #8 were present with a group of 20 preschoolers. When the staff were asked to identify the names and whereabouts of the children in their care groups, only 16 of the 20 children were accounted for. Requirement: 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. Correction: Staff persons #7 and #8 were immediately retrained on active supervision and the requirement to know the names and whereabouts of every child in their care at all times. All classroom staff will conduct and document regular name-to-face attendance checks during transitions, outdoor play, and throughout the day to ensure accurate accountability of all children. Any time a new child enters the classrooms, the staff will conduct a new name to face check to ensure all children are accounted for. When doing the name to face they will verbally out loud name all children. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Building Surfaces (3270.76)

An area of the fence on the preschool playground was cracked, creating a sharp edge. Requirement: Floors, walls, ceilings and other surfaces, including the facility's outdoor play space surfaces shall be kept clean, in good repair and free from visible hazards. Correction: The damaged section of fencing was repaired. The cracked/sharp portion of the fence was cut off and smoothed to eliminate the sharp edge and restored it to a safe condition. Staff will conduct routine playground safety inspections to monitor fencing and playground equipment for damage or hazards. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Heat Source (3270.71)

The kitchen contained a working stove, which was accessible to the children that use the neighboring hallway / play area. Requirement: Hot water pipes and other sources of heat exceeding 110° F that are accessible to children shall be equipped with protective guards or shall be insulated to prevent direct contact. Correction: At the time of the inspection the door was shut but not locked to the kitchen. On April 27th, a child protective lock was placed on the door to restrict immediate child access. The kitchen was secured with the child lock so children did not have access to opening the door if they were in the hallway. The kitchen will remain a staff only area at all times. A sign was placed on the door stating "Staff Only-No Child Access". Staff have been retrained on supervision requirements and the importance of preventing child access to the kitchen appliances and cooking equipment. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Locked or inaccessible (3270.66(a))

K-prep - Hand sanitizer was observed on a child's bag in an area accessible to the children in the room. (CORRECTED ON SITE) Requirement: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children. Correction: The hand sanitizer was immediately removed from the child's bag upon discovery during the inspection. The item was relocated to a staff only storage area that is inaccessible to children. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Comply with CPSL/CPSL information (3270.32(a)/3270.192(4))

Staff person #7 complete mandated reporter training 3/3/2020 and subsequently more than 60 months later on 8/15/25. The disclosure statements on file for facility persons #11 and #12 were incomplete as they each were not signed by a witness. Requirement: 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. Correction: Staff have been retrained on the requirement to complete mandated reporter trainings at minimum every 60 months to ensure they stay within compliance. Facility persons #11 and #12 are no longer volunteering at the facility. A centralized staff compliance tracking system has been implemented to monitor mandated reported training expiration dates which will be completed by the Center Director and reviewed on a monthly basis. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Fire safety - 1 yr. (3270.31(e)(4)(ii))

Staff persons #1 and #4 completed fire safety trainings in February of 2025 and subsequently more than 12 months later in April of 2026. Staff persons #2, #3, and #9 completed fire safety trainings in February of 2025 and subsequently more than 12 months later in March of 2026. Staff persons #5, #8, #10 completed fire safety trainings in March of 2025 and subsequently more than 12 months later in April of 2026. Staff person #6 completed fire safety trainings in August of 2024 and subsequently more than 12 months later in April of 2026. Requirement: 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. Correction: A training tracking system in the form of both an excel sheet and calendar reminders have been implemented to monitor all staff training expirations dates. All fire safety trainings will be scheduled at least 30 days prior to expiration. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Mantoux TB/Health assessment, TB test (3270.151(c)(2)/3270.192(3))

At the time of inspection, documentation of the date of TB test results was not available for facility person #2, #4, and #5. Requirement: An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis. Correction: Individuals #2, #4, and #5 had complete TB tests however the results were housed at the CTC since they were students in the CTC program. Individual #2, #4 and #5 concluded their volunteer services at the end of the academic year and are no longer in the Center. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Physical examination/Health assessment, TB test (3270.151(c)(1)/3270.192(3))

At the time of inspection, the date of the health assessment was not available for facility person #2. The initial health assessment for facility person #7 was observed to have been obtained after the person's start date with the program as evidenced by a health assessment dated 9/8/23 - see LIS for first date working with children. Requirement: An adult health assessment must include a physical examination. 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. Correction: Individual #2's file was obtained for the program's files, including a health appraisal, which was housed at the CTC since they were a student participant in the CTC program. The health assessment for facility person #7 is on file and noted as late. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Building Surfaces (3270.76)

Ceiling tiles in the K Prep, Pre-K 2, and Infant 1 rooms contained water stains, reportedly from the HVAC system pipes above the tiles. Requirement: Floors, walls, ceilings and other surfaces, including the facility's outdoor play space surfaces shall be kept clean, in good repair and free from visible hazards. Correction: Ceiling tiles in K Prep, Pre-K 2, and Infant 1 rooms will be replaced by June 20th. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Has all items (3270.75(c))

In the Preschool 1 room, tweezers were observed to be missing from the first aid kit. In the Two's room, tape was observed to be missing from the first aid kit. BOTH CORRECTED ON SITE. Requirement: A first-aid kit must contain the following: soap, an assortment of adhesive bandages, sterile gauze pads, tweezers, tape, scissors and disposable, nonporous gloves. Correction: Tweezers were added to the Preschool 1 first aid kit and tape was added to the Twos first aid kit during the licensing visit. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Comply with CPSL/CPSL information (3270.32(a)/3270.192(4))

Valid PA State Police Clearance documents were not available for facility person #1 and #3. The clearance document for #1 did not contain the top portion of the form containing the identifying information. The clearance document for #3 did not contain the bottom portion of the form containing the disseminated date information. It was observed that disclosure forms were not obtained from CTC volunteers at time of hire as evidenced by a uniform start date of 10/1/24 and disclosure signature dates of 5/1/25 and 5/2/25. Child abuse clearance for facility person #8 was observed to be late as evidenced by a previous clearance dated 2/20/20 and a new clearance dated 2/26/25. Requirement: 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, #3, #6, and #7 may not work in a child care position at the facility. Correction: Valid PA State Police Clearance documents for facility persons #1 and #3 were obtained. Disclosure forms were on file and noted as late. Child abuse clearance for facility person # 8 is on file and noted as late. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Training regarding plan (3270.27(c))

Documentation showed that the annual emergency plan training for staff occurred beyond the 12-month requirement as evidenced by the fact that a majority of existing staff completed emergency plan training 9/18/23 and again 10/14/24. Requirement: 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. Correction: Emergency plan was conducted 10/14/25 and is noted as late. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).