BETHANY ACADEMY

2025

1. Medium risk6/24/2025

   Staff evaluations (3270.34(a)(6))

   At the time of inspection facility people #3 & 4 did not have a staff evaluation on file. Requirement: A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months. Correction: Provide staff #3 & #4 with a staff evaluation and add to their staff file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 7/1/2025
2. Medium-High risk6/24/2025

   Emergency plan (3270.27(f))

   At the time of the inspection, the operator did not send a copy of the emergency plan and subsequent plan updates to the local municipality and to the county emergency management agency. Requirement: 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. Correction: Provide a copy of the updated emergency plan to all local municipal and emergency management agency. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 6/30/2025
3. Medium-High risk6/24/2025

   Emergency plan (3270.27(a)(6))

   At the time of inspection, the facility's Emergency drills were not conducted annually. Annual emergency drills were not documented and on file at the facility. Requirement: Emergency drills shall be conducted annually. Annual emergency drills shall be documented and on file at the facility. Correction: We will conduct annual Emergency drill inspections and document on the correct emergency drill log. The drill conducted in January 2025 has been added to the emergency drill log and added to our DHS binder. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 6/25/2025
4. Medium-High risk6/24/2025

   Emergency plan (3270.27(a)(5))

   At the time of inspection, the facility did not have an emergency plan that provided for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions. Requirement: The facility shall have an emergency plan that provides for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions. Correction: provide an updated section of the emergency plan that states the accommodations for all children with medical conditions and disabilities. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 6/30/2025
5. Medium-High risk6/24/2025

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

   At the time of inspection facility person #2 did not have a Mantoux test reading and results on file. 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: Provide staff with the correct staff assessment form to be completed by their physician. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 7/1/2025
6. Medium-High risk6/24/2025

   Updated every 6 months (3270.124(f))

   At the time of inspection, children #2, 3, 4, 5 and 6 did not have a 6-month update of their emergency contact form and financial agreement on file. Requirement: 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. Correction: Provide periodic reviews of all children's files to ensure they are updated with the most recent information. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 6/30/2025
7. Medium-High risk6/24/2025

   Each child care space (3270.124(c))

   At the time of the inspection, child #1 in the school-age classroom did not have an updated emergency contact form. Requirement: When children are in the facility, emergency contact information shall be present in a child care space for children receiving care in the space. Correction: Corrected on site. Provide staff with updated documents to be placed in their classroom binders. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 6/24/2025
8. Medium-High risk6/24/2025

   Has all items (3270.75(c))

   At the time of the inspection the preschool classroom's first aid kit did not have a pair of scissors in them. 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: Corrected on site. Provide staff with scissors to be added to their first aid kit located in the classroom. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 6/24/2025
9. Medium-High risk6/24/2025

   Locked or inaccessible (3270.66(a))

   At the time of the inspection the infant class had a plugin being used while children were in care. Requirement: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children. Correction: Corrected on site. Provide staff with a outlet cover to be placed where the plugin was located. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 6/24/2025
10. Medium risk6/24/2025

    Protective Outlet Covers 5 yrs. or less (3270.65)

    At the time of the inspection, the infant and preschool classes both had one unprotected electrical outlet. Requirement: Protective receptacle covers shall be placed in electrical outlets accessible to children 5 years of age or younger. Correction: Corrected on site. Both outlets were covered with the appropriate outlet covers. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 7/24/2025
11. Medium risk6/24/2025

    Comply with CPSL (3270.32(a))

    At the time of inspection facility person #4 did not have mandated reporter training on file. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Facility Person # 04 may not alone work in a childcare position at the facility. Correction: A copy of the training certificate completion has ben provided by person #4 and added to the staff file and updated on the staff data sheets. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 7/1/2025
12. Medium-High risk6/24/2025

    Training regarding plan (3270.27(c))

    At the time of inspection facility persons #1, 2, 3 and 4 did not have emergency plan training on file. 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: Provide emergency plan training for all staff. Document and place a copy in each staff binder. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 6/30/2025
13. Medium-High risk6/24/2025

    Plan reviewed/updated annually (3270.27(b))

    At the time of the inspection, the operator did not review the emergency plan at least annually and did not update the plan as needed. The operator did not document in writing each review and did not update the emergency plan and have it kept on file at the facility. Requirement: 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. Correction: I will review the emergency plan annually and updated as needed. I will ensure an updated copy is posted around the center and all involved receives a copy. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 6/30/2025
14. Medium-High risk6/24/2025

    Contact when ended (3270.27(a)(4))

    At the time of inspection, the facility did not have an emergency plan that provided for a method for facility persons to inform parents that the emergency has ended and to provide instruction as to how parents can safely be reunited with their children. Requirement: The facility shall have an emergency plan that provides for a method for facility persons to inform parents that the emergency has ended and to provide instruction as to how parents can safely be reunited with their children. Correction: I will provide an updated section to both the family handbook and emergency plan with detailed instructions on when an emergency has ended and how the parents can safely reunite with their children. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 7/1/2025
15. Medium-High risk6/24/2025

    Pertinent Laws & Regulations/General Health and Safety (3270.14/3270.21)

    At the time of inspection facility did not have written policy addressing: The strategies for coping with a crying, fussing, or distraught child on file. Facilities emergency plan did not address continuity of operations. Requirement: 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. Correction: I will provide a section in our emergency plan and handbook describing effective ways and strategies on how to cope with crying, fussing and distraught children. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 7/1/2025
16. Medium-High risk6/24/2025

    Pick-up and drop-off points (3270.171(a))

    At the time of the inspection, the operator did not notify local traffic safety authorities annually in writing of the location of the facility and the program's use of pedestrian and vehicular routes around the childcare facility. Requirement: An operator shall notify local traffic safety authorities annually in writing of the location of the facility and the program's use of pedestrian and vehicular routes around the child care facility. Correction: Locate the signage for informing the local traffic authorities annually of our location and our program use of pedestrian and vehicle routes. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 7/1/2025