LIGHTBRIDGE ACADEMY BLUE BELL

Age and Training/Exp, educ., training at facility (3270.31(e)(4)(i)/3270.192(2)(iii))

At the time of inspection, the file for staff member #1 contained a Pediatric first aid/ CPR training certificate which was not an approved training conducted by a PQAS Instructor. Requirement: Competence is the completion of training by a professional in the field of first-aid and cardiopulmonary resuscitation (CPR). All staff persons shall renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility. Correction: The director will assist staffer #1 with scheduling the training to ensure the individual enrolls in an approved training which will be conducted a PQAS certified instructor. Staff member #2 will complete an approved Pediatric first aid/ CPR training course conducted by a PQAS instructor, as soon as possible. Staff member #2 will not work alone without another qualified staff member supervising, until staffer #2 has completed the required approved Pediatric first aid/ CPR training conducted by a certified PQAS instructor. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Diapering materials storage (3270.135(d))

At the time of inspection, a staff member was observed placing a contaminated gloved hand, which touched the child's diaper area, into a container of diaper cream prior to applying. Requirement: Cloth and paper materials used as diapering aids shall be stored in a manner that prevents cross-contamination from a soiled diaper, contaminated hands or other changing materials. Correction: The staff member was instructed that when using diaper cream, it should be dispensed onto a tissue to prior diapering a child to prevent cross contamination of the cream inside the container. The director will instruct all staff in safe and sanitary diapering practices. If using diaper cream, all staff will dispense it onto a tissue to prevent touching the container with a contaminated hand. Also, if gloves are used for diaper change, and diaper cream is needed, it is to be applied with a freshly gloved finger to prevent cross contamination. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Written consent/Consent for administration of minor first-aid required prior to admission (3270.124(b)(4)/3270.182(5))

At the time of inspection, the emergency contact form for child #2 and child #4 did not contain signed parental consent for emergency medical care and administration of minor first-aid procedures by facility person. Requirement: Emergency contact information must include the written consent signed by a parent for emergency medical care. 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. Correction: The director will contact the child's parent to have them sign their signature on the emergency contact form giving consent for emergency medical care and administration of minor first-aid procedures by facility staff. The director and staff will review all emergency contact forms to ensure written consent is documented with the parent's signature. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Emergency info/agreement updated 6 mos (3270.181(c))

At the time of inspection, the financial agreement for child #1 and child #4 had not been updated or reviewed by the parents of the children in the last 6 months. The financial agreement for child #1 was last signed by the parent on 9/28/24. The financial agreement for child #4 was last signed by the parent on1/9/25. Requirement: 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. Correction: The director will contact the parents of the children listed to have the children's parents review and/or update their financial agreement with date and signature. 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, the health assessment observed in the file for staff member #2 did not contain the result of TB screening. 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: Staff member #2 will submit the results of initial tuberculosis screening completed recently or within the last 12 months, as soon as possible. The director will ensure that staff member #2 submits the results of TB screening, as soon as possible. The initial TB results submitted shall be dated within the 12 the last month and maintained in the staff member's file at the facility. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Name/address/phone release person (3270.124(b)(7))

At the time of inspection, the emergency contact forms for child #2, and child #4 were missing the addresses of the individual designated by parent to who the child may be released. Child #3's emergency contact form was missing the phone number of the individual designated by the parent to who the child may be released. Requirement: 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. Correction: The director will contact the parent of children listed to obtain the missing release persons information. The emergency contact forms for child #2, child #3, and child #4 will include the name, address and telephone number of the individual designated by the parent to whom the child may be released. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Building Surfaces (3270.76)

At the time of inspection, the door closer device at the top of the exterior door in room 3, that regulates and controls the door's swing was in disrepair. Also, in classroom #4 a small amount of chipped/ peeled paint was observed on the window frame of the window facing the hallway. 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 director will ensure the door closer device for the exterior door in room 3 will be reattached and/or repaired to good working condition so the door will work in the way it was intended. The director will ensure the chipped paint on the window frame in room #4 will be repaired to good condition so no peeling paint is present. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

HS/GED + 2 yrs (3270.36(b)(5))

At the time of inspection, the file for staff member #3, hired as an assistant group supervisor and observed working alone, included a high school diploma but was missing the verification of two years (2500 hours) of experience working with children. Requirement: An assistant group supervisor shall have a high school diploma or a general educational development certificate and 2 years experience with children. Correction: The director will provide staff member #3 with a blank verification of experience form(s) to have completed by the individual's previous employer(s) to document the individual's experience working with children. Staff member #3 will submit 1.5 years of verified experience with children to qualify for the position of assistant group supervisor (1/2 yr. documented in file). If two years of experience isn't verified, then staff member #3 would only qualify as an aid and can't work alone without another staff member who must qualified for the position of assistant group supervisor or higher. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

At the time of inspection, the file for staff member #1 contained a PA State Police Clearance with a rap sheet missing the disposition information for an offense dated in 2023. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Facility Person # -- may not work in a child care position at the facility. PROVISIONAL HIRE UNSUPERVISED: A provisional employee may not be permitted to work alone with children and must work within the vicinity of a permanent employee. 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. Correction: Staff member #1 will obtain the disposition information missing from the rap sheet attached to the individual's PA State Police Clearance from the Clerk of Courts Office in the county where the offence occurred. The director will ensure staff member #1 obtains the missing information necessary to make the individual's PA State Police Clearance with corresponding rap sheet complete with the required information in order to be in compliance with the CPSL. The disposition report for staff member #1 will be submit to the facility files and attached to the individual PA State Police Clearance rap sheet. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Age and Training/Exp, educ., training at facility (3270.31(e)(4)(i)/3270.192(2)(iii))

At the time of inspection, the file for staff member #2 contained a Pediatric first aid/ CPR training certificate which was not an approved training conducted by a PQAS Instructor. Requirement: Competence is the completion of training by a professional in the field of first-aid and cardiopulmonary resuscitation (CPR). All staff persons shall renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility. Correction: The director will assist staffer #2 with scheduling the training to ensure the individual enrolls in an approved training which will be conducted a PQAS certified instructor. Staff member #2 will complete an approved Pediatric first aid/ CPR training course conducted by a PQAS instructor, as soon as possible. Staff member #2 will not work alone without another qualified staff member supervising, until staffer #2 has completed the required approved Pediatric first aid/ CPR training conducted by a certified PQAS instructor. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

12 months prior to service and every 24 months thereafter (3270.151(a))

At the time of inspection, the file for recently hired staff member #1 did not include an initial health assessment with TB results. Requirement: 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. Correction: The director will provide the staff members listed with a Child Care Staff Health Assessment form. The staff members will immediately request to have a medical professional complete the form reflecting a physical exam with TB testing completed within the last 12 months. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Two written references (3270.192(5))

At the time of inspection, the file for staff member #1 did not contain two written nonfamily reference letters from individuals attesting to the person's suitability to serve as a facility person Requirement: 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. Correction: Staff member #1 will submit two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Child's hands washed (3270.134(a))

At the time of inspection, staff members in the mobile infant room failed to wash a child hand before feeding. Requirement: A staff person shall ensure that a child's hands are washed before meals and snacks, after toileting and after being diapered. Correction: The staff members in the mobile infant room will wash the children's hands before meals and snacks. Hand washing signs indicating that hands must be washed before meals and snacks, after toileting and after being diapered will be posted at the sink and diaper changing area. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

At the time of inspection, staff member #1 observed in the multiple purpose room was unable to name the children in their assigned group. 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: ratios will be in compliance at all times to ensure proper supervision. Each staff person will be assigned the responsibility for supervision of specific children. The staff person will know the names and whereabouts of the children in his assigned group. The staff members will complete a training related to supervision and the importance of staff: child ratio in child care. The director will ensure the trainings have been completed and will conduct monitoring to ensure ratios are compliant. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Exp, educ., training prior to facility/Transcript, diploma and letters (3270.192(2)(ii)/3270.192(2)(iv))

At the time of the unannounced inspection, staff person #2 did not have verification of childcare experience, education and training prior to service at the facility Requirement: A facility person's record shall include verification of childcare experience, education and training prior to service at the facility. A facility person's record shall include acceptable verification of experience, education or training is a transcript or a diploma or a letter signed by a representative of the experiential, educational or training entity. Correction: Verification of staff person #2 education, experience and education was placed in file. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Two written references (3270.192(5))

At the time of the unannounced inspection, staff person #1 did not have two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person. Requirement: 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. Correction: 2 formal references forwarded and placed in file. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Individual Records (3270.191)

At the time of the unannounced inspection, staff person #2 did not have the required individual file at the facility. Requirement: An individual record is required for each facility person. Correction: Staff person #2 file was replaced with required items and will be maintained at the facility as required. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Training regarding plan (3270.27(c))

At the time of the unannounced inspection, staff person #1 file did not contain verification of the facility's Emergency Plan training. 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 reviewed Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

At the time of the unannounced inspection, staff person #1 file did not have verification of fire safety training. Requirement: Staff persons shall participate, at least annually, in firesafety 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: Fire Safety class completed Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Health and Safety Training (3270.31(f))

At the time of the unannounced inspection, staff person #1 file did not contain verification of required CCDBG health and safety training. Requirement: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Correction: Completed Health and Safety course on Better Kids Care. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Conducted by physician, PA or CRNP/Physical examination (3270.151(b)/3270.151(c)(1))

At the time of the unannounced inspection, staff person #1 did not have a completed and signed health assessment form on file from medical professional. Requirement: A health assessment shall be conducted and a report shall be written and signed by a physician, physician's assistant or CRNP. The signature must include the individual's professional title. An adult health assessment must include a physical examination. Correction: New health assessment. Inspection: Unannounced Monitoring. 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 the unannounced inspection, the staff person #1 did not have verification of TB screening. 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: New TB test completed. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Exam communicable disease/Physician/CRNP assessment (3270.151(c)(3)/3270.151(c)(5))

At the time of the unannounced inspection, staff person #1 did not have a health assessment must 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. An adult health assessment must include the physician's or CRNP's assessment of the person's suitability to provide child care. Correction: New health assessment completed with all questions answered. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).