ELIZABETH SETON CENTER-CHILDRENS PROGRAM

2025

1. Medium-High risk10/17/2025

   Training regarding plan/Exp, educ., training at facility (3270.27(c)/3270.192(2)(iii))

   The file for Staff #14 contained documentation of Emergency Plan training on 8.4.24 and 9.8.25, which exceeded the annual requirement. 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. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility. Correction: This staff member has an up-to-date emergency plan sign off in their file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 11/7/2025
2. Medium risk10/17/2025

   Admission date/Application, admission, withdrawal dates (3270.123(a)(6)/3270.182(2))

   The Agreement in the file for Child #9, did not specify the date of the child's admission. Requirement: An agreement shall specify the date of the child's admission. A child's record shall contain the dates of application, admission and withdrawal of the child. Correction: The date of the child's admission has been added to the contract. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 11/7/2025
3. Medium-High risk10/17/2025

   Physician name, address, phone (3270.124(b)(2))

   The Emergency Contact form, in the file for Child #2, did not include address or phone number of the child's physician or source of medical care. The Emergency Contact form, in the file for Child #6, did not include the address of the child's physician or source of medical care. Requirement: Emergency contact information must include the name, address and telephone number of the child's physician or source of medical care. Correction: The emergency contact form has been updated to include all of the physician information. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 11/7/2025
4. Medium-High risk10/17/2025

   Parent home/work address, phone (3270.124(b)(3))

   The Emergency Contact form, in the file for Child #8, did not include the work phone number of the enrolling parent. The Emergency Contact form, in the file for Child #9, did not include the work address or work phone number of the enrolling parent. Requirement: Emergency contact information must include the home and work addresses and telephone numbers of the enrolling parent. Correction: These emergency contact forms have been updated to include all of the necessary information. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 11/7/2025
5. Medium-High risk10/17/2025

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

   The Emergency Contact form, in the file for Child #7, did not include the name of the release person. 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 emergency contact for this child has been updated for this child to include the name of the release person. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 11/7/2025
6. Medium risk10/17/2025

   Toddler/preschool: updated health report every 12 months/Initial and subsequent health reports (3270.131(b)(2)/3270.182(1))

   The Health Assessment in the file for Child #3, a preschool child, exceeded the 12-month renewal requirement. Requirement: The operator shall require the parent to provide an updated health report at least every 12 months for an older toddler or preschool child. A child's record shall contain initial and subsequent health reports. Correction: This child has handed in a current physical. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 11/7/2025
7. Medium-High riskStandard 1210/17/2025

   12 months prior to service and every 24 months thereafter/Health assessment, TB test (3270.151(a)/3270.192(3))

   The two (2) most recent Health Assessments, in the files for Staff #3 and Staff #5, exceeded the 24-month renewal requirement. 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. 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: These staff members have a current physical in their file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 11/7/2025
8. Medium-High risk10/17/2025

   Health and Safety Training - Pediatric First Aid and CPR (3270.31(f)(10))

   The file for Staff #14 (see IS Code Sheet) contained documentation of Pediatric First-Aid/CPR training on 2.18.25, which exceeded the 90 days of hire requirement. Requirement: Staff persons shall complete professional development in the topic of pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire. Correction: This staff member has a current CPR/First Aid in their file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 11/5/2025
9. Medium-Low risk10/17/2025

   Devices must be compliant/Director or designated staff person ensure compliance (3270.95(a)/3270.95(b))

   The Fire System Testing Log contained documentation of testing on 3.7.25 and 4.13.25, which exceeded the 30-day requirement. 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)). The Director or designated staff person who is responsible for compliance with this chapter shall ensure the requirements under subsection (a) are met. Correction: The Fire System Testing Log is currently up to date and testing will be done within the next 30 days. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 11/7/2025
10. Medium risk10/17/2025

    Arrival/departure times (3270.123(a)(4))

    The Agreement in the files for Child #5 and Child #9, did not specify the child's arrival and departure times. Requirement: An agreement shall specify the child's arrival and departure times. Correction: The arrival and departure times have been added to the contracts. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 11/7/2025
11. Medium risk10/17/2025

    Date fee to be paid (3270.123(a)(2))

    The Agreement in the file for Child #1, Child #4, Child #5, and Child #6, did not specify the date on which the fee is to be paid. Requirement: An agreement shall specify the date on which the fee is to be paid. Correction: The dates that fees are paid has been added to the contracts. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 11/7/2025
12. Medium risk10/17/2025

    Amount of fee (3270.123(a)(1))

    The Agreement, in the files for Child #1, Child #3, Child #4, Child #5, Child #6, Child #7, and Child #8, did not specify the amount of the fee to be charged. Requirement: An agreement shall specify the amount of the fee to be charged per day or per week. Correction: Fees have been added to the children's contract. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 11/7/2025
13. Medium risk10/17/2025

    Above ground window opening restricted to 6" (3270.72(d))

    In Room 8, which is above the ground floor, had a broken stopper on the window to the far left of the back wall, allowing the window to fully open, which was not limited to six (6) or fewer inches. Requirement: Windows or doors above the ground floor that open directly to the outdoors and are accessible to children shall be constructed, modified or adapted to limit the opening to 6 or fewer inches. Correction: This window was fixed, and the opening is limited to 6 or fewer inches. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 11/7/2025
14. Medium-High risk10/17/2025

    Comply with CPSL (3270.32(a))

    The file for Staff #1 contained Child Abuse Clearances dated 1.18.19 and 9.23.24, which exceeded the 60-month renewal requirement. The file for Staff #2 contained State Police Clearances dated 5.18.20 and 7.30.25, and Child Abuse Clearances dated 6.1.20 and 8.7.25, both of which exceeded the 60-month renewal requirement. The file for Staff #4 did not contain a Disclosure Statement. The file for Staff #6 contained NSOR Certificates dated 6.4.20 and 7.3.25, which exceeded the 60-month renewal requirement. The file for Staff #7 contained State Police Clearances dated 3.3.20 and 4.14.25, Child Abuse Clearances dated 3.17.20 and 4.10.25, and NSOR Certificates dated 6.4.20 and 7.30.25, each of which exceeded the 60-month renewal requirement. The file for Staff #8 contained State Police Clearances dated 3.3.20 and 4.14.25, Child Abuse Clearances dated 3.27.20 and 4.11.25, and NSOR Certificates dated 6.4.20 and 7.23.25, each of which exceeded the 60-month renewal requirement. The file for Staff #9 contained valid, FBI Clearances dated 5.21.19 and 7.8.25, which exceeded the 60-month renewal requirement. The file for Staff #10 contained State Police Clearances dated 4.6.20 and 4.7.25, and Child Abuse Clearances dated 5.29.20 and 7.31.25, both of which exceeded the 60-month renewal requirement. The file for Staff #11 contained NSOR Certificates dated 6.4.20 and 7.30.25, which exceeded the 60-month renewal requirement. The file for Staff #13 contained NSOR Certificates dated 6.4.20 and 7.8.25, which exceeded the 60-month renewal requirement. The file for Staff #18 contained State Police Clearances dated 5.18.20 and 7.29.25, and Child Abuse Clearances dated 3.20.20 and 8.5.25, both of which exceeded the 60-month renewal requirement. The file for Staff #19 contained State Police Clearances dated 4.6.20 and 10.1.25, FBI Clearances dated 8.7.15 and 10.20.20 with none thereafter, NSOR Certificates dated 6.3.20 and 10.7.25, each of which exceeded the 60-month renewal requirement, and no Disclosure Statement. The file for Staff #2 contained documentation of Mandated Reporter training on 5.29.20 and 9.15.25, which exceeded the 60-month renewal requirement. The file for Staff #6 contained documentation of Mandated Reporter training on 3.13.20 and 5.15.25, which exceeded the 60-month renewal requirement. The file for Staff #7 contained documentation of Mandated Reporter training on 3.16.20 and 4.10.25, which exceeded the 60-month renewal requirement. The file for Staff #8 contained documentation of Mandated Reporter training on 3.14.20 and 4.9.25, which exceeded the 60-month renewal requirement. The file for Staff #16 contained documentation of Mandated Reporter training on 6.25.20 and 7.25.25, which exceeded the 60-month renewal requirement. The file for Staff #19 contained documentation of Mandated Reporter training on 7.18.20 and 10.3.25, which exceeded the 60-month renewal requirement. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Staff #4 and Staff #19 may not work in a child care position at the facility. Correction: This staff members all have the updated/current paperwork in their file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 11/7/2025
15. Medium risk10/17/2025

    Health and Safety Training (3270.31(f))

    The file for Staff #15 (see IS Code Sheet) contained documentation of Health and Safety training, Part 1 and Part 2, on 10.1.25, which exceeded the 90 days of hire requirement. Requirement: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Correction: This staff member has completed their Health & Safety training, and it is in their file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 11/7/2025
16. Medium-High risk10/17/2025

    Fire safety - 1 yr./Exp, educ., training at facility (3270.31(e)(4)(ii)/3270.192(2)(iii))

    The file for Staff #19 contained documentation of Fire Safety training on 11.7.23 and 12.10.24, which exceeded the annual requirement. 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. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility. Correction: This staff member has a current Fire Safety in their file and is taking their 2025 training this week. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 11/7/2025
17. Medium-High risk10/17/2025

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

    The file for Staff #12 contained documentation of Pediatric First-Aid/CPR training which expired on 5.16.25, and it was not renewed until 7.2.25. The file for Staff #17 contained documentation of Pediatric First-Aid/CPR training which expired on 8.9.24, and it was not renewed until 10.13.24. 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: This staff member has a current CPR/First Aid training in their file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 11/7/2025
18. Medium-Low risk10/16/2025

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

    Staff #1 placed Child #1 in the back storage room/closet, in the back of Room 5, leaving the door slightly ajar, and walked away from it. Staff #1 was not physically present with Child #1. 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: This incident was investigated, and the staff member involved no longer works at the center. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 11/7/2025
19. Medium risk10/16/2025

    Supervised at all times (3270.113(a))

    Staff #1 placed Child #1 in the back storage room/closet, in the back of Room 5, leaving the door slightly ajar, and walked away from it. Child #1 was not supervised by a staff person. 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. Correction: This incident was investigated, and the staff member involved no longer works at the center. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 11/7/2025
20. Medium-High risk10/16/2025

    Similar Age Level (3270.51)

    Staff #1 placed Child #1 in the back storage room/closet, in the back of Room 5, leaving the door slightly ajar, and walked away from it. The Staff:Child ratio was 0:1. Requirement: When children are grouped in similar age levels, the following maximum child group sizes and ratios of staff persons apply: Infants 1:4 with a maximum group size of 8; Young toddlers 1:5 with a maximum group size of 10; Older toddlers 1:6 with a maximum group size of 12; Preschool children 1:10 with a maximum group size of 20; Young school-age children 1:12 with a maximum group size of 24; Older school-age children 1:15 with a maximum group size of 30. Correction: This incident was investigated, and the staff member involved no longer works at the center. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 11/7/2025
21. Medium-Low risk10/16/2025

    No physical punishment (3270.113(b))

    Staff #1 grabbed Child #1 by the arm and head/hair area and dragged the child and aggressively put the child in a chair. Staff #1 then grabbed the child again and dragged the child back to the storage room/closet. Requirement: A facility person may not use any form of physical punishment, including spanking a child. Correction: This incident was investigated, and the staff member involved no longer works at the center. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 11/7/2025
22. Medium risk10/16/2025

    No harsh language (3270.113(d))

    Staff #1 yelled at Child #1 who was crying in the doorway of Room 5. Staff #1 used harsh language towards Child #1. Requirement: A facility person may not use harsh, demeaning or abusive language in the presence of children. Correction: This incident was investigated, and the staff member involved no longer works at the center. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 11/7/2025
23. Medium risk10/16/2025

    Restraints prohibited (3270.113(e))

    Staff #1 placed Child #1 in the back storage room/closet, in the back of Room 5, leaving the door slightly ajar, and walked away from it. Staff #1 placed child #1 in a confined space/closet. Requirement: A facility person may not restrain a child by using bonds, ties or straps to restrict a child's movement or by enclosing the child in a confined space, closet or locked room. The prohibition against restraining a child does not apply to the use of adaptive equipment prescribed for a child with special needs. Correction: This incident was investigated, and the staff member involved no longer works at the center. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 11/7/2025
24. Medium risk8/5/2025

    No ridicule or threaten harm (3270.113(c))

    During a complaint investigation conducted on 8/5/25, based on information obtained during staff interviews, it was determined that Staff #1 singled out and expressed a negative attitude towards a specific child in front of other children and staff. On July 30th, when Staff #1 had been given the option to supervise children on a swim outing, Staff person #1 was overheard saying that 'if Child #1 is not going to swim, I will go swimming but if Child #1 is going swimming I do not want to go'. Staff person #1 has also been heard saying things such as, 'have fun with Child #1' or 'watch out for Child #1'. During transition times, Staff person #1 has been heard saying that they 'do not want to deal with Child #1 so [Child #1] can stay in the room'. Requirement: A facility person may not single out the child for ridicule, threaten harm to the child or the child's family and may not specifically aim to degrade the child or the child's family. Correction: Staff #1 was given an improvement plan which was discussed with [Facility Person #2] and [Staff person #3]. Staff #1 was assigned 4 training sessions dealing with behavior management and positive interactions with school age children. There will be another meeting once the training is completed and a staff evaluation will be completed as well. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 10/3/2025
25. Medium risk7/2/2025

    Lifeguard training/supervision (3270.115(a)(6))

    During an unannounced monitoring visit at a swimming activity, it was observed that the LE had children and staff from 2 separate locations at the pool, with only one lifeguard present, supervising swimming activity for 2 locations simultaneously. Requirement: When children are swimming, supervision shall include one person certified in lifeguard training, as described in § 3270.31(e)(4)(iii) (relating to age and training). Correction: The appropriate staff who participate in the swimming activity will be retrained on the procedures, including that when 1 lifeguard is present, each location will swim for 1 hour while the other location is in the park outside of the pool area and that only one facility location will be in the pool area at a time. Inspection: Swimming. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 7/28/2025