BUTLER YMCA EARLY CARE AND SCHOOL AGE CENTER

Exam communicable disease/Health assessment, TB test (3270.151(c)(3)/3270.192(3))

The health assessment of staff #1 contained documentation an examination for communicable diseases but did not contain the explanation in conjunction with the results. Requirement: An adult health assessment must include an examination for communicable diseases and the results of that 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: Staff reached out to their PCP and informed them of the error. They will be providing her a corrected version which will go into her file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Small Toys and Objects (3270.103)

The toddlers, who are still placing objects in their mouths, were observed coloring with Crayola crayons which were less than an inch in diameter. Requirement: 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. Correction: All crayons were inspected for size, and using the age guidelines on the box itself. All small crayons were removed from the room and placed with age appropriate ones. The child who had the crayon, was given a teether to bite on after the crayon was removed. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Clean, good repair, proper size (3270.104(a))

A dorm-size refrigerator/freezer approximately 3 feet tall was on a counter and not anchored making it unsafe due to the risk of falling of the counter. Requirement: Furniture must be durable, safe, easily cleaned and appropriate for the child's size, age and special needs. Correction: This director placed a request with the Maintenace team at main site to anchor the fridge to the wall. Until that time, the refrigerator was removed from the room. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The financial agreement of child #1 did contain the amount of the fee to be charged by day or week. Requirement: An agreement shall specify the amount of the fee to be charged per day or per week. Correction: This Director reached out to the billing department and was scanned a copy of the information, which was placed in the child's file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The financial agreement of child #1 did not contain 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: This Director reached out to the billing department, and was scanned a copy of the origional agreement, and it was placed in her file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Parent receives original (3270.123(b))

The file of child #4 contained the original financial agreement. Requirement: A parent shall receive the original agreement. The facility shall retain a copy of the agreement. Correction: The origional was taken out of the file, copied, then given to the parent. The copy was then placed into the child's file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Written emergency plan posted (3270.124(e))

A written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency was not posted in the gym or the toddler classrooms. Requirement: 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. Correction: A written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency was displayed conspiculouisly in every child care space. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Immunization record/Dismissal policy (3270.131(d)(5)/3270.131(e)(3))

The immunization record on file for child #2 did not contain documentation of 1 of the 4 DTaP immunizations to be in compliance with the recommendations of the ACIP based or an acceptable exemption. Requirement: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in child care group settings). Correction: The child's parent gave the center documentation of the vaccination. It was placed in the child's file and added to Procare. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The file of facility person #4 contained consecutive health assessments dated 5/22/2023 and 8/12/2025, which were more than 24 months apart. 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: Going forward, staff will have access to their own staff data sheet. This director will also keep an excel file of their information, utilizing the outlook calendar where applicable. 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))

The file of staff #3 did not contain documentation of their tuberculosis 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: This director reached out to Main Site, and was scanned a copy of the initial health assessment with TB results. This was placed in staff's file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Safe pick-up and drop-off in writing (3270.171(b))

The facility did not have documentation of safe pedestrian crossways, pick-up and drop-off points and bike routes determined in the vicinity of the facility which was communicated to the families in writing. Requirement: Safe pedestrian crossways, pick-up and drop-off points and bike routes shall be appropriately determined in the vicinity of the facility and communicated to the children and parents in writing. Correction: Safe pedestrian crossways, pick up and drop off points, and bike routes were determined and posted at the front entrance and back office for parents to see. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

Documentation of the 6-month reviews and/or updates to the emergency contact forms of child #2 and #3 were dated 6/2024 and 12/2024, exceeding 6 months. 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: These two children we on vacation the week that the forms were updated, so they were signed the following week. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The file of staff #5 contained documentation of 2 annual training hours during their annual training year of 12/2023 to 12/2024 lacking 10 hours. The file of staff #6 contained documentation of 6 annual training hours during their annual training year of 2/2024 to 2/2025 and an additional 6 hours (4/4/2025 and 4/10/2025) making staff #6 complaint with 12 training hours. The file of staff #7 contained documentation of 8 annual training hours during their annual training year of 12/2023 to 12/2024 and an additional 4.5 hours (1/2025 and 4/2025) making staff #7 complaint with 12 training hours. Requirement: A staff person shall obtain an annual minimum of 12 clock hours of child care training. 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 director will develop a system of tracking PD hours that may better assist staff. This director will also go over this information at the next staff meeting. Staff person # 5 will complete 10 training hours by 10/1/25. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Clean and good repair (3270.102(a))

A plastic slide in the outdoor play space had a small crack on the top platform. Requirement: 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. Correction: Staff removed the slide from the play area, and disposed of it. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

No peeling paint or plaster (3270.77(a))

A small area, approximately the size of a quarter, on the bottom right corner of the shed was peeling. Requirement: Peeled or damaged paint or damaged plaster is not permitted on indoor or outdoor surfaces in the child care facility. Correction: This director sent a request for the Maintenace team at the main site to come out and fix the shed as soon as possible. Until then, tape was placed on it to prevent injury 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))

The file of staff #2 contained documentation of an NSOR verification certificate date 8/25/2025, after their start date at the facility. 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: This director will, along with the HR department, assure all clearances are received before the new staff being at the facility. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Training regarding plan (3270.27(c))

The most current documented emergency plan training for facility person #4 was dated 4/1/2024, more than 12 months prior to the date of the inspection. 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: This director will assure all staff are present at these annual trainings. Facility person # 4 will complete EOP training on 9/23/25. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

On file at facility (3270.18(a))

Documentation of comprehensive general liability insurance to cover the persons who are on the premises was not on file at the facility. Requirement: The legal entity shall have comprehensive general liability insurance to cover the persons who are on the premises. A current copy of the insurance policy shall be on file at the facility. Correction: An email was sent to the financial specialist at the Main Site YMCA, [Staff #8]. [Staff #8] sent the paperwork via email to this center. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

Based on the documentation of testing the fire detection system, manual testing exceeded 30 days from 9/10/2024 to 12/10/2024 to 1/13/2025. 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 former director failed to manually test the fire detection system every 30 days. An immediate plan of correction is not available as this cannot be corrected. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Handwashing signs (3270.82(h))

A handwashing sign was not posted in the diapering area of the infant classroom. Requirement: A facility person and an able child shall wash his hands after toileting and before eating. A sign on which this requirement is written shall be posted at each toilet, training chair, diapering area and sink in the facility. Correction: The teacher in the classroom replaced the fallen handwashing sign in the diapering area. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Bottles labeled (3270.166(4))

In the infant classroom, 4 bottles were not labeled with the name of the child to whom they belonged. Requirement: Disposable nursers and bottles shall be labeled with the child's name. Correction: The bottles were labeled with the child's name. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Written record (3270.94(a)(9))

The fire drill log contained documentation of fire drills being conducted on 10/10/2024 and 11/2024 but did not contain the time of day, the hypothetical location, evacuation time, number of children or names of staff who participated in the fire drill written on the log. Requirement: The Director 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. Correction: The previous director failed to complete the fire drill log for October and November so an immediate plan of correction is not available. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

2 feet apart (3270.106(f))

SECOND CITATION - ORIGIANLLY CITED ON 9/10/2024: During rest time, in the toddler classroom, 2 children asleep on their mats were both positioned in corners against a wall at the top of the mat and a shelf on the side. The mats did not have at least 2 feet of space on three sides. Requirement: At least 2 feet of space is required on three sides of a bed, cot, crib or other rest equipment while the equipment is in use. Correction: The mats were immediately moved to have at least 2 feet on three sides. A discussion will be had with the staff regarding the mat placements to remind staff there needs to be at least 2 feet on three sides. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Comply with CPSL (3270.32(a))

Current mandated reporter training for staff #1 was dated 8/18/2024, which was more than 60 months from the previous training dated 5/19/2019. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Correction: When it was recognized that staff #1 was out of compliance with Mandated Reporter Training, they were pulled from the classroom, and they completed the training. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Staff evaluations (3270.34(a)(6))

The only written evaluation of staff #1 was dated 4/22/2024, which was more than 12 months from their start date at the facility (see coded LIS sheet). Requirement: A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months. Correction: Director was able to find missing evaluation for staff #1 that was missing from file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).