CARLOW UNIVERSITY EARLY LRG CENTER

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

Based on a self-reported noncompliance and staff statements, on 6/17/26 at approximately 11:45am Staff person #1 was in the gross motor space with a group of older toddlers, when Child #1 required a diaper change. Staff #1 directed and observed Child #1 to go down the hallway to the Older Toddler classroom where the staff thought another staff was waiting to complete the diaper change. However, there was a miscommunication between the staff and there was not a staff in the Older Toddler classroom. Child #1 was unsupervised in the classroom for approximately two minutes. 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: Child was immediately placed back into a supervised environment. Staff was removed from the room to discuss the incident. Staff involved were placed on a suspension. Staff are assigned 36 hours of continuing education hours around supervision, safety, and professionalism. Staff are completing hourly name to face checks. Staff are using child ratio tags to ensure compliance. Staff meeting was held to discuss transitions and face to face hand off of children. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Supervised at all times (3270.113(a))

Based on a self-reported noncompliance and staff statements, on 6/17/26 at approximately 11:45am Staff person #1 was in the gross motor space with a group of older toddlers, when Child #1 required a diaper change. Staff #1 directed and observed Child #1 to go down the hallway to the Older Toddler classroom where the staff thought another staff was waiting to complete the diaper change. However, there was a miscommunication between the staff and there was not a staff in the Older Toddler classroom. Child #1 was unsupervised in the classroom for approximately two 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. Correction: Child was immediately placed back into a supervised environment. Staff was removed from the room to discuss the incident. Staff involved were placed on a suspension. Staff are assigned 36 hours of continuing education hours around supervision, safety, and professionalism. Staff are completing hourly name to face checks. Staff are using child ratio tags to ensure compliance. Staff meeting was held to discuss transitions and face to face hand off of children. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Original container (3270.133(1))

In the Infant Room, a tube of Mupirocin ointment for Child #1 was observed to lack the original container. Requirement: A prescription or nonprescription medication may be accepted only in an original container. The medication shall remain in the container in which it was received. Correction: Contacted family to clarify and receive the script. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

No peeling paint or plaster (3270.77(a))

In the Young Toddler Room, damaged plaster was observed on the wall where a gate used to be. Requirement: Peeled or damaged paint or damaged plaster is not permitted on indoor or outdoor surfaces in the child care facility. Correction: Maintenance supervisor was contacted about the damage and confirmed that the onsite painter will repair the damage. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Health and Safety Training (3270.31(f))

Staff person #3 had not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Health and Safety Training. Staff person #3 has since completed the trainings on 10/3/25 and 10/6/25. Requirement: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Correction: Staff person #3 has since completed the training prior to inspection. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The staff file for Staff person #1 contained a current National Sex Offender Registry (NSOR) check dated 5/23/25 which was not renewed within 60 months of the previously dated 5/14/20 NSOR expiring. The disclosure statement in the file for Staff person #2 was not signed at time of hire and was from prior employment with the legal entity. 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 person #1 had the required clearances on file prior to the inspection. Staff Person #2 completed a new and corrected disclosure statement. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Comply with CPSL (3270.32(a))

The staff file for Staff person #1 contained current mandated reporter training dated 5/20/25 which was not renewed within 60 months from the previously existing mandated reporter certificate dated 5/4/20. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Correction: Staff person #1 had the required training on file prior to the inspection. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The child file for Child #1 through Child #3 were observed to contain a current financial agreement form that lacked 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 were corrected immediately for Child #1 [through] Child #3 Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Admission date (3270.123(a)(6))

The child file for Child #4 was observed to contain a current financial agreement form that lacked the date of the child's admission. Requirement: An agreement shall specify the date of the child's admission. Correction: Child #4 admission date was added to the form. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Insurance coverage information (3270.124(b)(6))

The child file for Child #4 was observed to contain a current emergency contact information form that lacked the health insurance name and policy number. Requirement: Emergency contact information must include health insurance coverage and policy number for a child under a family policy or Medical Assistance benefits, if applicable. Correction: Insurance information was received and updated. All required information has been added to the emergency contact form for Child #4 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 staff file for Staff person #2, contained a health assessment dated 10/21/23 which was conducted more than 12 months prior to them providing service in a childcare setting. 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: Staff Person #2 has been suspended from work until the required health assessment is completed. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The staff file for Staff person #3, contained a current health assessment dated 9/10/24 was observed to lack the physician's or CRNP's assessment of the person's suitability to provide childcare. Requirement: An adult health assessment must include the physician's or CRNP's assessment of the person's suitability to provide child care. Correction: Staff person #3 has been asked to get a new health assessment with the proper state forms to ensure compliance before returning to work. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The staff file for Staff person #3, contained a current health assessment dated 9/10/24 was observed to lack 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 #3 has been asked to get a new health assessment with the proper state forms to ensure compliance before returning to work. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Mantoux TB (3270.151(c)(2))

The staff file for Staff person #4 was observed to contain a tuberculosis screening test results dated 7/12/23 which was conducted more than 12 months prior to providing initial service in a childcare setting. 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. Correction: Staff person #4 has been asked to receive a new tuberculous screening test prior to returning to work. 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))

The staff file for Staff person #1, contained a current health assessment dated 3/5/24 which was conducted more than 24 months from the previously dated 2/25/22 health assessment on file. 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: Staff person #1 has an updated health assessment on file for 3/5/24. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Disposable diapers (3270.135(a)(3))

At approximately 10:15am in the Young Toddler Room, during a diaper change, Staff was observed to not immediately discard the soiled diaper into a plastic-lined, hands-free covered can until completing the diaper change. Requirement: If disposable diapers are provided by a parent or by a facility, a soiled diaper shall be discarded by immediately placing the diaper into a plastic-lined, hands-free covered can. Correction: Staff has been reoriented to diaper changing policies to ensure that during a diaper change either the soiled diaper remains underneath the child for the entire change or is immediately discarded. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Name on bottle (3270.133(3))

In the Young Toddler Room, a bottle of children's Zyrtec was observed to not be labeled with the child's name for whom the medication is intended for. Requirement: The label of a medication container shall identify the name of the medication and the name of the child for whom the medication is intended. Medication shall be administered to only the child whose name appears on the container. Correction: The medication was immediately labeled with the child's name. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Insurance coverage information (3270.124(b)(6))

The child file for Child #1 was observed to contain a current emergency contact information form that lacked the health insurance policy number. Requirement: Emergency contact information must include health insurance coverage and policy number for a child under a family policy or Medical Assistance benefits, if applicable. Correction: I contacted the parent immediately when we discovered the missing information on 11/21/24. The parent replied immediately with the information. The child's file was updated day of. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Similar Age Level (3270.51)

In the Young Toddler Room, at approximately 10:00am, three staff and ten young toddlers were observed. After conducting a first supervision/ ratio check including all 3 staff, the director stated that one of the staff were new and were not serving as part of the child: staff ratio. A second supervision/ ratio check was conducted. Staff person #2 identified and named 6 young toddlers as part of her supervision group and Staff person #1 identified and named all 10 young toddlers as part of her supervision group. Therefore, Staff #1 exceeded the child: staff ratio by one child and Staff #2 exceeded the child: staff ratio by 4 children. 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: Staff person 1 and 2 were reminded to either supervise as group size or within ratio so to not exceed the staff: child ratio. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Staff evaluations (3270.34(a)(6))

The staff file for Staff person #1 contained current staff evaluation dated 3/4/24 which was not completed at least one every 12 months from the previous staff evaluation on file dated 2/6/23. The staff file for Staff person #2 contained current staff evaluation dated 3/1/24 which was not completed at least one every 12 months from the previous staff evaluation on file dated 2/6/23. Requirement: A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months. Correction: The evaluations will be completed within the 12-month time frame moving forward. Both staff persons have updated evaluations dated 3/4/24 and 3/1/24. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).