UPMC Passavant Childrens House

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

The child file for Child #2 contained a current emergency contact form that was not reviewed and signed by the parent at least once every 6 months; the two most recent reviews of the emergency contact form were signed on 1/5/26 and 6/5/25. The child file for Child #3 contained a current emergency contact form that was not reviewed and signed by the parent at least once every 6 months; the two most recent reviews of the emergency contact form were signed on 12/15/25 and 5/12/25. The child file for Child #4 contained a current emergency contact form that was not reviewed and signed by the parent at least once every 6 months; the two most recent reviews of the emergency contact form were signed on 12/19/25 and 5/4/25. The child file for Child #5 contained a current emergency contact form that was not reviewed and signed by the parent at least once every 6 months; the two most recent reviews of the emergency contact form were signed on 12/16/25 and 1/2/25. 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 child file for child #2 had an emergency contact form that was not updated within six months but was corrected on 1/5/26. The child file for child #3 had an emergency contact form that was not updated within six months was corrected on 12/15/25 . The child file for child #4 had an emergency contact form that was not updated within six months was corrected on 12/19/25. The child file for child #5 had an emergency contact form that was not updated within six months was corrected on 12/16/25. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The child file for Child #2, who is a preschool age child, was observed to contain an updated health report dated 1/6/25 which was conducted more than 12 months from the previously dated 10/31/24 health report on file. 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: The child file for child #2 was corrected on 1/6/25. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Signed (3270.123(a))

The child file for Child #1 contained a current financial agreement for that lacked the operator's signature. Requirement: An agreement shall be signed by the operator and the parent. Correction: The financial agreement for child #1 was signed on the date of inspection, 1/21/26. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Locked or inaccessible (3270.66(a))

In the PreK Room, a travel sized hand sanitizer was observed attached to a child's jacket that was hanging approximately a foot and a half from the floor in a cubby allowing it to be accessible to the preschool age children 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: The hand sanitizer, that was attached to a child's coat, was removed on the date of inspection, 1/21/26. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

HS/GED + 2 yrs/Exp, educ., training prior to facility (3270.36(b)(5)/3270.192(2)(ii))

The staff file for Staff person #3 who is functioning as an Assistant Group Supervisor, lacked proof of education. Requirement: An assistant group supervisor shall have a high school diploma or a general educational development certificate and 2 years experience with children. A facility person's record shall include verification of child care experience, education and training prior to service at the facility. Correction: Staff person #3 was notified immediately on 1/12/26 to provide their proof of education and will provide their proof of education by 2/28/26. 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 and Staff person #2 contained a current staff evaluation dated Dec. 2025 which was not completed at least once every 12 months from the previous staff evaluation on file dated Nov. 2024. Requirement: A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months. Correction: Staff persons #1 and #2 had their annual evaluation on December 2025 and the written evaluations were placed in their files in December 2025. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The staff file for Staff person #4 was observed to contain fire safety trainings that were conducted more than 12 months apart; those fire safety trainings are dated 12/24/25 and 10/9/24. 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. Correction: Staff person # 4 completed the annual fire safety training on 12/24/25. The staff file for person #4 was corrected on 12/24/2025. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Building Surfaces (3270.76)

In the Gym, one ceiling tile located on the left side of the room nearest the built in shelving unit was observed to not be kept clean as evidence by having a water spot from a previous leak. In the hallway outside of the Toddler 2 Room one ceiling tile was observed to not be kept clean as evidence by having a water spot from a previous leak. 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 ceiling tiles in the Gym and Hallway outside of the Twos classroom were replaced and are now in good repair, free from water spots. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Each staff person meets quals/Transcript, diploma and letters (3270.33(a)/3270.192(2)(iv))

The staff file for Staff person #1, who is functioning as an assistant group supervisor, contained a foreign diploma that lacked additional documentation to show that the diploma had been evaluated to determine its validity and whether or not it meets qualifications for the position. Requirement: A staff person or a substitute staff person shall meet one of the applicable staff qualifications for the position in which the person is performing. 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: The center director will send staff person #1 will have their foreign diploma evaluated to determine the validity and whether it meets the qualifications for the position. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Plan reviewed/updated annually (3270.27(b))

The last two reviews of the facility emergency plan were not completed annually; those reviews were dated 8/21/23 and 11/16/24. 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: The emergency plan was corrected on 11/16/24. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Toddler/preschool: updated health report every 12 months (3270.131(b)(2))

The child file for Child #1, who is a preschool age child, was observed to contain an updated health report dated 1/8/25 which was conducted more than 12 months from the previously dated 12/27/23 health report on file. The child file for Child #2, who is a preschool age child, was observed to contain an updated health report dated 11/1/24 which was conducted more than 12 months from the previously dated 10/30/23 health report on file. 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. Correction: The child file for child #1 was corrected on 1/8/25 and child #2 was corrected on 11/1/24. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Emergency plan (3270.27(a)(6))

The most recent emergency drill documented at the facility dated 8/7/24 was observed to lack mention of special accommodation used for any category of children and problems/observations encountered during the drill. Requirement: Emergency drills shall be conducted annually. Annual emergency drills shall be documented and on file at the facility. Correction: The annual emergency drill now documents special accommodations for children and problems/observations encountered during the drill. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).