KATERINE TELLEZ

Emergency plan (3290.24(d))

Upon inspection of the facility emergency drill log, it was found that the last emergency drill [intruder] was conducted in January 2024. Requirement: Emergency drills shall be conducted annually. Annual emergency drills shall be documented and on file at the facility. Correction: Provider will conduct an intruder drill this month January Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

System in compliance/Operator or designated staff responsibility (3290.95(a)/3290.95(b))

Upon inspection of the fire detection device test log, it was found that the following tests exceeded the maximum of 30-days between required testing: 4.1.25 - 5.29.25 [58 days]. 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 operator or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in subsection (a) are met. Correction: Provider will make sure that fire detection device test do not exceed 30 day between testing day Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Hypothetical locations (3290.94(a)(4))

Upon inspection of the facility fire drill log, it was found that all the drills conducted during the last year utilized the same hypothetical location of the fire. Requirement: The hypothetical locations of the fire are rotated around the facility for each drill such that the hypothetical location is never the same for consecutive drills. Correction: Provider will conduct fire drills [hypothetical locations] in different location throughout the house Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Different times of day/Various activity times (3290.94(a)(2)/3290.94(a)(3))

Upon inspection of the facility fire drill logs, it was found that all the drills during the past year have been conducted at the same time of day/same program activity times. Requirement: Fire drills are conducted at different times of the day or night, or both, if applicable. Fire drills are conducted during various program activity times. Correction: Provider will conduct Fire drills at different times of the day. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Written statement (3290.166(1))

Upon completion of the inspection of the facility documents on file and posted, it was found that a written statement giving the formula and feeding schedule for the infant in care was not present. Requirement: A written statement giving the formula and feeding schedule for an infant shall be obtained from the parent. Correction: Provider will ask parent for child's feeding schedule. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).