NESBITT CHILD DEVELOPMENT CENTER

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

Staff #1 had State Police Clearances on filed dated 6/5/2020 and 8/1/2025. More than 60 months had lapsed between clearances. Staff #1 acknowledged that they had routine interaction and direct contact with children during the lapse. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A staff 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 #1 has completed and received an updated State Police Criminal History Clearance, which is now current and on file. The operator will comply with the CPSL and with Chapter 3490 (relating to protective services). Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Protective Outlet Covers 5 yrs. or less (3270.65)

One electrical outlet on an extension cord, that was hanging near the fish tank in the Preschool Room, was observed to be missing a protective receptacle cover. Preschoolers had access to this outlet. Requirement: Protective receptacle covers shall be placed in electrical outlets accessible to children 5 years of age or younger. Correction: A protective receptacle cover was installed on the extension cord outlet immediately while the inspector was on site. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Admission date (3270.123(a)(6))

The agreement on file for Child #4 did not specify the date of the child's admission. Requirement: An agreement shall specify the date of the child's admission. Correction: The admission agreement for Child #4 was updated to include the child's date of admission. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Updated every 6 months/Emergency info/agreement updated 6 mos (3270.124(f)/3270.181(c))

The most recent emergency contact and financial agreement information on file for Child #1 was dated 7/3/25. The most recent emergency contact information on file for Child #3 was dated 8/5/25. The most recent financial agreement information on file for Child #3 was dated 6/14/25. The emergency contact information on file for Child #5 was dated 1/7/25 and 1/13/26. The financial agreement information on file for Child #5 was dated 1/7/25. More than 6 months had lapsed since a parent last reviewed, updated, and signed the emergency contact and financial agreement forms. The financial agreement on file for Child #4 did not include the date the parent reviewed, updated, and signed the financial agreement. Requirement: The parent shall update in writing emergency contact information once in a 6-month period or as soon as there is a change in the information. 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: Parents were notified and updated emergency contact and financial agreement forms are being obtained for all affected children. Parents will review, update, sign, and date emergency contact and financial agreement forms for all the affected children. Missing dates were corrected where applicable. 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 only health assessment on file for Child #2 (see code sheet for date of birth) was dated 4/10/24, and the only health assessment on file for Child #3 (see code sheet for date of birth) was dated 8/11/22. Both children were required to have current health assessments on file, updated at least annually. Child #4 (see code sheet for date of birth) had health assessments on file dated 6/13/24 and 10/8/25. More than a year had lapsed between health assessments. 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: Parents of Children #2, #3, and #4 were notified that updated annual health assessments are required. Updated forms will be obtained and children will not continue care without valid health reports on file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Health information (3270.131(a))

The record for Child #5 (see code sheet for date of admission) did not contain any health reports and this child has been enrolled for more than 60 days. Requirement: The operator shall require the parent of an enrolled child, including a child, a foster child and a relative of an operator or a facility person, to provide an initial health report no later than 60 days following the first day of attendance at the facility. Correction: The initial health report for Child #5 has now been received and is on file. Although it was not submitted within the required 60-day timeframe, the child is currently compliant with having a valid health assessment. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Age and Training (3270.31(e))

Staff #1 had 3 hours of annual child care training on file, and not the required 12 clock hours of child care training. Requirement: A staff person shall obtain an annual minimum of 12 clock hours of child care training. Correction: Staff #1 was notified of the training deficiency and immediately enrolled in additional professional development to meet the required 12 clock hours. All required training hours will be completed and documented in the personnel file. 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))

The fire detection system was not tested at least once every 30 days as evidenced by the following fire detection system testing logs that were on file: 2/7/25 to 3/10/25, 5/5/25 to 6/16/25, 7/18/25 to 8/19/25, 8/19/25 to 9/21/25, and 11/14/25 to 12/17/25. 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: Fire detection system testing was completed and documented. Testing logs are now current and up to date. 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))

Staff #1 had health assessment on file that were dated 7/13/23 and 8/6/25. More than 24 months had lapsed between health assessments. 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 #1's health assessment dated 8/6/2025 is on file. Although the previous assessment exceeded the 24-month timeframe, the staff member now has a current and valid health assessment on record. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Emergency plan (3270.27(f))

There was no proof on file showing that a copy of the emergency plan had been sent to the local municipality. Requirement: The operator shall send a copy of the emergency plan and subsequent plan updates to the local municipality and to the county emergency management agency. Correction: On October 15, 2025, the Health and Nutrition Coordinator emailed a copy of the facility's emergency plan to the local municipality with a read receipt attached. Proof of the email and read receipt will be printed and placed in the facility's emergency preparedness binder. The Center will follow up if confirmation of receipt from the local agency is not received within ten business days. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

12 months prior to service and every 24 months thereafter/Mantoux TB (3270.151(a)/3270.151(c)(2))

The only health assessment on file for Facility Person #1 (see code sheet for first day with children) was dated 5/4/23. Also, the file for Facility Person #1 did not include any tuberculosis screening tests. It only included a chest x-ray that was dated 3/13/23. 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. 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: The list of required documentation---including an updated health assessment and Mantoux TB screening---was sent to the Facility Person #1's supervisor with the Foster Grandparent Program on 10/6/2025. The individual has not returned to the center and will not be permitted to return until all missing documentation is received and verified by the Child Development Council of NEPA. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

CPSL information/Two written references (3270.192(4)/3270.192(5))

Facility Person #1 (see code sheet for first day with children), who was observed in a volunteer capacity on 10/6/25, did not have a disclosure statement or two written, nonfamily references on file. Requirement: 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. Facility Person #1 may not work or volunteer in a childcare position that involves direct contact and routine interaction with children until all required paperwork is completed and on file at the facility. A facility person's record shall include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person. Correction: The list of missing documentation, including the required Disclosure Statement and two nonfamily references, was sent to the Facility Person #1's supervisor with the Foster Grandparent Program on 10/6/2025. Facility Person #1 has not returned to the center and will not be permitted to resume volunteer duties until all documentation is received, reviewed, and verified by the Child Development Council of NEPA. Inspection: Allocated Unannounced Monitoring. 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))

The fire detection system was not tested at least once every 30 days as indicated by the following fire detection system testing logs that were on file: 7/18/25 to 8/19/25 and 8/19/25 to 9/21/25. 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: As of 10/16/2025, the facility's fire detection system was checked to ensure it is in proper working order. Because the previous monthly test could not be retroactively completed, a new fire drill and system test are scheduled for 10/16/2025, and the results will be documented on the Fire Detection System Testing Log. Inspection: Allocated Unannounced Monitoring. 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))

The fire detection system was not tested at least once every 30 days as indicated by the following fire detection system testing logs that were on file: 2/7/25 to 3/10/25 and 5/5/25 to 6/16/25. 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 Health and Nutrition Coordinator has reviewed the 30-day requirement with the Center Director and discussed that a schedule must be put in place where 30 days is counted out- not simply having one training per month. A fire detection system test was completed on Monday, June 24, 2025 and has been logged. The fire detection system will be tested at least once every 30 days as indicated by our fire detection system testing logs. While we acknowledge that one of the gaps in documentation occurred during a period when the Center Director was on medical leave, we understand that regulatory responsibilities must continue uninterrupted. All planned extended absences will now be communicated in advance to administrative leadership to ensure continuity of operations. A designated staff member or interim administrator will be assigned to complete all required health and safety tasks during such absences, including monthly fire detection system tests. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Toddler/preschool: updated health report every 12 months/Immunization record (3270.131(b)(2)/3270.131(d)(5))

The last complete health assessment on file for the Child #3 was dated 8/11/22. 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 health report shall include a review of the child's immunized status according to recommendations of the ACIP. Correction: The parents or guardians of Child #3 were contacted to request an updated health report, including a review of the child's immunized status according to the Advisory Committee on Immunization Practices (ACIP) recommendations. The child has an appointment next month, but Dr. will provide an updated report in the meantime until next month's appointment. The Center Director will monitor the submission of the document to ensure that the updated health report is submitted and filed appropriately. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Emergency plan (3270.27(a)(6))

The only emergency drills on file were dated 11/29/22 and 12/20/24. More than a year had lapsed between emergency drills. Requirement: Emergency drills shall be conducted annually. Annual emergency drills shall be documented and on file at the facility. Correction: The facility is currently compliant with emergency drills. The most recent emergency drill occurred on 12/20/24 and documentation of this is on file at the facility. The Center Director will maintain a log of all emergency drills conducted, including dates, times, and details of each drill. The Department's form will be used to document future emergency drills. The Center Director will ensure that the documentation is easily accessible and filed in a designated location at the facility for review. A schedule for future emergency drills will be established to ensure they are conducted annually without lapses. 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 health assessments on file for Staff #4 were dated 3/25/22 and 4/11/24. More than 24 months had lapsed between health assessments. 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: The Center Director will maintain a log of when all health assessments were conducted for staff, including dates and details of the assessments. Anyone who is due for an assessment will be given ample notice to ensure the scheduling and completion of the health assessment. All documentation will be filed appropriately and will be easily accessible for review. The Health and Nutrition Coordinator will be designated to oversee the scheduling and documentation of health assessments. Staff #4 has a current health assessment on file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Updated every 6 months/Emergency info/agreement updated 6 mos (3270.124(f)/3270.181(c))

The most current emergency contact information on file for Child #1 was dated 3/14/24 and 1/24/25 and for Child #5 was dated 2/19/24 and 1/28/25. More than 6 months had lapsed between parental reviews, updates, and signatures on these emergency contact forms. The only emergency contact information on file for Child #2 was dated 5/2/24. The only financial agreement information on file for Child #1 was dated 3/18/24. There was no financial agreement information on file for Child #2. The most current financial agreement information on file for Child #3 was dated 3/7/24 and for Child #4 was dated 2/9/24. More than 6 months had passed since a parent last reviewed, updated, and signed emergency contact and financial agreement forms. Requirement: The parent shall update in writing emergency contact information once in a 6-month period or as soon as there is a change in the information. 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 parents or guardians of Children #1, #2, #3, #4, and #5 will be contacted to obtain updated emergency contact information and financial agreements. The Center Director will ensure that all forms are reviewed, updated, and signed by the parents or guardians. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Small Toys and Objects (3270.103)

A plastic Ziploc bag and two metal staples, that had a diameter of less than 1 inch, were observed on the Toddler Room floor. These items were accessible to the toddler aged children who were being supervised in that room. 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: The items were immediately removed from the Toddler Room floor and thrown away. The Center Director will conduct a thorough inspection of the Toddler Room to identify and remove any other small objects or hazardous items. The Center Director will conduct regular checks to ensure that no small or hazardous items are present in areas accessible to children and document these checks. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Clean and good repair (3270.102(a))

The radiator outside the Infant Room had a loose cover, revealing sharp metal edges. Similarly, the radiator outside the Toddler Room was missing part of its cover, exposing sharp metal edges. One toilet in the Boys' Restroom had two exposed bolts and two toilets in the Girls' Restroom had one exposed bolt. 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: The Center Director has covered sharp edges and exposed bolts with duct tape to ensure all hazardous conditions were addressed promptly. CDCs Maintenance Supervisor has been notified and will secure the loose cover on the radiator outside the Infant Room to eliminate sharp metal edges. He will replace the missing part of the radiator cover outside the Toddler Room to ensure no sharp edges are exposed and will cover the exposed bolts with toilet caps in the Boys' and Girls' Restrooms to prevent any potential injuries. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Handwashing signs (3270.82(h))

A hand washing sign was not observed at the sink area in the Boys' Restroom. 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: A new hand washing sign has been posted that clearly states the requirement to wash hands after toileting and before eating. This sign was posted at the sink area in the Boys' Restroom, as well as making sure the other hand washing signs are visible at each toilet, training chair, diapering area, and sink in the facility. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Emergency Numbers Posted (3270.74)

The telephone number of the nearest ambulance was not posted by the telephones in the Infant Room, Toddler Room, or Preschool Room. Requirement: The telephone number of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephone in the facility. Correction: A new phone list was created with telephone numbers for the nearest hospital, police department, fire department, ambulance, and poison control center. These telephone numbers were posted by each telephone in the Infant Room, Toddler Room, and Preschool Room. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Locked or inaccessible (3270.66(a))

Simply Right, Persani, and Up and Up hand sanitizers were observed on a table that was located near the Girls' Restroom. All of these items were labeled, "keep out of reach of children," but were accessible to the children who passed by the table to access the Girls' Restroom. Dial antibacterial hand soap, Equate sunscreen, and Coppertone sunscreen were observed, about ankle height, in an unlocked cabinet in the Preschool Room. Also, Dawn cleaner was observed in a blue container that was on a window shelf in the Preschool Room. These items, which were labeled, "keep out of reach of children, were accessible to the children who were being supervised in that room. Requirement: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children. Correction: All Simply Right, Persani, and Up and Up hand sanitizers were immediately removed from the table near the Girls' Restroom and placed in a locked cabinet. The Dial antibacterial hand soap, Equate sunscreen, and Coppertone sunscreen from was immediately relocated from the unlocked cabinet in the Preschool Room to a locked storage area. The Dawn cleaner was immediately relocated from the window shelf in the Preschool Room to a locked cabinet. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Training regarding plan (3270.27(c))

The most current emergency plan trainings on file for Staff #3 and #4 were dated 11/2023 and 12/2024. More than a year had lapsed between emergency plan trainings. 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: A schedule for future emergency plan trainings will be established by the Center Director to ensure they are conducted annually without lapses. A log will be maintained of all emergency plan trainings conducted, including dates, times, and details of each training. She will ensure that the documentation is easily accessible and filed in a designated location for review. Staff #3 and #4 have current emergency plan trainings on file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Pertinent Laws & Regulations/General Health and Safety (3270.14/3270.21)

Staff person #6 has completed the health and safety course titled Get Started with Center-Based Care: Building Blocks for Quality but has not completed the required health and safety update course titled Pennsylvania Health and Safety Update 2022 (1 hour) training. Requirement: A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. Staff person #6 must complete PA Required Health and Safety for Centers-Group Child Care Parts 1 and 2. Correction: Staff person #6 will be enrolled in the "PA Required Health and Safety for Centers-Group Child Care Parts 1 and 2" courses to ensure comprehensive compliance. Staff person #6 will complete the "PA Required Health and Safety for Centers-Group Child Care Parts 1 and 2" within the next 7 days. Upon completion of the courses, Staff person #6 will submit certificates of completion to the center director, who will maintain these certificates in the staff training records. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).