THREE STAGES DAY CARE AND LEARNING CORP

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

An unannounced complaint inspection occurred at the facility on 3/6/26. Regulation requires the operator to test the fire safety system at least every 30 days. The following tests did not occur at least every 30 days: 1/16/26 and 2/16/26. 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 operator will test the fire safety system at least every 30 days and document the tests. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Supervised at all times /Staff assigned to specific children (3270.113(a)/3270.113(a)(1))

An unannounced complaint inspection occurred at the facility on 3/6/26. During the inspection, a child was observed in the right room of the middle building unsupervised. At this time, Staff #2 was assigned the responsibility of this child, but Staff #2 was observed in the exit stairwell, with the door closed in between. After documentation review on this date, the operator reported that Staff #3 left a group of children unsupervised on 3/4/26 and received a suspension, which lead to note of termination in the file of Staff #3 as a result of the incident. 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. 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. TIERED LIS: 1. Children must be supervised at all times. (THIS PORTION OF THE PLAN SHALL HAVE AN IMMEDIATE CORRECTION DATE.) 2. The legal entity must arrange for all facility staff to receive a minimum of three hours of in-person, PQAS-approved training, regarding supervision and appropriate ratios of children. The legal entity must receive DHS approval of the training content prior to scheduling the training. To show proof of the training, the legal entity will submit the staff attendance/sign-in sheet to the Regional Office after completion of the training. (THE OPERATOR SHALL PROVIDE A DATE FOR WHEN THIS TRAINING WILL BE COMPLETED.) 3. The Director or Legal Entity of the program shall complete daily checks of supervision/ratio at differing times throughout the day and document these checks for a period of 3 months. At least one check per day must be documented in a format that is approved by the Department before using. The documentation must be kept on file at the facility for review by the Department at unannounced supervision visits. (THE CORRECTION DATE FOR THIS PORTION OF THE PLAN SHALL BE AT MINIMUM 3 MONTHS FROM THE DATE THE DATE THE REGIONAL OFFICE APPROVES THE PLAN AND FORMAT.) 4. The facility will have no areas of non compliance related to supervision for a period of 3 months. This will be monitored with at least 2 unannounced visits at the facility. (THE CORRECTION DATE FOR THIS PORTION OF THE PLAN SHALL BE AT MINIMUM 3 MONTHS FROM THE DATE THE DATE THE REGIONAL OFFICE APPROVES THE PLAN.) Correction: 1. Children will be supervised at all times. (3/6/26) 2. Will schedule and have all staff attend supervision and ratio training. Will provide the Regional Office of documentation that staff participated in the training. (5/25/26) 3. The operator will conduct daily supervision/ratio checks at the facility and will document at least one check per day. The documentation will be kept on file for review by the department at any visit. Will do this for 3 months. (8/6/26) 4. The facility will have no areas of non compliance related to supervision for a period of 3 months. This will be monitored with at least 2 unannounced visits at the facility by the department. (8/6/26) Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Meal time designated on facility schedule/No more than twice measured space (3270.61(h)(3)(ii)/3270.61(h)(3)(iii))

An unannounced complaint inspection occurred at the facility on 3/6/26. The rear room in the middle building has a capacity of 3 children. This room contained 9 children observed eating lunch, which exceeds the allowable capacity at a mealtime by 2 children. The mealtime where capacity may be exceeded was not listed on the facility's daily activity schedule. Requirement: The capacity established for an indoor space may not be exceeded except in situations described in § 3270.61(h)(1-3) When the capacity of a space is exceeded while children are eating, the meal time shall be designated on the facility's schedule of daily activities. When the capacity of a space is exceeded while children are eating, the number of children present in the space may not be more than twice the measured capacity of the space. TIERED LIS: 1. The facility may not exceed room capacity other than within the parameters of the regulation. (THIS PORTION OF THE PLAN SHALL HAVE AN IMMEIDATE CORRECTION DATE.) 2. The operator will adjust the facility daily's activity sheet to identify the times when capacity will be exceeded for the purposes of eating. (THIS PORTION OF THE PLAN SHALL HAVE A DATE FOR WHEN THIS REQUIREMENT WILL BE COMPLETED.) 3. The operator will post each room capacity at the facility to ensure capacity is not exceeded. The posting should also include the maximum capacity for mealtimes, if meals are provided in the child care space. (THIS PORTION OF THE PLAN SHALL HAVE A DATE FOR WHEN THIS REQUIREMENT WILL BE COMPLETED.) Correction: 1. Will not exceed room capacity other than within the parameters of the regulation. (3/6/26) 2. Will adjust the daily activity sheet to identify the times capacity will be exceeded for the purposes of eating. (5/20/26) 3. Will post each room capacity to ensure capacity is not exceeded. Will include the max capacity for mealtimes. (5/20/26) Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Employed and present 30 hrs/wk (3270.34(c))

An unannounced complaint inspection occurred at the facility on 3/6/26. Through interviews and documentation review, it was determined that the facility has not had a qualified director employed at the facility since November of 2025. Requirement: A director shall be employed by a facility and be present at the facility site a minimum of 30 hours per week. Correction: A director was hired on 3/30/26 and will be present at the facility for at least 30 hours per week. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Restraints prohibited (3270.113(e))

An unannounced monitoring verification visit occurred at the facility on 1/12/26. A physical site review was conducted. During the inspection, Staff #3 identified a child sitting who was sitting in a highchair eating and watching an iPad as 3 years of age. The child was observed attempting to get out of the highchair and was unsuccessful, nor was the child removed when requested by the child. Requirement: A facility person may not restrain a child by using bonds, ties or straps to restrict a child's movement or by enclosing the child in a confined space, closet or locked room. The prohibition against restraining a child does not apply to the use of adaptive equipment prescribed for a child with special needs. TIERED LIS: 1. A facility person may not restrain a child by using bonds, ties or straps to restrict a child's movement or by enclosing the child in a confined space, closet or locked room. This portion of the plan requires an immediate correction plan. 2. The Legal Entity shall establish a discipline policy. The policy will include the facility's use of acceptable methods of discipline as well as what discipline is prohibited at the facility. This must include the prohibition of equipment as discipline. The discipline policy must be submitted to the Department prior to implementation for approval. Once approved by the Department, the director will ensure that all current employees and any new hires are trained on this policy. Documentation of the training must be on file at the facility. This portion of the plan requires a date when this requirement will be complete. Correction: 1. A facility person will not restrain a child by using bonds, ties or straps to restrict a child's movement or by enclosing the child in a confined space, closet or locked room. 2. The Legal Entity will establish a discipline policy. The policy will include the facility's use of acceptable methods of discipline as well as what discipline is prohibited at the facility. This will include the prohibition of equipment as discipline. The discipline policy will be submitted to the Department prior to implementation for approval. Once approved by the Department, the director will ensure that all current employees and any new hires are trained on this policy. Documentation of the training will be on file at the facility. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Supervised at all times /Staff assigned to specific children (3270.113(a)/3270.113(a)(1))

CONTINUED NONCOMPLIANCE A renewal inspection occurred at the facility during the period of 11/18/25 to 11/26/25. A physical site review was conducted. In the rear building, middle room, a preschool child was observed working with an outside provider and this child was not supervised by a facility staff person. This child's file did not contain consent from the family for the child to work unsupervised with the outside provider. An acceptable plan of correction was obtained on 12/9/25. An unannounced monitoring verification visit occurred at the facility on 1/12/26. At the time of arrival, Staff #3 was the only staff present in the building and was observed in the rear room from the entrance door with one child. Five children were observed in the room with the entrance door, and three children were observed in the right room. 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. 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. TIERED LIS: 1. Children must be supervised at all times. This portion of the plan requires an immediate correction date. 2. The Legal Entity must arrange for all staff hired at the facility shall take the one-hour training titled "Supervision: What's Required?" through Better Kid Care. The training certificates shall be provided to the Northeast Regional Office and maintained in the staff files. This portion of the plan requires a correction date when the training will be completed. Correction: 1. Children will be supervised at all times. 2. All staff hired at the facility will take the one-hour training titled "Supervision: What's Required?" through Better Kid Care. The training certificates will be provided to the Northeast Regional Office and maintained in the staff files. 2/17/26 Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Mixed Age Level/Toddler and preschool children (3270.52/3270.55(a))

A unannounced monitoring verification visit occurred at the facility on 1/12/26. A physical site review was conducted. Staff #3 was present with a mixed age group of children, and the youngest child was identified by this staff as a young toddler. Staff #3 was with 9 children. This number of children would have required at least two staff to meet appropriate staff:child ratios. Requirement: When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff:child ratio and maximum group size in accordance with the requirements in § 3270.51 (relating to similar age level). The staff:child ratio while toddlers and preschoolers are napping is one staff person to 10 young toddlers, one staff person to 12 older toddlers, one staff person to 20 preschool children. The required staff:child ratios must be maintained at all times. TIERED LIS: 1. The required staff:child ratios must be maintained at all times. This portion of the plan requires an immediate correction date. 2. The Legal Entity must arrange for all staff hired at the facility to take the one-hour training titled "Supervision; Staff-to-Child Ratio" on Better Kid Care. The training certificates shall be provided to the Northeast Regional Office and maintained in the staff files. This portion of the plan requires a correction date when the training will be completed. Correction: 1. Staff:child ratios must be maintained at all times. 1/12/26 2. All staff hired at the facility to take the one-hour training titled "Supervision; Staff-to-Child Ratio" on Better Kid Care. The training certificates will be provided to the Northeast Regional Office and maintained in the staff files. 2/17/26 Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Training regarding plan (3270.27(c))

A renewal inspection occurred at the facility. A review of staff files was conducted. Regulation requires staff to review the emergency plan on an annual basis. The following staff did not review the emergency plan on an annual basis: Staff #1 (previous 9/30/24, current 11/18/25) and Staff #2 (previous 8/24/24, no current). 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: Will discuss the emergency plan with Staff #1 and Staff #2. Staff will sign off indicating their understanding of the plan. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

A renewal inspection occurred at the facility. A review of staff files was conducted. Regulation requires staff to participate in annual fire safety training. The following staff did not participate in annual fire safety training: Staff #1 (previous 10/18/24, no current) and Staff #2 (previous 8/26/24, current 9/11/25). 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 #1 will schedule and participate in fire safety training. Documentation of this completed training will be kept in the staff's file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Staff evaluations (3270.34(a)(6))

A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the date of hire. Regulation requires the director to evaluate staff on an annual basis. The following staff did not have annual evaluation conducted on them by the director: Staff #2. Requirement: A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months. Correction: An evaluation of Staff #2 will be conducted. This evaluation will be placed in the staff's file after reviewing with staff. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Building Surfaces/No peeling paint or plaster (3270.76/3270.77(a))

A renewal inspection occurred at the facility. A physical site review was conducted. The school age outdoor play pace contained a rusty fire pit and rusty tire rims. The preschool outdoor play space climber had peeling paint on the green poles. The middle building sunroom and bathroom contained a rusty baseboard heater. These areas were identified and addressed with the operator at the time of the inspection. 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. Peeled or damaged paint or damaged plaster is not permitted on indoor or outdoor surfaces in the child care facility. Correction: The rusty fire pit and tire rims will be removed from the outdoor play area. The peeling paint on the green poles will be repaired so the paint is no longer peeling. The rusty baseboard heaters will be repaired so that they no longer contain rust. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Clean and good repair (3270.102(a))

A renewal inspection occurred at the facility. A physical site review was conducted. In the preschool outdoor play area, the climber was missing screws at the game board area. Also in this area, was a Little Tikes small green rock climber that contained a crack. These pieces of equipment were identified and addressed with the operator at the time of the inspection. 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 screws will be replaced in the game board area in the outdoor climber. The little tikes small green climber will be removed from the outdoor play area. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Outdoor equip.- protective surfacing (3270.102(c))

A renewal inspection occurred at the facility. A physical site review was conducted. The mulch surrounding the outdoor climber in the preschool play area was measure and did not contain the 9 inches of loose fill as required by the CPSC. The depth of mulch surrounding this climber was measured to be between 2-3 inches surround the climber when measured in multiple areas. Requirement: Outdoor equipment that requires embedded mounting must be mounted over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission. The equipment must be anchored firmly and be in good repair. Correction: The mulch in the outdoor play area will be raked to ensure under the climber there is at least 9 inches of loose fill material under the equipment as required by the CPSC. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

A renewal inspection occurred at the facility. A physical site review was conducted. In the preschool outdoor play area, a chair was found that the legs were rusty. This chair was identified and addressed with the operator at the time of the inspection. Requirement: Furniture must be durable, safe, easily cleaned and appropriate for the child's size, age and special needs. Correction: The rust on the chair will be repaired and if a repair is not possible, the chair will be removed from the outdoor play area. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Supervised at all times /Staff assigned to specific children (3270.113(a)/3270.113(a)(1))

A renewal inspection occurred at the facility. A physical site review was conducted. In the rear building, middle room, a preschool child was observed working with an outside provider and this child was not supervised by a facility staff person. This child's file did not contain consent from the family for the child to work unsupervised with the outside provider. 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. 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. TIERED LIS: 1. Children must be supervised, and staff must be physically present with children at all times. ((This portion of the plan requires an immediate date of correction.)) 2. The operator shall develop a policy to address proper supervision of children during times an outside provider is providing services to a child. The policy shall identify how staff will be physically present to ensure proper supervision of children. The policy may identify other means of supervision of the child in an agreed upon service between the family and the facility staff. This policy must be sent to the Regional Office for review. Once approved, the operator will discuss with staff the policy and ensure the implementation of the facility. Correction: 1. Children will be supervised at all times by staff. (11/18/25) 2. A supervision policy will be developed as required above. The supervision policy will be submitted to the regional office for review. Once the policy is approved, it will be discussed with staff and staff will sign off indicating their understanding of the supervision policy. (12/13/25) Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Parent home/work address, phone (3270.124(b)(3))

A renewal inspection occurred at the facility. A review of children's files was conducted. Regulation requires the enrolling persons work address and phone number to be included in the file. This information was missing in the files of the following children: Child #1 and Child #5. Requirement: Emergency contact information must include the home and work addresses and telephone numbers of the enrolling parent. Correction: The parents work address and phone numbers for the listed children will be obtained and placed in the children's files. 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))

A renewal inspection occurred at the facility. A review of children's files was conducted. Regulation requires children's emergency contact and agreement forms to be reviewed and updated at least every 6 months. The following children's forms were not reviewed/updated at least every 6 months: Child #1 (emergency contact previous 11/8/24, current 7/29/25 and agreement previous 2/11/25, no current); Child #3 (agreement previous 1/25/25, no current) and Child #4 (no previous agreement, current 9/4/25). 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 listed children's emergency contact and agreement forms will be updated. These updates will be placed and maintained in the child's file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Infant: updated health report every 6 months/Initial and subsequent health reports (3270.131(b)(1)/3270.182(1))

A renewal inspection occurred at the facility. A review of children's files was conducted. See the code sheet for the child's date of birth. Regulation requires toddlers to have an updated health report in their file at least every 6 months. Child #1 had a health report in their file dated for 1/30/25. The file was missing the 6-month updated health report. Requirement: The operator shall require the parent to provide an updated health report at least every 6 months for an infant or young toddler. A child's record shall contain initial and subsequent health reports. Correction: An updated health report will be obtained in the child and placed in the child's file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Consent for emergency medical care required prior to admission/Consent for administration of minor first-aid required prior to admission (3270.182(3)/3270.182(5))

A renewal inspection occurred at the facility. A review of children's files was conducted. Regulation requires in the files of children consent for emergency medical care and admission of first aid treatment. The following children were missing these consents in their files: Child #3 and Child #5. Requirement: A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission. A child's record shall contain signed parental consent for administration of minor first-aid procedures by facility staff. Written consent is required prior to admission. Correction: Consent for emergency medical care and admission of first aid treatment will be obtained on the listed children and placed in their files. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Exceeding Capacity (3270.61(h))

A renewal inspection occurred at the facility. A review of staff files was conducted. The back building's rear room has a measured capacity of 3 children. During this inspection, a group of 10 children was observed to be receiving care in this room. This room was over capacity by 7 children. Requirement: The capacity established for an indoor space may not be exceeded except in situations described in § 3270.61(h)(1-3) Correction: Children were immediately moved to meet the appropriate room capacities. 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))

A renewal inspection occurred at the facility. A review of the facility's fire system testing log was conducted. Regulation requires the fire safety system to be tested at least every 30 days. The following tests did not occur at least every 30 days: 10/10/25 and 11/18/25. 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 fire safety system was tested at the time of the inspection and was observed to be in working order. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Toddler/preschool: updated health report every 12 months/Emergency info/agreement updated 6 mos (3270.131(b)(2)/3270.181(c))

A renewal inspection occurred at the facility. A review of children's files was conducted. See the code sheet for the date of birth of the children. Regulation requires an updated health report to be in the children's files at least every 12 months for older toddler and preschool children. The following child did not have an updated health report in their file conducted at least every 12 months: Child #3 (previous 1/3/24, no current). 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 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: An updated health report will be requested and obtained on the listed child. This health report will be maintained in the child's file for review at any time. 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))

A renewal inspection occurred at the facility. A review of children's files was conducted. Regulation requires the emergency contact information of children to be updated at least every 6-month period. The following child files did not update their emergency contact information at least every 6-month period: Child #3 (previous1/9/24, no current review) and Child #4 (previous 2/29/24, no current review). Regulation requires the agreement forms of children to be updated at least every 6-month period. The following child's files did not update their agreement forms at least every 6-month period: Child #3 (previous1/9/24, no current review) and Child #4 (previous 6/12/24, no current review). 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: Families of the listed children will review and update the emergency contact information, and the agreement forms in the child's file. Documentation of the review will be maintained in the file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Services proceeded (3270.123(a)(3))

A renewal inspection occurred at the facility. A review of children's files was conducted. See the code sheet for the date of enrollment. Regulation requires children to be assessed every 6-month period for their growth and development. The following children were missing their 6-month assessment: Child #3 (none in file since enrollment) and Child #4 (none in file since enrollment). Requirement: The services to be provided to the family and the child, including the Department's approved form to provide information to the family about the child's growth and development in the context of the services being provided. The operator shall complete and update the form and provide a copy to the family in accordance with the updates regarding emergency contact information in § 3270.124(f) (relating to emergency contact information). Correction: Growth and development assessments will be conducted on the children and copies of the assessment will be maintained in the children's files. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

A renewal inspection occurred at the facility. A review of staff files was conducted. Regulation requires staff to participate in annual fire safety training. Staff #1 did not participate in annual fire safety training (previous 5/8/23, current 12/26/24). Requirement: Staff persons shall participate, at least annually, in firesafety 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: In the future, staff will participate in annual fire safety training. Documentation of this training will remain in the staff's file at all times. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).