HERITAGE OUT OF SCHOOL TIME

Supervised at all times (3270.113(a))

At approximately 10:15 AM, Child #1 was asleep and left alone in the Dreamers classroom for 10-15 minutes while Staff #1 and Staff #2 went to the Gym with the rest of the group. 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: Children on the facility premises and during facility excursions will be supervised by a staff person at all times. The Provider will ensure quality supervision through consistent face to name roll call and visually sweeping the room to ensure that all students are accounted for especially during times of group transition at the facility. The Provider investigated the supervision violation thoroughly and followed through with appropriate disciplinary action for both Staff Person 1 and Staff Person 2. Inspection: Self-Reported Non Compliance. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

At approximately 10:15 AM, Child #1 was asleep and left alone in the Dreamers classroom for 10-15 minutes while Staff #1 and Staff #2 went to the Gym with the rest of the group. 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: The Provider will ensure that each staff person is assigned the responsibility of specific children in their designated groups. The staff will know the names and whereabouts of the children in their assigned group. Staff will be physically present with the children in their group while on and off the facility premises. Staff will utilize a supervision card system and consistently check their supervision group for face to name roll call at various times in the day to ensure proper supervision is upheld at all times. Inspection: Self-Reported Non Compliance. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Supervised at all times (3270.113(a))

At approximately 4:51 on 2/4/26, video footage taken in the facility shows a parent holding the door open to the Imagineers classroom while Child #1 exits into the hallway. Child #1 continues to walk alongside the family down the hallway and exits the building. 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. TIERED LIS: 1. 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. THIS PORTION OF THE PLAN SHALL HAVE AN IMMEDIATE CORRECTION DATE. 2. The legal entity shall ensure that all facility staff complete an in-person supervision and ratio training, coordinated through the ELRC, that include a component relating to supervision during times of transition. Training documentation must be retained on file that includes the date of the training and the names of the attendees. THE OPERATOR SHALL PROVIDE A DATE FOR WHEN THIS WILL BE COMPLETED. 3. The legal entity shall develop a written dismissal policy with procedures to include supervision regulations and center requirements, developed with the ELRC. The policy should also include clarification regarding staff placement during dismissal, relocating children to other rooms at the end of the day, and procedures for parents during dismissal. The written policy shall be forwarded to the Certification Representative for review. Following confirmation of the review, the dismissal policy shall be presented to all staff members at a staff meeting. Verification of completion will include copies of signed and dated acknowledgements for all staff, as well as the staff meeting agenda where the new policy was discussed. Documentation shall be forwarded to the certification representative upon completion and kept on file at the facility. THE OPERATOR SHALL PROVIDE A DATE FOR WHEN THIS WILL BE COMPLETED. 4. The legal entity shall ensure that all facility staff complete a technical assistance program regarding supervision of children coordinated through the ELRC, with an emphasis on supervision during transitions and appropriate supervision within the environment, including rest time. Documentation of completion of the TA shall be retained on file at the facility as well as submitted to certification representative upon completion. THE OPERATOR SHALL PROVIDE A DATE FOR WHEN THIS WILL BE COMPLETED. 5. The legal entity will develop a tool with which to complete daily supervision and ratio checks of all classrooms throughout the day to assess sightlines, staff positioning in the room, and supervision groups. The tool will include the classroom name, date and time of observation, staff person(s) present, the number of children and their age levels (Infant, YT, OT, PS, YSA, OSA) present. The tool will assess that a staff person is physically present with their group of children under their supervision. The tool will assess that the staff person can see, hear, direct and assess the activity of the children under their supervision. THE CORRECTION DATE FOR THIS PORTION OF THE PLAN WILL BE THE DAY THE ASSESSMENT TOOL IS SUBMITTED TO CERTIFICATION, PRIOR TO USE. 6. Random supervision and ratio checks will occur at least 3 times per week for the 4 months subsequent to training and after submission of the tool. Documentation of the checks will be made available to Certification upon request. THE CORRECTION DATE FOR THIS PORTION OF THE PLAN WILL BE AT A MINIMUM OF 4 MONTHS FROM DATE THE REGIONAL OFFICE APPROVES THE TOOL. Correction: Tier 1 Correction: The Provider will ensure that children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Teachers are required to utilize a Student ID Card system to appropr

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

At approximately 4:51 on 2/4/26, video footage taken in the facility shows a parent holding the door open to the Imagineers classroom while Child #1 exits into the hallway. Child #1 continues to walk alongside the family down the hallway and exits the building. 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: The Provider will ensure that each staff person is assigned the responsibility of the supervision of specific children. The staff person will know the names and whereabouts of the children in their assigned group. Staff will be physically present with the children in their group on the facility premises and on facility excursion that are off the facility premises. Program staff will utilize the required supervision student ID Card System that allows staff to separate students into supervision groups and to complete face to name roll call throughout the day and especially during times of transition. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Comply with CPSL (3270.32(a))

The two most recent mandated reporter trainings on file for Staff #1 (8/17/20 &8/25/25) and Staff #2 (4/30/20 & 6/7/20) are dated more than 60 months apart. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Correction: Staff have completed the necessary mandated reporter trainings. The Provider will ensure all staff have mandated reporter training completed at time of hire and renewed prior to the 5 year expiration date. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

General Health and Safety (3270.21)

Adult scissors were observed accessible on the teacher's desk in the Steelers and Penguins rooms. Requirement: Conditions at the facility may not pose a threat to the health or safety of the children. Correction: Adult Scissors will be removed from student access in all classrooms that it is applicable. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Training regarding plan (3270.27(c))

The initial emergency plan training on file for Staff #7 is dated 7/2/25, more than 90 days beyond the facility person's date of hire (SEE IS CODE SHEET). 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: Staff #7 has received the required training and will be required to complete annual training on the emergency plan. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Letter to parents (3270.27(e))

The facility's emergency plan parent letter lacked accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions. Requirement: The operator shall provide to the parent of each enrolled child a letter explaining the emergency procedures. The operator shall also provide to the parent of each enrolled child a letter explaining any subsequent update to the plan. Correction: Parent Letter will be corrected to include specific accommodations required during an emergency. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The two most recent fire safety trainings on file for Staff #1 are dated 6/30/23 and 7/10/24, more than 12 months apart. 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: Staff completed the necessary training and will complete annual fire safety training prior to the expiration date moving forward. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The file for Staff #10 contained an NSOR certificate dated 10/3/24, after date of hire, without a NSOR request on file at time of hire required for provisional hiring under the CPSL (SEE IS CODE SHEET). 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: NSOR for staff member was received. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Comply with CPSL (3270.32(a))

The two most recent mandated reporter trainings on file for Staff #1 (4/30/20 & 6/17/25), Staff #2 (4/20/20 & 7/11/25), and Staff #14 (4/27/20 & 6/4/25) are dated more than 60 months apart. Staff #3 and Staff #4 have not completed the mandated reporter training within 90 days of their date of hire (see LIS code sheet). Staff #7 did not complete the mandated reporter training within 90 days of their date of hire (see LIS code sheet). The training was completed on 7/13/25. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Correction: Staff without updated mandated reporter trainings will be required to complete the necessary training. New staff who are hired will be required to present complete mandated reporter training within 90 days of hire and prior to their training expiration date. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Staff evaluations (3270.34(a)(6))

The two most recent staff evaluations on file for Staff #13 are dated 5/23/24 and 6/30/25, more than 12 months apart. Requirement: A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months. Correction: Evaluation was completed and is now up to date. Staff evaluations will be scheduled to be completed prior to the 12 month expiration period. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Protective Outlet Covers 5 yrs. or less (3270.65)

A protective receptacle cover was missing in an outlet in the Dreamers, Imagineers, and Voyagers rooms. Requirement: Protective receptacle covers shall be placed in electrical outlets accessible to children 5 years of age or younger. Correction: Protective receptable covers were replaced in the Dreamers, Imagineers, and Voyagers. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Locked or inaccessible (3270.66(a))

Hand sanitizer in the Penguins room and antibacterial wipes in the Pirates room, both labeled 'Keep Out of Reach of Children', were observed accessible to children. Requirement: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children. Correction: Hand sanitizer and antibacterial wipes labeled " Keep out of reach of Children" were put up and out of reach of students. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Trash removed once a day (3270.67(a))

A trash can in the outside play space was observed with garbage from days prior. Requirement: Trash shall be removed from the facility at least once per day. Correction: Trash removal is contracted out to a third party, communication was made to have the outdoor trash cans emptied. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Contaminated trash in closed plastic-lined receptacle (3270.67(d))

In the Penguins and Panthers rooms, garbage cans containing napkins with human secretions lacked lids on the receptacles. Requirement: Trash that has been contaminated by human secretions or excrement shall be contained in closed, plastic-lined receptacles. Correction: All missing trash can lids will be replaced. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Building Surfaces (3270.76)

In the Panthers Room, a piece of baseboard trim was missing on the cabinet in the corner and was not in good repair. Broken tiles with sharp edges located at the bottom of the walls and standing water on the floor and in a bucket were observed in the Boys Bathroom. Broken tiles with sharp edges located at the bottom of the walls and a leaking sink was observed in the Girls Bathroom. In the outside play space, standing water was observed in the toy bins and play tables. 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: Classroom missing baseboard will be covered until there is a replacement ordered. Broken tiles with sharp edges in the restroom will be repaired/covered in the boys restroom. Standing water on both the floor and in a bucket were cleaned/removed as necessary. Broken tiles and leaking sink in the girls restroom will be repaired. Standing water in play bins in outdoor space has been removed. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Clean and good repair (3270.102(a))

A green toy bin in the Voyagers classroom was observed to have a broken handle and not in good repair. Foam blocks with ripped pieces and teeth marks were observed in the Pirates room. Peeling vinyl was observed on the couch in the Dreamers classroom, on the brown couch in the Voyagers classroom, a bean bag in the Panthers classroom, and on the front and back wall mats in the Gym. Rest equipment with torn vinyl and exposed foam was observed in the Dreamers and Imagineers classrooms. 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: Broken bin is removed from the classroom. Foam blocks with ripped pieces/ teethed pieces are removed from the classroom. Peeling couch/bean bag vinyl in both classrooms will be repaired and/or the furniture has been removed from the space. Peeling Wall Gym Mats will be repaired/covered as necessary. Rest equipment replacements has been ordered to replace torn mats and exposed foam mats have been temporarily repaired until new equipment is in place. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

2 feet apart (3270.106(f))

Rest equipment in the Dreamers and Imagineers classrooms lacked two feet on three sides of the rest equipment while the equipment was in use. Requirement: At least 2 feet of space is required on three sides of a bed, cot, crib or other rest equipment while the equipment is in use. Correction: Classroom teachers will ensure proper spacing is implemented during rest times. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Services proceeded (3270.123(a)(3))

The most recent child service report on file for Child #2 is dated 1/7/25, more than 6 months from the child's date of enrollment (SEE IS CODE SHEET). The two most recent child service reports on file for Child #8 are dated 12/1/23 & 2/10/25, more than 6 months apart. 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: Child Service Reports were completed and will be completed prior to the 6th month mark. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Parent receives original/Consent for emergency medical care required prior to admission (3270.123(b)/3270.182(3))

The file for Child #5, Child #7, Child #9, and Child #10 contained the original financial agreement when the parent is to receive the original agreement. Requirement: A parent shall receive the original agreement. The facility shall retain a copy of the agreement. A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission. Correction: The fee agreement for each child will be given to the parent and a copy made for student files. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Physician name, address, phone (3270.124(b)(2))

The emergency contact form on file for Child #7 and Child #8 lacked a complete address and phone number for the child's physician or source of medical care. Requirement: Emergency contact information must include the name, address and telephone number of the child's physician or source of medical care. Correction: Child #7 and Child #8 are no longer enrolled as of 8/8/25 Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The emergency contact form on file for Child #1, Child #5, Child #6, and Child #7 lacked complete addresses for the enrolling parent's home and work address. Requirement: Emergency contact information must include the home and work addresses and telephone numbers of the enrolling parent. Correction: Emergency contact forms that are missing complete addresses for enrolling parent's home and work addresses will be filled in by the parent. Child #7 is no longer enrolled as of 8/6/25. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Written consent/Consent for emergency medical care required prior to admission (3270.124(b)(4)/3270.182(3))

The emergency contact form on file for Child #3 and Child #6 lacked the enrolling parent's signature giving the facility written consent to obtain emergency medical care. Requirement: Emergency contact information must include the written consent signed by a parent for emergency medical care. A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission. Correction: Child #3 is no longer enrolled as of 7/17/25. Emergency Contact forms missing proper signatures will be updated by the parent with proper signatures. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The emergency contact form on file for Child #5 lacked the health insurance policy or medical assistance 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: Emergency Contact missing the health insurance policy/medical policy number will be updated with the appropriate number. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).