UPMC Passavant Childrens House

The last two reviews of the facility emergency plan were not completed annually; those reviews were dated 8/21/23 and 11/16/24.

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.

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.

*In the Preschool Room, at approximately 10:30am, two staff and 16 preschool age children were observed. During the onset of supervision and ratio, Staff person #1 identified and named 8 preschool aged children and Staff person #2 identified and named 7 preschool aged children thus leaving 1 child unaccounted for. Staff were again asked to identify and name the children whom they were responsible for; Staff person #1 identified and named 8 preschool aged children and Staff person #2 identified and named 7 preschool aged children thus still leaving 1 child unaccounted for.

***In the Preschool Room, at approximately 10:30am, two staff and 16 preschool age children were observed. During the onset of supervision and ratio, Staff person #1 identified and named 8 preschool aged children and Staff person #2 identified and named 7 preschool aged children thus leaving 1 child unaccounted for. Staff were again asked to identify and name the children whom they were responsible for; Staff person #1 identified and named 8 preschool aged children and Staff person #2 identified and named 7 preschool aged children thus still leaving 1 child unaccounted for.

**In the Preschool Room, at approximately 10:30am, two staff and 16 preschool age children were observed. During the onset of supervision and ratio, Staff person #1 identified and named 8 preschool aged children and Staff person #2 identified and named 7 preschool aged children thus leaving 1 child unaccounted for. Staff were again asked to identify and name the children whom they were responsible for; Staff person #1 identified and named 8 preschool aged children and Staff person #2 identified and named 7 preschool aged children thus still leaving 1 child unaccounted for.

In Kindergarten Prep Room a stapler was observed on a table and accessible to children in care. In the School Age Room a stapler was observed stored on an arts and crafts wood shelving unit and accessible to children in care.

The staff file for Staff person #3 contained a current National Sex Offender Registry check dated 7/20/23 which was applied for timely though not received within 45 days of hire [See IS CODE SHEET] as required for provisional hiring under the Child Protective Service Law (CPSL).

The child file for Child #2, who is a preschool age child, was observed to contain an updated health report dated 6/5/23 which was conducted more than 12 months from the previously dated 5/24/22 health report on file.

Staff person #1, Staff person #2, and Staff person #4 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Revised 10hr Health and Safety Training 2022. Staff person #1, Staff person #2, and Staff person #4 contained the old ten-hour Health and Safety Training and the 1hr updated training were on file which are not acceptable for new staff hired after 10/4/22.

The child file for Child #1 contained a current child service report dated 12/1/23 that was not completed every 6 months from the previous report dated 5/15/23. The child file for Child #2 contained a current child service report dated 12/4/23 that was not completed every 6 months from the previous report dated 5/30/23.

During a swimming inspection, at approximately 10:15am, Staff person #1 and eleven young school aged children were observed. During the onset of supervision and ratio, Staff person #1 identified and named 6 young school aged children thus leaving 5 children unaccounted for. Staff person #2 was observed coming out of the restroom and claimed responsibility for the 5 young school aged children allowing all children to be accounted for. Staff person #2 was observed to not be physically present with their assigned group of children.

During a swimming inspection, at approximately 10:15am, Staff person #1 and eleven young school aged children were observed resulting in the staff:child swim ratio being 1:11. Staff person #2 was observed coming out of the restroom and claimed responsibility for the 5 other young school aged children resuming compliance with staff-child ratios.

At approximately 11:15am, outside in the toddler play space, 3 staff and 29 preschool age children were observed outside playing and a first-aid kit was not present.

At approximately 11:15am, outside in the toddler play space, 3 staff and 29 preschool age children were observed outside playing and the emergency contact forms for all of the children were not present.

The file for Staff person #1 was observed to lack documentation of having applied for and received a State sex offender check and State criminal background check from the State in which they resided in within the previous five years as required by the Child Protective Service Law (CPSL).

*Based on staff interviews it was determined that a young toddler was left alone in the gym for approximately nine minutes with no adult supervision. During this time, staff: child ratio was 0:1.

Based on staff interviews it was determined that a young toddler was left alone in the gym for approximately nine minutes with no adult supervision. During this time, staff: child ratio was 0:1.

Based on staff interviews it was determined that a young toddler was left alone in the gym for approximately nine minutes with no adult supervision.

**Based on staff interviews it was determined that a young toddler was left alone in the gym for approximately nine minutes with no adult supervision.

*Based on staff interviews it was determined that a young toddler was left alone in the gym for approximately nine minutes with no adult supervision.

***Based on staff interviews it was determined that a young toddler was left alone in the gym for approximately nine minutes with no adult supervision.

The staff file for Staff person #4, contained a current health assessment dated 11/1/21 which was conducted more than 24 months from the previously dated 10/28/19 health assessment on file.

The staff file for Staff person #2, was observed to contain a tuberculosis screening test results dated 11/16/20 which was conducted more than 12 months prior to providing initial service in a childcare setting (See IS CODE SHEET).

The staff file for Staff person #3 contained current first-aid/CPR training dated 11/5/22 which was not renewed on or before the expiration of the previous training certificate on file dated 1012/20.

Staff person #4 had not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Health and Safety Training; the health and safety training on file was completed prior to 9/30/16 and is not considered an acceptable training. Staff person #4 now has health and safety training on file dated 11/23/22.

The facility had verification of annual testing on 8-30-21 of the fire detection system by a fire safety professional that lacked the required documentation showing that the deficiencies listed on the report were corrected and the fire detection system was in full compliance with 62 P.S. 1016(c)(3). A new report was submitted on 5-5-22 showing that the fire detection system was re-inspected on 5-3-22 and was in full compliance with 62 P.S. 1016(c)(3). The fire detection system was not in compliance between 8-30-21 to 5-3-22.

At approximately 10:25 a.m., the patio and sidewalk outside the back exit doors from the preschool room were observed to be covered with snow.

In the gym, the first-aid kit was in a cabinet with the lock not functioning and was unlocked resulting in the first-aid kit being accessible to children. The pre-k group was observed in the gym, and the backpack with the first-aid kit inside was on the floor and accessible to children.

In the pre-k room, there was peeling paint in one area on the back right wall near the cots.

In the pre-k room, there was Children's Advil for child #1, and the medication log lacked the name of the medication.

The facility lacked proof of purchase of the interconnected fire detection system in accordance with 62 P.S. 1016(c)(3).