Embark at The Poconos

Citation, renewal inspection : 55 Pa. Code § 3800.21 Applicable Health and Safety Laws

Staff member A had a driver's license on in file that expired in . Staff member A was employed until and would have been transporting children.

Citation, renewal inspection : 55 Pa. Code § 3800.54.d Child Care Supervisor

No copy of degree was found in Staff person D's file.

Citation, renewal inspection : 55 Pa. Code § 3800.142 Health and Safety Plan

Child A’s health and safety assessment identified a health or safety risk, and the facility did not write or implement a plan within 24 hours after the assessment is completed to protect the child.

Citation, renewal inspection : 55 Pa. Code § 3800.151 Staff Health Statement

Staff person B did not have the required statement signed and dated by a licensed physician, certified registered nurse practitioner or licensed physician’s assistant, within 12 months prior to working with children or food service and every 2 years thereafter. Most recent health statement located in the staff's file was dated 10/27/2023.

Citation, renewal inspection : 55 Pa. Code § 3800.151 Staff Health Statement

Staff person C did not have the required statement signed and dated by a licensed physician, certified registered nurse practitioner or licensed physician’s assistant, within 12 months prior to working with children or food service and every 2 years thereafter. Staff person C health statement was dated 6/16/23 and not updated until 9/8/25.

Citation, renewal inspection : 55 Pa. Code § 3800.31.d Notification of Rights and Grievance Procedures

The statement for Child C's rights is signed but did not have a date to show when it was signed

Citation, renewal inspection : 55 Pa. Code § 3800.51 Child Abuse and Criminal History Checks

Staff member E was hired on and did not obtain required Child Abuse clearances until 2/14/24.

Citation, renewal inspection : 55 Pa. Code § 3800.51 Child Abuse and Criminal History Checks

Staff member F was hired on and did not obtain required Pennsylvania State Police clearances until 9/27/24.

Citation, renewal inspection : 55 Pa. Code § 3800.58.d Staff Training

Staff person A did not have 40 hours of annual training after the initial year of employment. Staff A's training file only showed 14.5 hours of annual training.

Citation, renewal inspection : 55 Pa. Code § 3800.141.a Child Health and Safety Assessment

Child C did not have a written health and safety assessment within 24 hours of admission. Child C did have a written health and safety assessment, but there was no date and time to show when the document was created.

Citation, renewal inspection : 55 Pa. Code § 3800.142 Health and Safety Plan

Child C’s health and safety assessment identified a health or safety risk, and the facility did not write or implement a plan within 24 hours after the assessment is completed to protect the child. Child C's safety plan did not have a date or time to show when the document was created.

Citation, renewal inspection : 55 Pa. Code § 3800.142 Health and Safety Plan

Child A’s health and safety assessment identified a health or safety risk, and the facility did not write or implement a plan within 24 hours after the assessment is completed to protect the child. Child A's safety plan did not have a date or time to show when the document was created.

Citation, renewal inspection : 55 Pa. Code § 3800.151 Staff Health Statement

Staff person D did not have the required statement signed and dated by a licensed physician, certified registered nurse practitioner or licensed physician’s assistant, within 12 months prior to working with children or food service and every 2 years thereafter.

Citation, renewal inspection : 55 Pa. Code § 3800.184.b Medication Log

Staff member B administered on 11/17/24 at 9AM and there were no initials entered into the medication log. The log only included a small dot indicating that the medications were given, but it did not include Staff member B's signature.

Citation, renewal inspection : 55 Pa. Code § 3800.88.c Water

Water testing needs to be completed at least every 3 months. Testing was done on 02/23/23 and was not tested again until 06/14/2023.

Citation, renewal inspection : 55 Pa. Code § 3800.132.a Fire Drills

The fire drill for April 2023 was missing.

Citation, renewal inspection : 55 Pa. Code § 3800.132.a Fire Drills

The drills conducted during 09/2023 and 10/2023 were "elopement/shelter in place" drills, not fire drills.

Citation, partial inspection : 55 Pa. Code § 3800.31.c Notification of Rights and Grievance Procedures

On 11/29/2022 it was observed that the child's rights were not posted in the facility.

Citation, partial inspection : 55 Pa. Code § 3800.51 Child Abuse and Criminal History Checks

Staff member B was hired on and did not obtain required PSP clearances until 9/22/22. Staff member E was hired on and did not obtain required PSP clearances until 9/22/22. Staff member F was hired on and did not obtain required PSP clearances until 9/22/22. Staff member I was hired on and did not obtain required PSP clearances until 9/22/22. Staff member L was hired on and did not obtain required PSP clearances until 9/22/22, and Child Abuse Clearance until 11/14/22. Staff member T was hired on and did not obtain required PSP clearances until 9/22/22. Staff member U was hired on and did not obtain required PSP clearances until 9/22/22. Staff member W was hired on and did not obtain required PSP clearances until 9/22/22 Staff member AG was hired on and did not obtain required PSP clearances until 9/22/22 Staff member AH was hired on and did not obtain required PSP clearances until 9/22/22 Staff member AL was hired on and did not obtain required PSP clearances until 9/22/22 Staff member AO was hired on and did not obtain required PSP clearances until 9/22/22 Staff member AS was hired on and did not obtain required PSP clearances until 9/22/22 Staff member C was hired on and facility did not obtain required PSP clearances. Staff member G was hired on and facility did not obtain required PSP clearances. Staff member H was hired on and facility did not obtain required PSP clearances. Staff member N was hired on and facility did not obtain required PSP clearances. Staff member S ...

Citation, partial inspection : 55 Pa. Code § 3800.55.g Child Care Worker

Facility does not have documentation that Staff persons A, C, G, K, M, N, P, S, T, Y, Z, AA, AD, AE, AJ, AK, AP, and AT has the minimum child care educational qualifications.

Citation, partial inspection : 55 Pa. Code § 3800.58.b Staff Training

Staff persons A, J, X, and AT did not have training in First Aid/CPR within 120 days of hire and prior to working alone with children. There is no evidence that the training had been obtained within 12 months prior of date of hire.

Citation, partial inspection : 55 Pa. Code § 3800.58.a Staff Training

Staff person G, AA, AE, AH, and AJ did not complete an orientation to the person's specific duties and responsibilities and policies and procedures of the facility, including reportable incident reporting, discipline, care and management of children, medication administration and use of restrictive procedures prior to working with children. Staff person H did not complete orientation training on incident reporting. Staff person L did not complete orientation training on facilities policies and procedures. Staff person N did not have orientation training ion the topic of reportable incident reporting. Staff person T did not complete an orientation to the person's specific duties and responsibilities and policies and procedures of the facility, including reportable incident reporting, and use of restrictive procedures prior to working with children. Staff person U did not complete an orientation to include reportable incident reporting prior to working with children. Training on reportable incident reporting occurred on 8/16/22. Staff person W did not complete an orientation to include reportable incident reporting prior to working with children. Training on reportable incident reporting occurred on 10/14/22. Staff person AR did not complete an orientation to include reportable incident reporting prior to working with children. Training on reportable incident reporting occurred on 10/11/22. Staff person Z did not complete orientation training on incident reporting. Staff ...

Citation, partial inspection : 55 Pa. Code § 3800.58 Staff Training

Staff person L was hired on and did not have Mandated Reporter Training within 90 days. Training did not occur until 9/22/22. Staff person N was hired on and did not have Mandated Reporter Training within 90 days. Staff person T was hired on and did not have Mandated Reporter Training within 90 days. Training did not occur until 10/11/22. Staff person W was hired on and did not have Mandated Reporter Training within 90 days. Training did not occur until 8/17/22. Staff person Y was hired on and did not have Mandated Reporter Training within 90 days. Staff person AC was hired on and did not have Mandated Reporter Training within 90 days. Training did not occur until 10/31/22. Staff person AK was hired on and did not have Mandated Reporter Training within 90 days.

Citation, partial inspection : 55 Pa. Code § 3800.58 Staff Training

Staff person G hired did not have training in the requirements of Chapter 3800 within 120 days of hire and prior to working alone with children. There is no evidence that the training had been obtained within 12 months prior of date of hire. Staff person L hired did not have training in the requirements of Chapter 3800 within 120 days of hire and prior to working alone with children. There is no evidence that the training had been obtained within 12 months prior of date of hire. Staff person S hired did not have training in the requirements of Chapter 3800 within 120 days of hire and prior to working alone with children. There is no evidence that the training had been obtained within 12 months prior of date of hire. Staff person Y hired did not have training in the requirements of Chapter 3800 within 120 days of hire and prior to working alone with children. There is no evidence that the training had been obtained within 12 months prior of date of hire. Staff person AA hired did not have training in the requirements of Chapter 3800 within 120 days of hire and prior to working alone with children. There is no evidence that the training had been obtained within 12 months prior of date of hire. Staff person AK hired did not have training in the requirements of Chapter 3800 within 120 days of hire and prior to working alone with children. There is no evidence that the training had been obtained within 12 months prior of date of hire. Staff person AP hired did not have training ...

Citation, partial inspection : 55 Pa. Code § 3800.58.b Staff Training

Staff person Q did not have formal certification from a recognized health care organization that they completed training in First Aid/CPR within 24 months per the guidelines of the health care organization. Initial training was 9/30/20 and was not updated until 11/3/22. Staff person L did not have formal certification from a recognized health care organization that they completed training in First Aid within 24 months per the guidelines of the health care organization. Initial training was 8/11/20 and was not updated until 11/3/22. Staff person AI was hired on , but formal certification from a recognized health care organization that the staff completed a First Aid/CPR course prior to working with children and within 120 days of hire. Certification was obtained on 4/21/22. Staff person AM did not have formal certification from a recognized health care organization that they completed training in First Aid/CPR within 24 months per the guidelines of the health care organization. Initial training expired in February 2022, and was not updated until 3/12/22. Staff person AN did not have formal certification from a recognized health care organization that they completed training in First Aid/CPR within 24 months per the guidelines of the health care organization. Initial training expired on 10/5/22, and was not updated until 11/23/22.

Citation, partial inspection : 55 Pa. Code § 3800.58 Staff Training

Staff person L was hired on and did not have training in fire safety within 120 days of hire and prior to working alone with children. There is no evidence that the training had been obtained within 12 months prior of date of hire. Training for staff L occurred on 9/22/22. Staff person T was hired on and did not have training in fire safety within 120 days of hire and prior to working alone with children. There is no evidence that the training had been obtained within 12 months prior of date of hire. Training for staff T occurred on 10/21/22. Staff person W was hired on and did not have training in fire safety within 120 days of hire and prior to working alone with children. There is no evidence that the training had been obtained within 12 months prior of date of hire. Training for staff T occurred on 8/3122.

Citation, partial inspection : 55 Pa. Code § 3800.58 Staff Training

Staff person AH hired did not have training in crisis intervention within 120 days of hire and prior to working alone with children. There is no evidence that the training had been obtained within 12 months prior of date of hire. Staff AH completed the training on 11/16/22.

Citation, partial inspection : 55 Pa. Code § 3800.132.a Fire Drills

The facility did not conduct an unannounced fire drill at least once a month. There were no fire drills conducted for August 2022, and October 2022. It is noted that the facility conducted intruder drills during these months, however the residents sheltered in place, rather than evacuate the facility.

Citation, partial inspection : 55 Pa. Code § 3800.132.c Fire Drills

The fire drill records at the facility do not indicate if the fire alarm or smoke detector was operative.

Citation, partial inspection : 55 Pa. Code § 3800.132.e Fire Drills

The facility did not conduct a fire drill during sleeping hours at least every 6 months. Last fire drill that occurred during sleep hours was on 12/27/2021.

Citation, partial inspection : 55 Pa. Code § 3800.141.a Child Health and Safety Assessment

Child D did not have a written health and safety assessment within 24 hours of admission. Child was admitted on and did not have a health and safety assessment until 7/28/2022

Citation, partial inspection : 55 Pa. Code § 3800.142 Health and Safety Plan

Child E's health and safety assessment identified a health or safety risk, and the facility did not write or implement a plan within 24 hours after the assessment is completed to protect the child. Child was admitted on and safety plan was not completed until 2/18/2022

Citation, partial inspection : 55 Pa. Code § 3800.142 Health and Safety Plan

Child F’s health and safety assessment on 5/5/2022 identified a health or safety risk of , and the facility did not write or implement a plan within 24 hours to protect the child.

Citation, partial inspection : 55 Pa. Code § 3800.142 Health and Safety Plan

Child G's health and safety assessment on 9/13/2022 identified a health or safety , and the facility did not write or implement a plan within 24 hours to protect the child. On 11/27/2022 Child G went to the emergency room and the paperwork identified an . The facility did not write or implement a plan within 24 hours to protect the child.

Citation, partial inspection : 55 Pa. Code § 3800.142 Health and Safety Plan

Child B’s health and safety assessment identified a health or safety risk of self-harm, and the facility did not write or implement a plan within 24 hours after the assessment is completed to protect the child.

Citation, partial inspection : 55 Pa. Code § 3800.142 Health and Safety Plan

Child C’s health and safety assessment identified a health or safety risk of suicidal ideation, and the facility did not write or implement a plan within 24 hours after the assessment is completed to protect the child.

Citation, partial inspection : 55 Pa. Code § 3800.144.b Dental Care

Child E did not have dental exams in accordance with the AAP dental recommendations. Child E had a dental exam prior to placement . Child would have needed an appointment within 30 days of placement, but no appointment was secured. Child F did not have dental exams in accordance with the AAP dental recommendations. Child had a dental exam prior to placement, however it was not within the recommended timeframe of 6 months. The facility did not secure an appointment with 30 days of placement.

Citation, partial inspection : 55 Pa. Code § 3800.151 Staff Health Statement

Staff O was hired on had did not have the required health statement until 2/3/22. Staff AF was hired on and the staff physical dated 6/30/22, did not state if AF was free/not free of serious communicable disease. Staff AJ was hired on , and the staff physical dated 1/23/22, did not state if AJ was free/not free of serious communicable disease. Staff person D did not have the required health statement signed and dated by a licensed physician, certified registered nurse practitioner or licensed physician’s assistant, within 12 months prior to working with children or food service and every 2 years thereafter. Staff person AN did not have the required health statement signed and dated by a licensed physician, certified registered nurse practitioner or licensed physician’s assistant, within 12 months prior to working with children or food service and every 2 years thereafter. Staff person AQ did not have the required health statement signed and dated by a licensed physician, certified registered nurse practitioner or licensed physician’s assistant, within 12 months prior to working with children or food service and every 2 years thereafter.

Citation, partial inspection : 55 Pa. Code § 3800.224.e Development of the ISP

The ISP dated 4/18/22 for child B does not contain signatures or evidence of the opportunity to sign the ISP being provided to all parties.

Citation, partial inspection : 55 Pa. Code § 3800.224.c Development of the ISP

Child B’s record does not reflect that reasonable efforts were made by the facility to involve responsible parties of child and parents for the ISP dated 4/8/2022.

Citation, partial inspection : 55 Pa. Code § 3800.229 Education

No notification of admission to facility education form was found in file for Child A. Child E was admitted on . The notification of admission to facility education form was sent on 2/18/2022.

Citation, partial inspection : 55 Pa. Code § 3800.229 Education

Staff member B was hired on and did not obtain required PSP clearances until 9/22/22. Staff member E was hired on and did not obtain required PSP clearances until 9/22/22. Staff member F was hired on and did not obtain required PSP clearances until 9/22/22. Staff member I was hired on and did not obtain required PSP clearances until 9/22/22. Staff member L was hired on and did not obtain required PSP clearances until 9/22/22. Staff member T was hired on and did not obtain required PSP clearances until 9/22/22. Staff member U was hired on and did not obtain required PSP clearances until 9/22/22. Staff member W was hired on and did not obtain required PSP clearances until 9/22/22 Staff member AG was hired on and did not obtain required PSP clearances until 9/22/22 Staff member AH was hired on and did not obtain required PSP clearances until 9/22/22 Staff member AL was hired on and did not obtain required PSP clearances until 9/22/22 Staff member AO was hired on and did not obtain required PSP clearances until 9/22/22 Staff member AS was hired on and did not obtain required PSP clearances until 9/22/22 Staff member C was hired on and facility did not obtain required PSP clearances. Staff member G was hired on and facility did not obtain required PSP clearances. Staff member H was hired on and facility did not obtain required PSP clearances. Staff member N was hired on and facility did not obtain required PSP clearances. Staff member S was hired on and facility did not obtain ...

Citation, partial inspection : 55 Pa. Code § 3800.229 Education

Staff member AA was hired on and facility did not obtain FBI clearances until 1/13/22 Clearances (continued) Staff member K was hired on and facility did not obtain required FBI clearances. Staff member N was hired on and facility did not obtain required FBI clearances.

Citation, partial inspection : 55 Pa. Code § 3800.229 Education

Staff member L was hired on and did not obtain required Child Abuse Clearance until 11/14/22.

Citation, renewal inspection : 55 Pa. Code § 3800.51 Child Abuse and Criminal History Checks

Staff member A was hired on , and did not obtain required PSP clearances until 1. Staff member B was hired on , and did not obtain required FBI and child abuse clearance until and3/15/21. Staff member C was hired on and did not obtain FBI clearance until . Staff member D was hired on 1, and did not obtain FBI clearance until Staff member F was hired on and did not obtain PSP , Child Abuse clearances prior to hire. Staff member H was hired on , and did not obtain PSP clearance until Staff member I was hired on and did not obtain PSP , Child Abuse prior to hire. Staff member K was hired on , and did not obtain PSP , and child abuse clearance prior to hire. Staff member L was hired on , and did not obtain PSP clearance until Staff member M was hired on , and did not obtain PSP and FBI clearances prior to hire. Staff member U was hired on , and did not obtain Child abuse and FBI clearances prior to hire. Staff member V was hired on , and did not obtain PSP clearance until Staff member W was hired on and did not obtain PSP and child clearances prior to hire. Staff member X was hired on , and did not obtain PSP clearances prior to hire. There was also no child abuse clearance found in Staff X's file. Staff member Y was employed by facility and did not have Child Abuse and FBI clearance on file. Staff member Z was employed by the facility there was no record of FBI clearance on file. Staff member AA was hired on and did not have FBI clearance done until Staff member AC was hired on ...

Citation, renewal inspection : 55 Pa. Code § 3800.54 Child Care Supervisor

The facility does not have documentation that supervisors F, X, Y and AB have the required education and background experience. to be a child care supervisor.

Citation, renewal inspection : 55 Pa. Code § 3800.55.g Child Care Worker

The facility does not have documentation that staff persons A, J, L, M, N, O, Z, AA, AND AC have the minimum child care educational qualifications for direct care staff.

Citation, renewal inspection : 55 Pa. Code § 3800.58 Staff Training

Staff persons A,D, K, L, M, O, S, V, AA, did not complete First Aid/CPR training within 120 calendar days of date of hire.

Citation, renewal inspection : 55 Pa. Code § 3800.58 Staff Training

Staff persons A,B,C,D,F,G,H,I,J,K,L,M,N,O,S,U,V,AA,AB,AD,and AF did not complete 30 hours of training within 120 calendar days of date of hire.

Citation, renewal inspection : 55 Pa. Code § 3800.58 Staff Training

Staff person G did not complete 30 hours of training within 120 calendar days of date of hire.

Citation, renewal inspection : 55 Pa. Code § 3800.141 Child Health and Safety Assessment

Child 1’s assessment did not include assessment related to known or suspected suicide or self-injury attempts or gestures and emotional history which may indicate a predisposition for self-injury or suicide. Child 2’s assessment did not include assessment related to known or suspected suicide or self-injury attempts or gestures and emotional history which may indicate a predisposition for self-injury or suicide.

Citation, renewal inspection : 55 Pa. Code § 3800.141 Child Health and Safety Assessment

Child 5’s assessment did not include completed medical information and health concerns such as hospitalizations, illness in the family , or other illness.

Citation, renewal inspection : 55 Pa. Code § 3800.142 Health and Safety Plan

Child 1’s health and safety assessment identified a health or safety risk, and the facility did not write or implement a plan within 24 hours after the assessment is completed to protect the child. The safety plan was completely missing from the record. Child 2’s health and safety assessment identified a health or safety risk, and the facility did not write or implement a plan within 24 hours after the assessment is completed to protect the child. Safety plan was completely missing from the record. Child 3’s health and safety assessment identified a health or safety risk, and the facility did not write or implement a plan within 24 hours after the assessment is completed to protect the child. Safety risks of self harm and suicide were identified during the assessment, however there was not a safety plan for these risks in the record. Child 4’s health and safety assessment identified a health or safety risk and the facility did not write or implement a plan within 24 hours after the assessment is completed to protect the child. No safety plan was found in the record. Child 5’s health and safety assessment identified a health or safety risk and the facility did not write or implement a plan within 24 hours after the assessment is completed to protect the child. Admission date for this child is . Safety plan was dated 11/29/2021 which is outside the 24 hour window.

Citation, renewal inspection : 55 Pa. Code § 3800.143.a Child Health Examination

Child 1 was admitted to the facility on and did not have a health examination after admission and annually as required and did not have record of prior examination on file.

Citation, renewal inspection : 55 Pa. Code § 3800.144.b Dental Care

Child 1,3, 4 and 5 did not have dental exams in accordance with the AAP dental recommendations.

Citation, renewal inspection : 55 Pa. Code § 3800.145.a Vision Care

Child 2 did not receive vision screening and services to include diagnosis and treatment including eyeglasses, for defects in vision. Child 4 did not receive vision screening and services to include diagnosis and treatment including eyeglasses, for defects in vision. Child 5 did not receive vision screening and services to include diagnosis and treatment including eyeglasses, for defects in vision.

Citation, renewal inspection : 55 Pa. Code § 3800.146.b Hearing Care

Child 1 did not receive a hearing screening within 30 days after admission nor had record of prior exam in accordance with the periodicity schedule recommended by the American Academy of Pediatrics. Child 2 did not receive a hearing screening within 30 days after admission nor had record of prior exam in accordance with the periodicity schedule recommended by the American Academy of Pediatrics. Child 3 did not receive a hearing screening within 30 days after admission nor had record of prior exam in accordance with the periodicity schedule recommended by the American Academy of Pediatrics. Child 4 did not receive a hearing screening within 30 days after admission nor had record of prior exam in accordance with the periodicity schedule recommended by the American Academy of Pediatrics. Child 5 did not receive a hearing screening within 30 days after admission nor had record of prior exam in accordance with the periodicity schedule recommended by the American Academy of Pediatrics.

Citation, renewal inspection : 55 Pa. Code § 3800.151 Staff Health Statement

Staff persons B, D, G, H, I, K, M, O, U, W, X, Z, AA, AB, AC and AF did not have the required statement signed and dated by a licensed physician, certified registered nurse practitioner or licensed physician’s assistant, within 12 months prior to working with children or food service and every 2 years thereafter.

Citation, renewal inspection : 55 Pa. Code § 3800.224 Development of the ISP

Child 1 was admitted on and the ISP was incomplete and missing elements . Child 2 was admitted on and the ISP was incomplete and missing elements Child 3 was admitted on 1 and the ISP was incomplete and missing elements Child 4 was admitted on and the ISP was incomplete and missing elements Child 5 was admitted and the ISP was incomplete and missing elements

Citation, renewal inspection : 55 Pa. Code § 3800.224 Development of the ISP

Child 1's record does not reflect that reasonable efforts were made by the facility to involve interested parties for the ISP meetings during admission . Child 2's record does not reflect that reasonable efforts were made by the facility to involve interested parties for the ISP meetings during admission . Child 3's record does not reflect that reasonable efforts were made by the facility to involve interested parties for the ISP meetings during admission . Child 4's record does not reflect that reasonable efforts were made by the facility to involve interested parties for the ISP meetings during admission . Child 5's record does not reflect that reasonable efforts were made by the facility to involve interested parties for the ISP meetings during admission .

Citation, renewal inspection : 55 Pa. Code § 3800.224 Development of the ISP

The ISPs for child 1 do not contain signatures or evidence of the opportunity to sign the ISP being provided to all parties. The ISPs for child 2 do not contain signatures or evidence of the opportunity to sign the ISP being provided to all parties. The ISPs for child 3 do not contain signatures or evidence of the opportunity to sign the ISP being provided to all parties. The ISPs for child 4 do not contain signatures or evidence of the opportunity to sign the ISP being provided to all parties. The ISPs for child 5 do not contain signatures or evidence of the opportunity to sign the ISP being provided to all parties.

Citation, renewal inspection : 55 Pa. Code § 3800.226 Content of the ISP

The ISP for child 1 did not contain goals that were measurable, attainable, time bound and specific which include one goal addressing education and one addressing the family . The ISP for child 2 did not contain goals that were measurable, attainable, time bound and specific which include one goal addressing education and one addressing the family . The ISP for child 3 did not contain goals that were measurable, attainable, time bound and specific which include one goal addressing education and one addressing the family . The ISP for child 4 did not contain goals that were measurable, attainable, time bound and specific which include one goal addressing education and one addressing the family . The ISP for child 5 did not contain goals that were measurable, attainable, time bound and specific which include one goal addressing education and one addressing the family .

Citation, renewal inspection : 55 Pa. Code § 3800.228.b Copies of the ISP

Child 1’s record does not include copies of ISPs, revisions to the ISP and monthly documentation of progress. Child 2’s record does not include copies of ISPs, revisions to the ISP and monthly documentation of progress. Child 3’s record does not include copies of ISPs, revisions to the ISP and monthly documentation of progress. Child 4’s record does not include copies of ISPs, revisions to the ISP and monthly documentation of progress. Child 5’s record does not include copies of ISPs, revisions to the ISP and monthly documentation of progress.

Citation, renewal inspection : 55 Pa. Code § 3800.228 Copies of the ISP

There is no record for the ISP for child 1 was provided to all parties who participated in the development and revisions to the ISP. There is no record for the ISP for child 2 was provided to all parties who participated in the development and revisions to the ISP. There is no record for the ISP for child 3 was provided to all parties who participated in the development and revisions to the ISP. There is no record for the ISP for child 4 was provided to all parties who participated in the development and revisions to the ISP. There is no record for the ISP for child 5 was provided to all parties who participated in the development and revisions to the ISP.

Citation, renewal inspection : 55 Pa. Code § 3800.229 Education

Child 2's record did not include a copy of the Admission to Facility form dated within 24 hours of admission, Child 3's record did not include a copy of the Admission to Facility form dated within 24 hours of admission, Child 4's record did not include a copy of the Admission to Facility form dated within 24 hours of admission, Child 5's record did not include a copy of the Admission to Facility form dated within 24 hours of admission,

Citation, renewal inspection : 55 Pa. Code § 3800.243 Content of Records

The records for children 1, 2,3, and 5’s did not contain identifying personal information such as a dated photograph.

Citation, renewal inspection : 55 Pa. Code § 3800.243 Content of Records

Staff member A was hired on and did not obtain required PSP clearances until Staff member B was hired on and did not obtain required FBI and child abuse clearance until and3/15/21. Staff member C was hired on , and did not obtain FBI clearance until Clearances (continued) Staff member D was hired on , and did not obtain FBI clearance until Staff member F was hired on , and did not obtain clearances prior to hire. Staff member H was hired on , and did not obtain PSP clearance until Staff member I was hired on , and did not obtain prior to hire. Staff member K was hired on and did not obtain , and child abuse clearance 4 prior to hire. Staff member L was hired on and did not obtain PSP clearance until . Staff member M was hired on , and did not obtain , and clearances prior to hire. Staff member U was hired on and did not obtain Child abuse , and clearances prior to hire. Staff member V was hired on , and did not obtain PSP clearance . Staff member W was hired on , and did not obtain , and child abuse clearances prior to hire. Staff member X was hired on and did not obtain clearances prior to hire. There was also no child abuse clearance found in Staff X's file. Staff member Y was employed by facility and did not have Child Abuse and FBI clearance on file. Staff member Z was employed by the facility , there was no record of FBI clearance on file. Staff member AA was hired on and did not have FBI clearance done until Staff member AC was hired on and did not have required PSP ...

Citation, renewal inspection : 55 Pa. Code § 3800.243 Content of Records

Staff person A, H, I, L, M, O, U, AA, AB, and AC did not complete the mandated reporter training within the first 90 days of employment.