Killington/Pico Ski Resort Partners

Regulation 5.2.3.11: Each diaper changing procedure shall include: * Preparation: assemble supplies, staff member washes hands, prepares changing surface with either a disposable covering or ensure that the surface was recently cleaned and disinfected and bring the child to the diaper changing area. * Dirty Phase: remove soiled diaper, dispose of diaper, and cleanse diaper area of the child. * Clean Phase: put on clean diaper, dress child, and wash the child's hands. * Clean up: clean and disinfect the diaper changing surface, and staff member washes their own hands. * Record diaper change.

“Diaper changes were observed in two (2) classrooms; the changes in the infant room did not meet compliance as neither child that was changed had their hands washed post change. This is a repeat violation. Corrective Action: Review the diaper changing procedure with all staff, to include how to properly wash children's hands who are not developed enough to hold their heads up for traditional hand washing. Develop a system to spot check this process in all applicable rooms to ensure compliance is maintained.”

Correction date in the state record: Apr 9, 2025

Regulation 6.2.1.3: The program director shall ensure that the number of staff present meets requirements described in the chart below for ages of children, maximum group size, and staff/child ratios at any time of day.

“Upon arrival in the infant classroom there were ten (10) infants with four (4) teachers. During the time in the infant classroom two (2) additional children were signed in. Two (2) of the four (4) staff were asked if staff are assigned to any group of children; they both stated no. Further they confirmed that children do things as one (1) group and staff provide care to all children. Observations of the group confirmed staff statements. The maximum group size for children in this age group is eight (8). During the visit one (1) child was dropped off for the first time; the parent identified the child needed a diaper change and bottle. The child was observed having their diaper changed then placed on the floor propped on a boppy pillow. A bottle was not observed being prepared or given to the child. A staff person holding a child asked another staff person the name of the child they were holding, after identifying the child by the incorrect name prior. Once the maximum group size was identified to the Director the groups were reconfigured so that one (1) group of four (4) children was on one (1) side of the room with two (2) staff, while eight (8) children were on the other side with two (2) staff. This is a serious violation. Corrective Action: Ensure group size is maintained and staff know which children they are directly responsible for providing care to. Submit a copy of this report to all children enrolled and to families whose children were in attendance as drop in on 2/19/2025. Provide that list and contact information to Supervisor Sheldrick-Humphries.”

Correction date in the state record: Mar 6, 2025

Regulation 7.3.1.5: The program director of a CBCCPP licensed for thirteen (13) or more children shall complete within one (1) year of employment start date a three (3) college credit course in managing an early care and education program that includes budgeting and financial management, approved by the Division; or the licensee shall employ a business manager as in the rule 7.6.1 of these regulations.

“The current Director does not meet qualifications for this position as they have not obtained the college course in managing an early care and education program that includes budgeting and fiancial management, nor has the program identified a qualified Business Manager in lieu of the Director obtaining the required coursework. This is a repeat violation; it has been cited four (4) times prior. Corrective Action: Submit a program improvement plan outlining how the program will be overseen by a qualified Program Director.”

Correction date in the state record: Mar 25, 2025

Regulation 5.2.1.2: The program director shall ensure that adults also wash their hands: * Before and after giving medications; * Before and after caring for a child who is injured or may be sick; * Before diapering; and * After coming into contact with blood, fecal matter, urine, vomit, nasal secretions or other body fluids.

“Staff B was not observed washing their hands after wiping a child's nose. Staff C was not observed washing their hands before diapering a child. Previous violations have been cited to rules releated to hand washing. Corrective Action: Ensure all staff, including substitutes complete the Better Kid Care training: Your #1 Priority: Keeping Children Healthy and Safe. Provide Supervisor Sheldrick-Humphries with confirmation certificates for all staff by the identified due date. In addition to this training, ensure this violation is reviewed with all staff and that each staff person signs a statement that this violation has been reviewed.”

Correction date in the state record: Mar 10, 2025

Regulation 5.2.1.1: CBCCPP staff shall ensure that adults and children wash their hands: * Upon arrival at the CBCCPP; * Before they eat, prepare or handle food; * Before and after handling raw meat; * Before feeding children; * After toileting or diapering; * After cleaning; * After taking out the garbage; * After handling animals; and * After outdoor play.

“Child D and Child E were observed returning from outdoor play; neither child washed their hands upon coming indoors. Staff F was not observed washing their hands after sweeping the floor. Previous violations have been cited for handwashing requirements not being met. Corrective Action: Ensure all staff, including substitutes complete the Better Kid Care training: Your #1 Priority: Keeping Children Healthy and Safe. Provide Supervisor Sheldrick-Humphries with confirmation certificates for all staff by the identified due date. In addition to this training, ensure this violation is reviewed with all staff and that each staff person signs a statement that this violation has been reviewed.”

Correction date in the state record: Mar 10, 2025

Regulation 3.4.7.3: Within six (6) months of the initial date of employment; staff and auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations, and the program director shall maintain an up-to-date BFIS Quality and Credential Account. Documentation, verification of qualifications, and all annual professional development activities as specified in the rules in sections 7.3 and 7.4 of these regulations shall be submitted to Northern Lights at CCV to be verified and maintained in BFIS.

“A review of staff BFIS quality and credential accounts were completed. It was found that the program had made progress since the last violation to this rule, however several staff still did not have required education documents in their accounts to confirm qualifications, as well as a few other staff missing professional development certiifcates. Corrective Action: Ensure all staff, to include seasonal staff have all missing education and professional development certificates submitted to Northern Lights at CCV. Send one (1) email to Supervisor Sheldrick-Humphries identifying each staff person and the dates documents were submitted to Northern Lights.”

Correction date in the state record: Mar 10, 2025

Regulation 7.3.2: Staff The program director shall ensure and maintain documentation that staff meet one (1) of the following qualifications:

“Upon review of BFIS and on-site files, it was found that nineteen (19) staff were in positions requiring documentation to confirm their qualifications but documentation was not found in either system. Corrective Action: Ensure all education documents are collected, and submitted to Northern Lights at CCV for all staff without this documentation reflected in their BFIS account. When submitting to Northern Lights at CCV ensure Supervisor Sheldrick-Humphries is cc'd in those submissions. Moving forward when hiring new staff, ensure documentation is collected to confirm their qualifications for the position they will be serving in.”

Correction date in the state record: Mar 6, 2025

Regulation 5.4.1.5: Children shall be supervised by staff while napping or resting. Staff shall directly observe a sleeping infant at least every fifteen (15) minutes to check the infant's face, view the color of the infant's skin, and check on the infant's breathing.

“Seven (7) minutes upon arrival in the infant classroom, Staff A was observed completing a check on an infant child sleeping. Staff B was observed nine (9) minutes later looking through the window of the nap room, and again eleven (11) minutes later. The infant's face, color of the infant's skin, breathing could not be observed through peering through the window. The infant child was not directly observed every fifteen (15) minutes as required. This rule was discussed and documented in the prior licensing visit. Corrective Action: Identify one (1) staff person as the individual responsible for checking infants every fifteen (15) minutes while they are napping/resting. Review this violation with all staff and provide a signed statement from all staff to ensure they understand the requirement to enter the room and directly observe sleeping infants to check their face, color of skin and breathing. Ensure all staff complete the Better Kid Care training: Safe Sleep Practices for Caregivers: Reduce the risk of SUID by the identified due date. Provide Supervisor Sheldrick-Humphries with confirmation of completed certificates for all staff.”

Correction date in the state record: Mar 10, 2025

Regulation 6.2.6.6: The program director shall ensure that no person be left alone with children without approval from the Division based on the results of a background check that includes fingerprinting; with the exception of a parent may be left alone with his/her own child(ren).

“Two (2) staff were together in a classroom providing care and supervision to children with no other staff present. Neither of the two (2) staff had been cleared to be alone with children. Pairing uncleared staff with other uncleared staff does not meet the intent of this rule. Corrective Action: As discussed during the licensing visit, ensure staff are not alone with children or paired with other staff not cleared to be alone until the program receives written confirmation of the clearance. Provide Supervisor Sheldrick-Humphries of the schedule to show how staffing will be in place to ensure compliance with this rule.”

Correction date in the state record: Jan 17, 2025

Regulation 5.2.3.11: Each diaper changing procedure shall include: * Preparation: assemble supplies, staff member washes hands, prepares changing surface with either a disposable covering or ensure that the surface was recently cleaned and disinfected and bring the child to the diaper changing area. * Dirty Phase: remove soiled diaper, dispose of diaper, and cleanse diaper area of the child. * Clean Phase: put on clean diaper, dress child, and wash the child's hands. * Clean up: clean and disinfect the diaper changing surface, and staff member washes their own hands. * Record diaper change.

“Staff A was observed changing three (3) children's diapers and did not wash any of the childrens hands post change. Staff B was observed changing one (1) diaper but did not wash their hands prior. Corrective Action: Ensure diaper changing is reviewed with all staff. Implement a system to monitor staff completing diaper changes to ensure they are doing so properly.”

Correction date in the state record: Jan 10, 2025

Regulation 7.4.4: All staff shall complete fifteen (15) clock hours of annual professional development activities as required in the rule 7.4.2 of these regulations. Substitutes filling a staff position for less than thirty (30) consecutive days within a 365 day period shall be exempt.

“Of the staff required to complete annual professional development training, five (5) are missing between 3.5- 15 hours based on the last full annual professional development period assessed, which has been shared with the program via email. Corrective Action: Ensure the staff missing annual professional development hours submit confirmation of completing those missing hours by 1/17/2025. Ensure those documents are submitted to Northern Lights at CCV and that Supervisor Sheldrick-Humphries is cc'd in those submissions. Inform Supervisor Sheldrick-Humphries of the system the program will put in place to track each staff's individual professional development period to ensure they obtain the required hours during each period.”

Correction date in the state record: Feb 21, 2025

Regulation 7.2.2: The licensee shall ensure that all new staff and auxiliary staff, prior to working with children in the CBCCPP; and any new individual designated as the representative of the licensee shall submit a Records Check Authorization form to the Division and shall submit to fingerprinting at a location designated by the Division after having received the Fingerprinting Authorization Certificate by the Division.

“Staff B has not returned the out of state record check forms. Staff C has not completed fingerprinting; the form to submit to fingerprinting was generated 12/11/23. Staff D has not completed fingerprinting; the form to submit to fingerprinting was generated 12/20/23 and also has not submitted the out of state record check forms. Staff E has not returned the out of state record check forms, but submitted to fingerprinting on 10/10/24. Staff F has not completed fingerprinting; the fingerprint authorization form was generated 8/30/24. Staff G has not submitted to fingerprinting; the fingerprint authorization form was generated 1/9/23. Staff H has not completed fingerprinting; the fingerprint authorization form was generated on 1/9/23 and also has not returned out of state record check forms. Staff J has not completed fingerprinting; the fingerprint authorization form was generated 7/22/24. Staff K has not completed fingerprinting; the fingerprint authorization form was generated on 11/29/22. Staff L has not returned out of state record check forms. Staff M has not completed fingerprinting; the fingerprint authorization form was generated 12/13/21, additionally Staff M has not returned out of state record check forms. Corrective Action: Ensure all staff submit updated record checks who require fingerprinting to ensure staff have the most up-to-date form. Ensure staff obtain a receipt when fingerprinted; provide a copy of that receipt to Supervisor Sheldrick-Humphries to confirm completion by the due date. For staff missing out of state record check forms, please submit those forms to the Licensor on Duty email and cc Supervisor Sheldrick-Humphries in those submissions. Lastly, inform Supervisor Sheldrick-Humphries of the system the program will use to monitor 1) staff have submitted a record check to the Division, 2) that out of state record check forms are returned to the Division with ten (10) business days if applicable, 3) that staff schedule and submit to fingerprinting within two (2) weeks of the fingerprint authorization form being generated, 4) that a receipt is gathered from staff to confirm fingerprinting has been completed, 5) monitor that results have been generated within sixty (60) days of submitting out of state record check forms and/or fingerprinting.”

Correction date in the state record: Mar 6, 2025

Regulation 3.4.7.3: Within six (6) months of the initial date of employment; staff and auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations, and the program director shall maintain an up-to-date BFIS Quality and Credential Account. Documentation, verification of qualifications, and all annual professional development activities as specified in the rules in sections 7.3 and 7.4 of these regulations shall be submitted to Northern Lights at CCV to be verified and maintained in BFIS.

“Prior to the licesning visit a review of staff BFIS Quality and Credential accounts was completed. It was found that all staff had one (1) or more items not reflected in their account. Post visit an email was sent to Northern Lights at CCV to determine if they had documentation in their queue to be updated for staff; they confirmed they did not. This is a repeat violation. Corrective Action: Submit a program improvement plan that 1) identifies who is responsible for collecting items from staff that are required to be in their BFIS accounts, 2) identifies who is responsible for submitting documentation to Northern Lights at CCV, 3) who will monitor staff BFIS accounts to ensure documents are ultimately reflected in accounts, and 4) who will reach out to the Resource Advisor if documents submitted are not reflected in a timely manner.”

Correction date in the state record: Jan 17, 2025

Regulation 2.3.9.3: The licensee shall ensure that all staff have met ongoing background check requirements by submitting at least once every five (5) years a Records Check Authorization form to the Division and as required shall submit to fingerprinting.

“Staff A's fingerprints expired 1/17/23; the program was notified through the Annual Assurance Letter dated 10/29/23 and another dated 10/28/24 that Staff A's record check and fingerprinting expired. Staff A submitted the record check but did not comply with fingerprinting. Corrective Action: Ensure Staff A submits to fingerprinting and provides a receipt to the program; provide Supervisor Sheldrick-Humphries with a copy of the receipt. Inform Supervisor Sheldrick-Humphries of the sytem moving forward to ensure all staff submit record checks and complete fingerprinting prior to their expiration date.”

Correction date in the state record: Jan 10, 2025

Regulation 5.10.4.5.3: The licensee shall ensure that the CBCCPP is kept free from rodent and insect infestation.

“In the kitchen space rodent feces were observed along the baseboards and refrigerator. Photos documenting these concerns were shown to the Director during the debrief. Corrective Action: Ensure all spaces that are used to prepare or serve food are properly sanitized daily prior to and after use. Properly clean all areas where rodent feces are found and ensure daily monitoring of additional feces are properly cleaned if found. Ensure the rodent issue is properly addressed to eradicate the issue. Inform Supervisor Sheldrick-Humphries 1) who is reponsible for ensuring daily cleaning/sanitizing/disenfecting occurs and monitoring of rodent feces, as well as what the progrm has taken for action steps to eradicate the rodent issue.”

Correction date in the state record: Jan 4, 2025

Regulation 5.10.4.5.1: The program director shall ensure that the CBCCPP, its furnishings, and toys are kept in a clean and orderly condition.

“Carpets, flooring, baseboards, toilets, and walls were observed with dirt and grime that extended what would be typical for the current days expected conditions. The Director was presented with photos taken of areas in the licensed space; they stated that the mountain had cleaning personnel who was responsible for ensuring those areas are properly cleaned. Corrective Action: Ensure a deep clean is done to properly clean, sanitize and disinect all areas. Develop a system to ensure inspections are done daily for areas responsible to be cleaned by staff employed by the mountain outside of the program. Ensure there is a follow up when areas of concern are identified, to include on-site staff ensuring cleanliness and maintenance.”

Correction date in the state record: Jan 4, 2025

Regulation 3.7.1.3: The licensee shall ensure that the Emergency Response Plan is reviewed and updated at least once every 365 days.

“The Emergency Response Plan was last updated 11/2022. The plan should have been reviewed and updated twice since that date. Some of the staff listed in the plan with identified steps to take in the event of an emergency are no longer employed at the program. Corrective Action: Submit the updated Emergency Response Plan to Supervisor Sheldrick-Humphries, in addition inform what the system will be to ensure the plan is reviewed and updated every 365 days.”

Correction date in the state record: Feb 14, 2025

Regulation 7.1.2.2: Staff who are counted in the staff/child ratios and auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations shall obtain training in pediatric first aid and in infant and child CPR within three (3) months of beginning work in the CBCCPP and remain currently certified.

“Six (6) staff employed three (3) months or longer are either 1) without First Aid certification, or without current CPR/First Aid certification. This is a repeat violation. Corrective Action: Ensure all staff employed three (3) months or longer have obtained current CPR/First Aid certification. Submit completion certificates to Northern Lights at CCV by the due date for anyone with outstanding current certification in their BFIS Quality and Credential account; cc Supervisor Sheldrick-Humphries in those submissions. Inform Supervisor Sheldrick-Humphries how the program will monitor due dates/expiration dates for all staff, including seasonal staff to ensure compliance to this rule is maintained.”

Correction date in the state record: Mar 6, 2025

Regulation 7.2.2: The licensee shall ensure that all new staff and auxiliary staff, prior to working with children in the CBCCPP; and any new individual designated as the representative of the licensee shall submit a Records Check Authorization form to the Division and shall submit to fingerprinting at a location designated by the Division after having received the Fingerprinting Authorization Certificate by the Division.

“During a regulatory compliance visit conducted on 12/28/22, five (5) staff were determined to be working for the program but had not completed the fingerprinting process as required by this rule. All letters had been sent to staff at least four (4) months prior to the compliance visit. Review of BFIS shows Staff B was indicated in the violation on 12/28/22, still has yet to complete fingerprinting. Corrective action given at the time of the initial violation was due by 1/26/23 and has yet to be reported as completed to the Division. Several attempts have been made by the Division to confirm corrective action has been completed.This is a repeat violation. Corrective Action: By the corrective action due date provide receipts to confirmthat all staff members missing fingerprinting have since completed the fingerprinting process. Submit a Program Improvement Plan to include details on a system for tracking fingerprinting completion.”

Correction date in the state record: Jul 1, 2024

Regulation 5.2.1.1: CBCCPP staff shall ensure that adults and children wash their hands: * Upon arrival at the CBCCPP; * Before they eat, prepare or handle food; * Before and after handling raw meat; * Before feeding children; * After toileting or diapering; * After cleaning; * After taking out the garbage; * After handling animals; and * After outdoor play.

“This rule was cited as a violation on 12/28/22 based on observations of the Licensor during the regulatory compliance visit. At that time three (3) staff were observed as not washing their hands prior to preparing meals or bottles, and one (1) staff was observed not washing their hands after completing a diaper change. Corrective action provided at that time was due 1/26/23 and has yet to be reported as completed to the Division. This is a repeat violation. Corrective Action: Review this rule with all staff. Ensure that hands are washed, both staff and children, at least during all the required times as identified by this rule. Several attempts have been made by the Division to confirm corrective action has been completed.”

Correction date in the state record: Jun 5, 2024

Regulation 7.1.3: The licensee, in consultation with the program director, shall establish written program policies and procedures and provide these to staff and to auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations during an orientation training session approved by the Division prior to being left alone with children. Trainees under eighteen (18) years of age and other staff not left alone with children shall complete the orientation training within at least one (1) month of their first date of working with children. Complete written information and the orientation training session shall include: Basic knowledge of child growth and development; Routine and emergency health protection of children including health related exclusions; Safety and sanitation requirements including handling and storage of hazardous materials and disposal of bio contaminants; Positive behavior management; Supervision of children; Child accident and injury procedures including building and physical premises safety; Safe sleep practices; Administration of medication requirements; Emergency and evacuation requirements; Nutrition and food safety including prevention of and response to emergencies due to food and allergic reactions; Recordkeeping; Transportation and child passenger safety; Release of children; Respectful engagement of families; Preventing, recognizing, and reporting child abuse and neglect; including information about the signs and symptoms of sexual abuse, sexual violence, grooming processes, recognizing the dangers of child sexual abuse, and other predatory behaviors of sex offenders; Recognition of and response to the symptoms of common childhood illnesses; Preventing the spread of infectious disease; Providing developmentally appropriate activities and experiences for children; Inclusion of children with special needs; Guidelines for volunteers, partner staff, auxiliary staff, and business managers; Responsibility to comply with current applicable licensing regulations; Staffing requirements to include opening and closing; and Ensuring children have extra clothes and diapers available.

“Review of BFIS as well as staff files on site on 12/28/22 found two (2) staff did not complete this required training. These staff were identified by Staff A as counted in staff/child ratio. This rule was also cited in violation on 1/26/22 and 7/13/22. Corrective action for this violation has yet to be reported as completed to the Division. Several attempts have been made by the Division to confirm corrective action has been completed. This is a repeat violation. Corrective Action: Review all current staff files and accounts to ensure any staff who have not yet completed this training do so and that training completion certificates are emailed to Northern Lights at CCV and cc'd to this Licensor by the corrective action due date given. Also by the due date, submit a Program Improvement Plan detailing how completion of this training will be tracked to ensure it is completed within the time frame given in this rule.”

Correction date in the state record: Mar 10, 2025

Regulation 7.1.2.2: Staff who are counted in the staff/child ratios and auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations shall obtain training in pediatric first aid and in infant and child CPR within three (3) months of beginning work in the CBCCPP and remain currently certified.

“This is a repeat violation. Initial violation of this rule was cited during a regulatory compliance visit conducted on 12/28/22 due to eleven (11) staff having expired CPR and First Aid. It was confirmed with Staff A at that time that all staff, including subsititutes, were counted in child/staff ratio. Corrective action for the initial violation was due 1/26/23 and has yet to be reported as completed to the Division. Corrective Action: Schedule any and all staff, including substitutes, who have either not completed CPR/First Aid training or whose training is expired for the first available CPR/First Aid training. Submit a Program Improvement Plan to include specific details on how CPR/First Aid training will be monitored and tracked.”

Correction date in the state record: Jun 21, 2024

Regulation 7.3.1.5: The program director of a CBCCPP licensed for thirteen (13) or more children shall complete within one (1) year of employment start date a three (3) college credit course in managing an early care and education program that includes budgeting and financial management, approved by the Division; or the licensee shall employ a business manager as in the rule 7.6.1 of these regulations.

“A review of BFIS Credential account as well as staff file on site, it has been determined that Staff A does not meet the qualifications for Director based on the courses required by this rule. This is a repeat violation. This rule was previously found to be in non-compliance and cited as a violation on 7/13/21 and 1/26/22. Corrective Action: Submit confirmation of completion of coursework not reflected in BFIS to Northern Lights at CCV and cc Licensor [name] in those submisstions. If Staff A doe not have additional coursework that qualifies them for this position provide confirmation of course enrollment to obtain qualifications, or identify a qualified Director to continue to serve in this position.”

Correction date in the state record: Mar 25, 2025

Regulation 3.3.5: The licensee, staff, and auxiliary staff shall be trained in prevention, identification and mandatory reporting of child abuse and neglect.

“Violation of this rule was cited during regulatory compliance visits on 12/28/22 and 12/13/23 due to multiple staff not having completed this required training. This was confirmed through BFIS review, staff file review on site, as well as post visit follow ups conducted with Staff A. To date no corrective actions have been reported as completed to the Division. Current review of BFIS indicates staff who still have yet to complete this training. This is a repeat violation. Corrective Action: Ensure all staff, including substitutes, who have not yet completed this required training do so, and completion certificates are emailed to Northern Lights at CCV and CC'd to this Licensor by the corrective action due date. Submit a Program Improvement Plan to include details on how the completion of this trainning will be tracked for all staff. Several attempts have been made by the Division to confirm corrective action has been completed.”

Correction date in the state record: Mar 10, 2025

Regulation 3.3.5: The licensee, staff, and auxiliary staff shall be trained in prevention, identification and mandatory reporting of child abuse and neglect.

“Upon review of staff files on site as well as staff BFIS Credential accounts it is determined that eleven (11) out of the twenty-eight (28) staff on the Associated Parties list have not completed the required Mandated Reporter training. This is a repeat violation. Corrective Action: Ensure all staff who have not yet completed this required training do so by the corrective action date given. Create and implent a Program Improvement Plan to track staff trainings and ensure completion.”

Correction date in the state record: Mar 10, 2025

Regulation 7.1.2.2: Staff who are counted in the staff/child ratios and auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations shall obtain training in pediatric first aid and in infant and child CPR within three (3) months of beginning work in the CBCCPP and remain currently certified.

“Review of all staff BFIS Credential Accounts and staff files on site determined that nineteen (19) out of twenty-two (22) staff that have been employed at the program for more than three (3) months have not completed the required CPR and First Aid trainings. Corrective Action: Review all staff files, including substitutes, to determine which staff are missing CPR/First Aid trainings are completed. Create and put into effect a Program Improvement Plan that includes a system for tracking employees CPR/First Aid certifications to ensure all are completed and up to date.”

Correction date in the state record: Jun 21, 2024