Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00265154 Renewal 03/20/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.84The annual fire safety inspection was completed on 11/12/2024, after individuals were admitted to the program.The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.The Compliance Director has scheduled an on-site inspection by a fire safety expert with the Pittsburgh Fire Department for November 2025 and annually thereafter. 05/06/2025 Implemented
2380.89(a)The agency did not conduct an unannounced fire drill in May or June 2024. Individuals were admitted on 5/29/2024.An unannounced fire drill shall be held at least once a month.Since July 2024, unannounced fire drills have been conducted by the Center Director at least once a month on different days of the week and at different times of the day. Each drill has been logged (date, time, individuals present) and will be kept on file. [A blank Fire/Evacuation Drill tracking sheet was received on 7/22/25 and reviewed 8/5/25. DPOC by HDKP, HSLS, on 8/5/25.] 07/10/2024 Implemented
2380.89(d)The fire drills from July 2024 to March 2025 were not completed within 2 minutes 30 seconds. The facility does not have an extended evacuation time. The fire drills that exceeded 2 minutes 30 seconds include, but are not limited to: 7/10/24 with an evacuation time of 6 minutes; 8/20/24 and 9/26/24 with an evacuation time of 5 minutes; 10/15/24, 11/7/24, and 12/3/24 with an evacuation time of 3 minutes.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.The Director will consult with a fire safety expert from the Pittsburgh Fire Department (PFD) to assess the need for extended evacuation time and will follow guidelines outlined in the assessment by the fire safety expert. 05/23/2025 Implemented
2380.91(c)Individual #1 does not have documentation of fire safety training being completed upon admission. Individual #2 does not have documentation of fire safety training being completed upon admission. Individual #3 does not have documentation of fire safety training being completed upon admission. Individual #4 does not have documentation of fire safety training being completed upon admission.A written record of firesafety training, including the content of the training and individuals attending, shall be kept.A written record of fire safety training will be kept in each consumer's file and maintained by the Case Managers. The record will include the content of the training (fire drills, evacuation procedures, meeting places, etc.) and the date the training was held. [A blank Consumer Intake checklist that includes fire safety training was received on 7/22/25 and reviewed 8/5/25. DPOC by HDKP, HSLS, on 8/5/25.] 05/06/2025 Implemented
2380.111(c)(3)Individual #1 did not have any documentation of immunizations being completed prior to admission.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Individual #1 has submitted documentation of tuberculin screenings. The consumer file has been updated to reflect as much. [A blank Consumer Intake checklist that includes immunizations was received on 7/22/25 and reviewed 8/5/25. DPOC by HDKP, HSLS, on 8/5/25.] 05/06/2025 Implemented
2380.111(c)(4)Individual #4 did not have vision and hearing screenings prior to admission.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Individual #4 has submitted documentation of tuberculin screenings. The consumer file have been updated to reflect as much. [Provider's plan to maintain compliance addresses hearing and vision screenings. DPOC by HDKP, HSLS, 5/16/25]. [A blank Consumer Intake checklist that includes hearing and visions screenings was received on 7/22/25 and reviewed 8/5/25. DPOC by HDKP, HSLS, on 8/5/25.] 05/06/2025 Implemented
2380.111(c)(5)Individual #1 did not have documentation of a tuberculin screening being completed prior to admission. Individual #4 did not have documentation of a tuberculin screening being completed prior to admission.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.Individual #1 and Individual #4 have submitted documentation of tuberculin screenings. The consumer files have been updated to reflect as much. [A blank Consumer Intake checklist that includes tuberculin evaluation was received on 7/22/25 and reviewed 8/5/25. DPOC by HDKP, HSLS, on 8/5/25.] 05/06/2025 Implemented
2380.113(a)Direct Service Worker #1, date of hire 2/3/25, did not have documentation of a physical examination being completed. Direct Service Worker #2, date of hire 12/2/2024, did not have documentation of a physical examination being completed. CEO #4, date of hire 1/29/2024, did not have documentation of a physical examination being completed.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.Direct Service Worker #1 and Direct Service Worker #2 have scheduled physical examinations to be conducted by 5/23/25. 05/23/2025 Implemented
2380.113(c)(2)Direct Service Worker #1, date of hire 2/3/2025, did not have documentation of a tuberculin screening being completed. Direct Service Worker #2, date of hire 12/2/24, did not have documentation of a tuberculin screening being completed. CEO #4, date of hire 1/29/2024, did not have documentation of a tuberculin screening being completed.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.Direct Service Worker #1 and Direct Service #2 have scheduled tuberculin (TB) screenings to be completed by 5/23/25. The employee files of each will be updated to reflect the skin test/chest x-ray results. 05/23/2025 Implemented
2380.181(a)Individual #1 did not have an assessment completed prior to or within 60 days of admission. Individual #2 did not have an assessment completed prior to or within 60 days of admission. Individual #4 did not have an assessment completed prior to or within 60 days of admission.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.Individual #1, Individual #2, and Individual #4 have had initial assessments completed. Each consumer will be assessed annually. 05/06/2025 Implemented
2380.21(u)Individual #2, date of admission 8/5/24, was informed and explained individual rights and the process to report a rights violation on 8/15/24. This exceeds upon admission. Individual #4, date of admission 5/29/24, was informed and explained individual rights and the process to report a rights violation on 8/31/24. This exceeds upon admission.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.Before admission into the facility, all consumers will receive an Individual Rights document (Consumer Bill of Rights) for signature. Before entering the facility, the Jasmine Nyree staff will explain the individual¿s rights annually thereafter. [A blank Client Intake Checklist that includes Individual Rights was received from the agency on 7/22/25 and reviewed 8/5/25. DPOC by HDKP, HSLS, on 8/5/25.] 05/06/2025 Implemented
2380.36(a)Direct Service Worker #1, date of hire 2/3/25, did not have documentation of fire safety training being completed. Direct Service Worker #2, date of hire 12/2/2024, did not have documentation of fire safety training being completed. Program Specialist #3, date of hire 2/3/2025, did not have documentation of fire safety training.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered.Direct Service Worker #1, Direct Service #2, and Program Specialist #3 have undergone Fire Safety Training as part of their orientation. The Staff Training Records have been updated to reflect completion. [A blank "Staff Training Record - Orientation and Annual" checklist that includes "Emergency Procedures: Fire Drill/Evacuation" was received on 7/22/25 and reviewed 8/5/25. DPOC by HDKP, HSLS, on 8/5/25.] 05/06/2025 Implemented
2380.38(b)(2)Direct Service Worker #1, date of hire 2/3/25, does not have documentation of the orientation topic: the prevention, detection and reporting of abuse, suspected abuse and alleged abuse being completed within 30 days of the hire date.The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Direct Service Worker #1 will complete the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse training via ODP. The Staff Training (Orientation) Record will be updated to reflect this completion. [A blank "Staff Training Record - Orientation and Annual" checklist that includes Abuse and Protective Service regulations was received on 7/22/25 and reviewed 8/5/25. DPOC by HDKP, HSLS, on 8/5/25.] 05/23/2025 Implemented
2380.38(b)(3)Chief Executive Officer (CEO) #4, date of hire 1/29/2024, did not complete individual rights training during orientation.The orientation must encompass the following areas: Individual rights.CEO #4 will complete the Individual Rights training via ODP. The Staff Training (Orientation) Record will be updated to reflect this completion. [A blank "Staff Training Record - Orientation and Annual" checklist that includes "Individual Rights" was received on 7/22/25 and reviewed 8/5/25. DPOC by HDKP, HSLS, on 8/5/25.] 05/23/2025 Implemented
SIN-00241242 Initial review 03/20/2024 Compliant - Finalized