Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00253944 Unannounced Monitoring 10/07/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)At 12:42PM, the hot water temperature measured 123.4 degrees Fahrenheit at the sink in the kitchen of the home.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. To address the excessive hot water temperature at the site, the maintenance team will immediately adjust the hot water heater to ensure that the water temperature does not exceed 120°F. Maintenance staff will verify that the adjustment is successful by remeasuring the water temperature at the kitchen sink and any other accessible taps. Based on a state inspector¿s recommendation, more effective thermometers (EXTECH39240) were ordered, have arrived, and are currently being distributed to all sites to enhance accuracy in temperature checks. Additionally, maintenance will inspect the hot water heater and related pipes to assess if any insulation or protective guards are needed to prevent potential contact with high temperatures. 12/16/2024 Not Implemented
6400.66At 12:10PM, the light on the front porch of the home was inoperable. There is not another source of light in that area.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. 12/16/2024 Implemented
6400.68(b)At 12:26PM, the hot water temperature measured 125.2 degrees Fahrenheit at the bathtub in the bathroom on the second floor of the home.[Repeated violation 7/23/2024 et al.] Hot water temperatures in bathtubs and showers may not exceed 120°F. To address the excessive hot water temperature at the site, the maintenance team will immediately adjust the hot water heater to ensure that the water temperature does not exceed 120°F. Maintenance staff will verify that the adjustment is successful by remeasuring the water temperature at the kitchen sink and any other accessible taps. Based on a state inspector¿s recommendation, more effective thermometers (EXTECH39240) were ordered, have arrived, and are currently being distributed to all sites to enhance accuracy in temperature checks. Additionally, maintenance will inspect the hot water heater and related pipes to assess if any insulation or protective guards are needed to prevent potential contact with high temperatures. 12/16/2024 Not Implemented
6400.74At 12:14PM, there was no nonskid surface on the bottom exterior step leading from the rear exit of the home.Interior stairs and outside steps shall have a nonskid surface. We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. 12/16/2024 Implemented
6400.80(b)At 12:18PM, there was a black, plastic, drainpipe attached to the gutter laying across the walkway in the back leading to the side of the home causing a tripping hazard. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. 12/16/2024 Not Implemented
6400.101At 12:24PM, there was a padlock, on the outside of the door to the staff office on the second floor of the home, posing an obstruced egress from this room.[Repeated violation 7/23/2024 et al.]Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. To address the obstruction caused by the padlock on the outside of the staff office door, the padlock has been removed immediately to ensure an unobstructed exit from the room. Staff have been reminded of the importance of maintaining clear and accessible egress paths at all times, especially in designated staff areas. 12/16/2024 Not Implemented
6400.32(r)(3)Individual #1 has not been provided the assistive technology to lock and unlock her bedroom door. The bedroom the door has a pinhole locking mechanism.Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance.To ensure Individual #1 can independently lock and unlock her bedroom door, the current pinhole lock will be replaced with an accessible locking mechanism that meets her needs for privacy and independence. Maintenance staff have been instructed to install an appropriate assistive lock device that does not require staff assistance. This replacement will be completed promptly, and staff will verify the functionality of the new lock. 12/16/2024 Not Implemented
6400.32(r)(5)Direct service workers providing services to Individual #1 do not have designated device to lock and unlock Individual #1's bedroom that is equipped with a pin locking mechanism on the doorknob.[Repeated violation 7/23/2024 et al.]Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.To ensure that Individual #1 can independently lock and unlock her bedroom door, the current pinhole lock will be replaced with an accessible locking mechanism that meets her needs for privacy and independence. Maintenance staff have been assigned to install an assistive lock device that Individual #1 can operate without assistance, and staff will verify the functionality of this new lock upon installation. Additionally, each direct service worker providing services to Individual #1 will be equipped with a designated entry device to unlock her door as needed. The device will be kept on hand at all times by Direct Support Professionals assigned to Individual #1¿s care to ensure immediate access in the event of an emergency. 12/16/2024 Not Implemented
SIN-00229166 Renewal 08/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill conducted on 4-12-23 at 3:00 PM did not indicate the amount of time it took for evacuation, or the exit route used to evacuate the home. The fire drill conducted on 9-6-22 at 4:38 AM did not indicate the amount of time it took for evacuation.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Team Leads have responsibility of completing the fire drills and have been trained on how to complete fire drill form in its entirety. [Additional information provided by the agency via email on 10/24/23: Training for Team Leads took place on or about 9/14/23. Fire drill forms will be reviewed on a monthly basis by the Quality Control Manager. Documentation of fire drill form reviews will be maintained. A fire drill review form, that was not dated or signed, was provided by the agency on 10/24/23. DPOC by HDKP, HSLS, on 11/1/2023]. 09/14/2023 Implemented
SIN-00210784 Renewal 08/30/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(c)On 8/31/22 at 10:50AM, there was not fire extinguisher located in the kitchen . A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). The fire extinguisher was moved to the kitchen immediately. 08/31/2022 Implemented
6400.111(e)The fire extinguisher in the dining room closet on the first floor of the home was locked and not accessible to staff persons and Individual #1. The fire extinguisher in staff office on the second floor of the home was locked and not accessible to staff persons and Individual #1. A fire extinguisher shall be accessible to staff persons and individuals. Fire extinguisher was moved to the 2nd floor hallway immediately during inspection. Fire extinguisher was removed from closet immediately during inspection. 08/31/2022 Implemented
6400.214(b)Individual #1's physical examinations, dental examinations, and psychiatric medication reviews were not present in the home on 8/31/21 at 11:20AM. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The documents where copied and placed in the home on 9/2/22. 09/02/2022 Implemented
SIN-00206683 Unannounced Monitoring 05/31/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)On 5/31/22, there was not a smoke detector in basement of the home. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Maintenance replaced the fire alarm on 6/17/22. 07/31/2022 Implemented
6400.214(b)On 5/31/22, Individual #1's current assessment was not at Individual #1's home. On 5/31/22, Individual #1's current ISP, most recently updated 4/29/22 was not at Individual #1's home. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. ISP and Assessment were placed in the home immediately by the Program Specialist on 6/17/22. 07/31/2022 Implemented
6400.18(f)On 5/19/2022, Individual #1 and Direct Service Worker #1 engaged in a verbal and physical altercation over the home's set of keys. Individual #1 called Adult Protective Services to report an allegation of abuse. Individual #1 also reported the allegation of abuse to House Manager #3. In addition, Direct Service Worker #2 witnessed the altercation. Direct Service Worker #1 continued to provide supports in the home until approximately 2:30PM on 5/19/22. Individual #1 spent most of the rest of the shift in her bedroom and not interacting with the direct services workers, which reportedly, is typical when she is upset. On 5/20/21, at 7:00AM, Direct Service Worker #1 reported to the home as scheduled to provide support to Individual #1 and stayed at the home until she was directed to leave by On-call Supervisor #5 at approximately 8:00AM. As of 6/16/22, the certified investigation by the agency is still ongoing.The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident.The staff member #1 is permanently removed from INDIVIDUAL #1's home. 07/31/2022 Implemented
6400.32(c)On 5/19/22, Direct Service Worker #1 and Direct Service Worker #2 were completing documentation at the beginning of the 7:00AM to 3:00PM shift in Individual #1's home. Individual #1 became upset, calling names directed at Direct Service Worker #1, when denied access to the logbook. Individual #1 then gained access to the home's set of keys. During the exchange, Direct Service Worker #1 attempted to gain access to the keys by grabbing the keys from Individual #1's hands. After the altercation, Individual #1 contacted the emergency services and Adult Protective Services and went to the neighbor's home. Individual #1 was evaluated by Emergency Medical Team and then released with no apparent injuries needing emergency medical services. House Manager #3 signed the release for Individual #1 and then proceeded to take Individual #1 for a 5-to-10-minute car ride. Upon returning to the home at approximately 8:00AM, Individual #1 spent most of the rest of the shift in her room and not interacting with the direct services workers, which reportedly, is typical when she is upset. At approximately 9:00PM, Direct Service Worker #4 took Individual #1 to the emergency department of the hospital after Individual #1 reported a pain level of 8 to 9 out of 10 in her hand and swelling was evident in Individual #1's hand. Upon discharge from the emergency department, Individual #1 was provided information for hand injury including for a thumb sprain rehabilitation exercise and for strain or sprain: care instructions.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Staff member #1and #2 was trained on Recognizing and Reporting Abuse on 6/21/22 and Positive De-escalation on 6/23.22 The responsible party is the training department. 07/31/2022 Implemented
6400.166(a)(11)Individual #1's May 2022 Medication Administration Record did not include the diagnosis or purpose for Biotin TAB 1000 mcg., take 1 tablet by mouth daily.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The reason for medication was added to MAR on 6/17/22. 07/31/2022 Implemented
6400.166(b)Cerave Cream, apply topically to affected areas twice a day for dry skin, prescribed to Individual #1 was not initialed as administered on 5/29/22, 5/30/22 and 5/31/22 at 8:00AM and on 5/1/22, 5/22/22, 5/24/22, 5/25/22, 5/26/22, 5/29/22, and 5/30/22 at 8:00PM. Clindamycin Lotion 1%, apply to affected area on face once to twice daily, prescribed to Individual #1 was not initialed as administered on 5/30/22 at 8:00AM and 5/1/22, 5/17/22, 5/20/22, 5/24/22, 5/25/22, 5/26/22, 5/29/22, and 5/30/22 at 8:00PM. Clonazepam TAB 0.5mg, take 1 tablet by mouth twice a day for anxiety, prescribed to Individual #1 was not initialed as administered on 5/6/22 at 8:00AM and 5/26/22 at 8:00PM. Ketoconazole Sha 2%, use to wash affected areas on body daily, leave on for 2 minutes, then rinse for pityriasis, prescribed to Individual #1 was not initialed as administered on 5/1/22 and 5/30/22 at 8:00AM. Prazosin HCL Cap 2 mg, take 2 capsules (4MG) by mouth at bedtime for PTSD, prescribed to Individual #1 was not initialed as administered on 5/8/22, 5/22/22, and 5/24/22 at 8:00PM. Quetiapine Tab 200 mg, take 1 tablet by mouth every night at bedtime for depression, prescribed to Individual #1 was not initialed as administered on 5/22/22 and 5/24/22 at 8:00PM.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The medications were verified as passed and staff corrected their errors. 07/31/2022 Implemented
SIN-00157304 Renewal 06/17/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Service Worker #1, date of hire 6/10/19, had a criminal background check requested on 4/3/18, more than a year prior to hire.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. On July 8, 2019, Direct Service Worker #1, obtained a criminal background check via epatch, control number R21946760. On July 1, 2019 Quinn Williams and Jaide Williams created a document which now includes the epatch as the source of the criminal background checks. This is a part of the checklist necessary for staff to obtain PRIOR TO BEING HIRED. On the first day of every month Quinn Williams and Jaide Williams will check all staff files to ensure that the criminal background checks have been provided within 1 year of the hire date. A copy of the form will be submitted following the completion of this POC. [Direct Service Worker #1 had a Pennsylvania criminal history record check completed on 7/8/2019. Immediately, upon hire and as stated above, the CEO or designee shall audit all staff persons' criminal history checks to ensure completion, timely. Documentation of audits shall be kept. (DPOC by AES,HSLS on 7/30/19)] 07/08/2019 Implemented
6400.31(b)Individual #1, date of admission 6/11/19, does not have signed statement acknowledging receipt of the information on rights upon admission.Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. On June 17, 2019, Program Specialist, obtained a signed statement from individual #1, acknowledging receipt of the information on rights upon admission. All other clients were checked by Program Specialist, to ensure that a signed statement acknowledging receipt of the information on rights has been obtained. During the last hour of admission day, Program Specialist and House Manager will check all client Program Binders to ensure that the rights have been explain and signed. [As per Human Resource Specialist, Program specialist and House manager were educated on the aforementioned responsibilities on July 1, 2019 by Human Resource Specialist and the Assistant Secretary. Documentation of the audits of the signed and dated statements acknowledging receipt of information of rights shall be kept. (DPOC by AES,HSLS on 7/30/19)] 06/17/2019 Implemented
6400.141(a)Individual #1, date of admission 6/11/19, does not have a physical examination.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. On May 30, 2019, Program Specialist, communicated via email, with Promising Practices Coordinator, attempting to obtain the Tuberculin evaluation documents for individual #1.Individual #1 was in the Allegheny County Jail. Program Specialist has made several attempts to obtain the Tuberculin evaluation documents from Jail officials. These attempts have been fruitless. Program Specialist will continue to obtain these documents from Jail officials and Promising Practices Coordinator. An email regarding these attempts will be forwarded upon completion of the POC. [Individual #1 had a physical examination completed on 6/20/2019. Immediately, upon admission and continuing annually, the CEO or designee shall audit all individual records to ensure all individuals have a current physical examination completed with all required information. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 7/30/19)] 05/30/2019 Implemented
6400.141(c)(6)Individual #1, date of admission 6/11/19, does not have record of a negative Tuberculin evaluation.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. On May 30, 2019, Program Specialist, communicated via email, with AE, attempting to obtain the Tuberculin evaluation documents for individual #1. Individual #1 was in the Allegheny County Jail and Program Specialist has made several attempts to obtain the Tuberculin evaluation documents from Jail officials. These attempts have been fruitless. Program Specialist will continue to obtain these documents from Jail officials and AE. An email regarding these attempts will be forwarded upon completion of the POC. [Individual #1 had a Tuberculin skin testing completed on 1/14/2019. Immediately, upon admission and continuing annually, the CEO or designee shall audit all individual records to ensure all individuals have a current physical examination completed with all required information including Tuberculin skin testing. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 7/30/19)] 05/30/2019 Implemented
SIN-00179078 Renewal 10/20/2020 Compliant - Finalized
SIN-00153735 Initial review 04/16/2019 Compliant - Finalized