| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | At 1:24 PM on 6/11/25, there was no mechanical exhaust fan or an operable window for ventilation in the full bathroom located in the apartment's bedroom hallway. At 1:26 PM on 6/11/25, there was no mechanical exhaust fan or an operable window for ventilation in the full ensuite bathroom located in Individual' #1's bedroom. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Vents are located on top of roof in the entire apartment building the bathrooms. A letter was requested from the property manager to explain how the exhaust fan works. |
06/28/2025
| Implemented |
| 6400.82(f) | At 1:23 PM on 6/11/25, there was no trash receptacle in the full bathroom located in the apartment's bedroom hallway. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. A trashcan was purchased and placed at site. |
06/28/2025
| Implemented |
| 6400.106 | This home had furnace inspections and cleanings completed by a professional furnace cleaning company on 5/10/23, and then again on 6/3/24 to 6/6/24. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The Residential Coordinator has created a tracking sheet of the cleaning inspections annual due date. |
06/28/2025
| Implemented |
| 6400.112(d) | According to the written fire drill record submitted from 7/2/24 to 5/10/25, the drill conducted on 4/16/25, documented an evacuation time of 2 minutes, 50 seconds. This home does not have an extended evacuation time approved by a fire safety expert. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | A fire drill conducted in May 2025 exceeded safe evacuation time (over 2 1/2 minutes), indicating an extended evacuation time. All Staff involved will be trained on the importance of following the designated route and evacuation timing.
2. 2. Systemic Preventive Measures:
The Fire Drill Documentation Form was updated to include:
Time started and ended
Route used
Number of individuals evacuated
Comments on barriers/delays
Staff will be re-trained by 6/30/2025 regarding fire drill procedures, use of alternate routes, and evacuation speed expectations. |
06/28/2025
| Implemented |
| 6400.113(a) | Individual #1 was trained 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, and smoking safety procedures if individuals smoke at the home on 9/24/23, and then again on 10/25/24. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. | An audit was conducted of all individuals annual general fire safety training including evacuation procedures, responsibilities during fire drills and the designated meeting place, ensuring the trainings were completed. |
07/01/2025
| Implemented |
| 6400.141(c)(4) | Individual #1 had a hearing screening performed on their current physical examination, completed 1/8/25, but not on their previous physical examination, conducted 1/3/24. Individual #1's content of records did not include any other hearing examinations that had been completed between 1/3/24 and 1/8/25. [Repeat Violation- 7/9/24 et al] | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The individual was immediately scheduled for both hearing and vison screenings upon identification of oversight. Screenings are scheduled as follows hearing exam 7/8/2025 at 10AM at UPMC Shadyside and Vision scheduled for 7/21/2025 at 8:30am at Blind and vison rehab services. |
07/01/2025
| Implemented |
| 6400.142(d) | Individual #1 had dental examinations completed on the following dates: 4/2/24; 8/14/24; 11/14/24; 1/20/25; and 5/14/25. However, none of these examinations documented that a teeth cleaning or the checking of gums or dentures was performed. | The dental examination shall include teeth cleaning or checking gums and dentures. | The program specialist contacted the dental provider advance dental solutions and obtained updated documentation clarifying whether a dental exam or cleaning was completed. The updated documentation has been filed in the individuals' records. |
07/02/2025
| Implemented |
| 6400.144 | On Individual #1's current physical examination, completed 1/8/25, the physician checked "Yes" for vision in reference to the field entitled, "Further Recommendation by A Specialist." However, the agency did not provide documentation showing that Individual #1 had completed a follow-up appointment with a vision specialist or that such an appointment had been scheduled. [Repeat Violation- 7/9/24 et al] | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The individual was immediately scheduled for a vison screening with a specialist upon identification of oversight. Vision screening scheduled for 7/21/2025 at 8:30am at Blind and vison rehab services. |
07/02/2025
| Implemented |
| 6400.151(a) | Direct Service Provider #1's date-of-hire is 9/20/24. They had a physical examination completed on 10/2/24. In addition, Direct Service Provider #1 had a tuberculin skin test via Mantoux method planted on 10/5/24 and read with negative results on 10/7/24. | 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, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | A review of all current employee files was conducted to ensure tb compliance for all staff. |
06/13/2025
| Implemented |
| 6400.181(e)(11) | Individual #1's current assessment, completed on 9/9/24, did not include an applicable psychological evaluation, as the corresponding field indicated that such an evaluation had been completed on 9/4/24, and read, "See attached." However, Individual #1's content of records did not include a psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | The file was reviewed to determine if a psychological evaluation was applicable. There was no Psychological eval completed 9/24/24 however it was a psych appointment completed on this date. And this field should have been documented as N/A. This field has been revised and sent to the team and individual on 7/3/2025. |
07/03/2025
| Implemented |
| 6400.51(b)(1) | Direct Service Provider #1's date-of-hire is 9/20/24. Their orientation training, conducted from 9/23/24 to 9/27/24, did not include completion of the following required content areas: individual choice and supporting individuals to develop and maintain relationships. [Repeat Violation- 7/9/24 et al] | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The identified staff who received incomplete orientation were immediately scheduled for a supplemental training session covering the missing topics. Supplemental training will be completed by 7/4/2025 and training certificates will site the source of training and training records will be updated accordingly. |
06/27/2025
| Implemented |
| 6400.51(b)(5) | Direct Service Provider #1's date-of-hire is 9/20/24. Their orientation training, conducted from 9/23/24 to 9/27/24, did not include completion of job-related knowledge and skills encompassing individual-specific reviews on the implementation of individual service plans and on the safe and appropriate use of behavior support plans. | The orientation must encompass the following areas: Job-related knowledge and skills. | We have updated the orientation checklist to include job-specific training topics based on role responsibilities (Direct Support Professional, Residential Manager, Program Specialist, Medication Administrator).
Include training scenarios and competency checks to confirm staff understanding of their specific duties. |
07/02/2025
| Implemented |
| 6400.182(c) | Individual #1's Service Plan, last updated 5/30/25, contained the following discrepancies between their current assessment, completed on 9/9/24, in the following health and safety skill domains: regarding fire safety evacuation, Individual #1's Service Plan, last updated 5/30/25, stated that "[Individual #1] knows to evacuate in the event of a fire." In contrast, Individual #1's assessment, completed on 9/9/24, informed that "[Individual #1] requires verbal prompting to evacuate" in the event of a fire; and regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #1's Service Plan, last updated 5/30/25, explained that "[Individual #1] knows about heat source safety" and "has heat source safety skills." However, Individual #1's assessment, completed on 9/9/24, indicated "No" for Individual #1 being able to identify heat sources and a "Score of 4," meaning that "[Individual #1] requires verbal prompting to avoid hazardous areas." [Repeat Violation- 7/9/24 et al] | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | A review of the individual's current status and support needs were conducted and request to have the ISP updated to reflect the individual requires verbal prompting to avoid hazardous areas. The request was sent 7/2/2025. |
07/02/2025
| Implemented |