Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00257637 Unannounced Monitoring 12/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(4)Individual #1, date of admission, 12/11/2023, has not completed a hearing screening.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. On 3/21/2024 a hearing screen attempt was made in which the practitioner documented, ¿unable to assess¿ and another attempt was made on 11/13/2024 in which the practitioner documented, ¿Hearing screen attempted. Unable to be completed due to patient inability to participate. Caregiver to notify if new onset hearing concerns occur. Return for next scheduled follow-up with PCP on 4/10/2025 at 11:00am.¿ To correct this violation, an appointment was scheduled with The HearWell Center of Pittsburgh for December 26, 2024. 12/26/2024 Implemented
6400.144Individual #2's Individual Service Plan, last updated 12/6/2024, states, "[Individual #1] USES A BI-PAP MACHINE ON A DAILY BASIS. [Individual #1] REQUIRES ASSISTANCE CLEANING THE MACHINE AND ENSURING HER MASK IS ON CORRECTLY." At 10:33AM on 12/17/2024, a Bi-Pap machine was unplugged on the floor, underneath the bed along with several other miscellaneous items in Individual #2's bedroom. Staff interviews revealed that they were unsure if Individual #2 should be using the machine and physician's orders were not present at the home.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. To correct this violation a copy of the physician's order to hold to Bi-PAP was placed in the chart. At an appointment on 12/20/2024 with the pulmonologist, an order was received to, "Continue to hold the BiPap until the sleep study." This order was also placed in the chart. The sleep study is scheduled for 2/7/2025. 12/23/2024 Implemented
SIN-00255130 Renewal 11/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At 10:55AM on 11/6/2024, there were several large areas of what appeared to be mold and/or mildew and water damage along the bottom of the floor in the back room of the basement of the home near the water meter. At 11:02AM on 11/6/2024, a pill crusher with a thick layer of pill residue along the bottom and sides of the inside was in the dish drainer. At 11:12AM on 11/6/2024, there was what appeared be mouse droppings on the floor under metal shelves in the dining room of the home. At 11:21AM on 11/6/2024, there was a rust-colored substance under the nonslip mat in the bathtub in the bathroom on the second floor of the home.Clean and sanitary conditions shall be maintained in the home. In order to correct these violations, the affected areas of the basement near the water meter, which exhibited mold, mildew, and water damage, were thoroughly cleaned and treated with an anti-microbial solution. The damaged flooring was repaired and sealed on November 18, 2024, to prevent further water intrusion, and maintenance staff addressed the source of the water damage to ensure no future issues. Regarding the pill crusher with a thick layer of residue, it was immediately removed from the dish drainer, cleaned, and sanitized on November 6, 2024. Staff responsible for medication administration were retrained on November 25, 2024, on proper cleaning and sanitizing procedures for medication equipment. What appeared to be mouse droppings found under the metal shelves in the dining room were cleaned and sanitized the same day, and a pest control company was contacted to address the issue. Pest control measures, including traps and sealing entry points, were implemented to prevent recurrence. Additionally, the rust-colored substance under the non-slip mat in the second-floor bathroom was cleaned and removed, and the area was thoroughly disinfected. Maintenance staff inspected the bathtub to ensure no further buildup. 11/18/2024 Implemented
6400.67(b)At 10:53AM on 11/6/2024, the floor at the top of the basement steps in the kitchen is uneven due to different types of flooring posing a tripping and falling hazard. In addition, there is not a threshold installed posing a slipping and falling hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.In order to correct these violations, the uneven floor at the top of the basement steps in the kitchen was repaired on November 11, 2024. The Maintenance Supervisor ensured that the transition between the two types of flooring is now smooth and safe, Additionally, to address the violation regarding the two closet doors leaning against the wall, it was clarified that this occurred in a bedroom at 7120 and not in the location cited in this violation. Nonetheless, the doors were promptly reinstalled to their proper location to ensure no safety hazards remain. Maintenance staff inspected the installation and confirmed that the doors are secure and functional. 11/11/2024 Implemented
6400.113(a)Individual #1, date of admission, 12/11/2023, was initially instructed in fire safety on 1/10/2024. 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. In order to correct this violation, on November 21, 2024, the Program Specialist was retrained on the admission process to ensure that all required fire safety training is completed and properly documented. The retraining emphasized the importance of timelines for fire safety instructions. Individual #1's fire safety training, completed on January 10, 2024, was reviewed during the retraining session and used as an example to reinforce proper procedures and documentation practices. 11/21/2024 Implemented
6400.141(c)(4)Individual #1, date of admission, 12/11/2023, has not completed a hearing screening.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. In order to correct this violation, Individual #1, whose date of admission was December 11, 2023, completed a hearing screening on November 13, 2024. The results of the screening have been documented in Individual #1's file to ensure compliance. 11/13/2024 Implemented
6400.32(r)(3)At 11:00AM on 11/6/2024, there was a keyed lock mechanism on Individual #1's bedroom door. Interviews revealed that Individual #1 is not able to utilize the key to independently lock and unlock the door without assistance.Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance.In order to correct this violation a meeting has been scheduled with Individual #1's legal guardian on December 9th to assess her ability to use the keyed lock and to determine an appropriate solution that respects her independence and ensures the safety of her belongings. Until a final decision is made, staff will continue assisting Individual #1 with locking and unlocking her door to maintain security while ensuring she has access as needed. Documentation of the outcome of the meeting, will be maintained in her file. 12/09/2024 Implemented
6400.34(a)Individual #1, date of admission, 12/11/2023, was initially informed and explained individual rights on 1/11/2024.The home 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 home and annually thereafter.In order to correct this violation, on November 21, 2024, the Program Specialist was retrained on the admission process to ensure that all required individual rights are explained and properly documented during admission. The retraining emphasized the importance of timelines for informing individuals of their rights. Individual #1¿s initial rights explanation, completed on January 11, 2024, was reviewed during the retraining session and used as an example to reinforce proper procedures and documentation practices. 11/21/2024 Implemented
6400.165(g)Individual #1 is prescribed medication to treat symptoms of a psychiatric illness. The most recent review of the prescribed psychiatric medication by a licensed physician was completed on 5/31/2024. [Repeat Violation, 3/5/2024]If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Immediately, the psychiatric medication review form was updated to comply with this regulation.. 12/20/2024 Implemented
6400.166(a)(4)Individual #1's November 2024 Medication Administration Record did not include the name for Lorazepam 1MG tablets.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.In order to correct this violation, Individual #1's November 2024 Medication Administration Record (MAR) was updated on November 8, 2024, to include the missing name for Lorazepam 1MG tablets. The corrected MAR was reviewed by the Medication Administration Trainer to ensure all required information was accurately documented. Additionally, staff responsible for updating the MAR are scheduled to be retrained on December 2, 2024, to reinforce the importance of complete and accurate medication documentation. 12/02/2024 Implemented
SIN-00249845 Unannounced Monitoring 07/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)Individual #1's financial ledger lists the following transactions without receipts: $20.00 for "Five Below" on 5/9/2024, $25.00 for "Target" on 6/5/2024, $50.00 for "purchasing `bathing suit and Sandcastle" on 6/19/2024, $40.00 for Idlewild weekend spending" on 6/25/2024, and $25.00 for "Dollar Tree" on 7/11/2024. The financial ledgers are also being rounded to the nearest dollar and do not list the actual amount of dollars and cents spent for each transaction. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. The agency is not the representative payee for any of our individuals but does assist our individuals with monitoring funds sent by their representative payees for monthly spending upon request. To correct this violation, a policy was established to assist with regulating funds that states, "Effective immediately, each residential client will have a financial binder held by the chief financial officer. In this binder, each individual who requests assistance, will hold their monthly spending money, accompanied by a balance ledger sheet. This sheet will document all incoming deposits and withdrawals to track monthly spending funds. Once funds are withdrawn, they will be documented on a second balance ledger sheet and given to the individual¿s direct support professional, along with withdrawn funds. ¿ 09/30/2024 Implemented
6400.62(a)At 12:56PM, a one-gallon can of Behr interior flat ceiling paint, a 32-ounce spray bottle of Clorox Clean-Up, a bottle of All Mighty Pacs laundry detergent, a quart bottle of lighter fluid, and five 1-quart bottles of Diversey Clinging toilet bowl cleaner were unlocked and accessible in a room in the basement of the home. [Repeat Violation, 3/7/2024]Poisonous materials shall be kept locked or made inaccessible to individuals. To correct this violation, all maintenance supplies, and equipment were removed from the home immediately by maintenance staff. 09/30/2024 Implemented
6400.64(b)At 12:56PM, a dead mouse was on a glue trap along with mice droppings were on the floor in the front room of the basement.There may not be evidence of infestation of insects or rodents in the home. To correct this violation, all debris was removed from front room of the basement immediately by the program coordinator. 09/30/2024 Implemented
6400.67(b)At 12:57PM, a wooden board with protruding rusty nails on the floor in the front room of the basement posing a laceration and puncture hazard. At 1:00PM, the floor at the top of the basement steps in the kitchen is uneven due to different types of flooring posing a tripping and falling hazard. In addition, there is not a threshold installed posing a slipping and falling hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.Immediately, maintenance supplies were removed from the home by maintenance staff. A transition strip was placed between the kitchen and the basement steps to correct this violation. 09/30/2024 Implemented
6400.72(a)At 1:03PM, the air conditioner in the window in Individual #1's bedroom is not tightly sealed leaving gaps approximately a half inch on the right side and top of the of the unit. [Repeat Violation, 3/7/2024]Windows, including windows in doors, shall be securely screened when windows or doors are open. To correct this violation, window foam was placed around the air conditioner for a secure fit by maintenance staff. 09/30/2024 Implemented
6400.73(a)At 12:53PM, there were two railings next each other along the exterior steps in the rear of the home. The inner metal railing was loose and wobbled approximately an inch in either direction. The outer wooden railing was missing at least 2 slats and had a hanging portion of a slat. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. To correct this violation, the metal railing was removed, and the wooden railing was removed and replaced by maintenance staff immediately. 09/30/2024 Implemented
6400.107At 1:06PM, a portable space heater was in the closet in the living room near the front entrance of the home.Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms. To correct this violation, the space heater was removed from the home immediately by the program coordinator. 09/30/2024 Implemented
6400.214(b)The most recent copies of Individual #2's dental examination and dental hygiene plan were not present at the home. [Repeat Violation, 3/7/2024] The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The individual #2 had a dental appointment on January 25, 2024, and dental hygiene plan update on April 15, 2024. On 3/6/2024, during an inspection, the agency was told files could be electronic if all staff has access. Staff present for this inspection pulled up the dental examination on the agency's SharePoint to show the state representative. The state representative stated, "I don't care. I'm still citing it. It needs to be in this book." The agency does not agree with this violation, to comply with the state, on August 30, 2024, a copy of the dental exam and dental hygiene plan was placed in the individual's file in the home by the program coordinator. 09/30/2024 Implemented
6400.163(a)At 1:21PM, Individual #1's prescribed medication, Polyethylene Glycol 3350 powder packets were not being stored in their original, pharmacy labeled container.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.To prevent this violation, the pharmacy was contacted for a label. They were unable to produce a label without billing for the medication. The medication was immediately reordered by the program coordinator. 09/24/2024 Implemented
6400.182(c)Individual #2's assessment, completed 4/1/2024, reads "Cannot use" and "2" (physical prompts) to avoid poisons. Individual #2's Individual Plan updated 7/1/2024 indicates "[Individual #2] needs verbal assistance to store and handle poisons, but [Individual #2] is not at risk for ingesting."The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.To correct this violation, an email was sent to the team for an ISP update on August 31, 2024. 09/30/2024 Implemented
SIN-00240263 Renewal 03/05/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66At 11:02AM on 3/6/2024, the room in the basement at the front of the home had two light fixtures without light bulbs. There is not another source of light in this room.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. In order to correct this violation, light bulbs have been immediately placed in the two light fixtures in the room located in the basement at the front of the home. 04/15/2024 Not Implemented
6400.72(a)At 10:54AM on 3/6/2024, the window adjacent to the closet in the front area of individual #1's bedroom did not have a securely fitting screen.Windows, including windows in doors, shall be securely screened when windows or doors are open. The screen in the window adjacent to the closet in the front area has been replaced with a securely fitted screen immediately. 04/15/2024 Implemented
6400.32(h)At 11:04AM on 3/6/2024, cameras were observed in the dining room and living room of the home. The agency did not have a current videography recording and retention policy and individuals #1 and #2 had not signed videography consents.An individual has the right to privacy of person and possessions.In order to correct this violation a Videography Policy and Consent form has been developed to ensure compliance with privacy regulations and to obtain explicit consent from individuals regarding videography in their living spaces. Individual #1 has now signed the Videography Policy and Consent form, and a copy has been placed in both the home and the client file for reference. 04/15/2024 Not Implemented
SIN-00221744 Renewal 03/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)At 10:38AM on 3/29/23, the hot water temperature measured 129.3°F at the bathtub in bathroom on second floor of the home. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water temperature was corrected on the day of inspection. Moving forward the DSP and program managers were trained how to check document and report water temperature readings. DSP will complete daily checks of the water temperatures. If any temperatures are found to be too high, the Program Manager will be notified and adjust the temperature. The Program Specialist will test the temperature of the water when completing their weekly house Audits. Documentation of this check will be maintained with the audit paperwork. In addition to the daily and weekly hot water temperature checks, documentation of all hot water temperature measurement checks shall be kept and reviewed monthly by the Residential Director. 04/03/2023 Implemented
SIN-00186598 Renewal 04/21/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)Individual #1's assessment was completed on 3/13/2019 and then again on 11/17/2020. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Individual # 1 had an initial assessment on 3/13/2019. The annual assessment was completed on 11/17/2020. According to regulation 181(a) [Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home.] The program specialist received conflicting training from the predecessor. The program specialist was taught to complete the annual assessment a month prior to the ISP meeting rather than annually. To correct this deficiency, the program specialist has been retrained and job description updated on 4/23/2021. 04/23/2021 Implemented
6400.32(d)The Office of Developmental Programs requires that staff who provide direct services wear a mask that covers the nose and mouth during the entirety of service provision. On 4/22/2021 at 11:52AM, Program Manager #1 was standing next to Individual #1 without a mask. Failure to wear masks is undignified and disrespectful in that it creates a risk of transmitting the COVID-19 virus from staff to individuals.An individual shall be treated with dignity and respect.Family Services United (FSU) has developed the mission statement and values around this regulation and protects the fundamentals of individual rights. This agency was under the impression that ODP followed the Center for Disease Control (CDC) guidelines that states fully vaccinated people can gather indoors with other fully vaccinated people without a mask or social distancing and with other unvaccinated people from one other household. Both the individual #1 and the program manager #1 are vaccinated. ODP requires that staff continue to wear a mask that covers the mouth and nose while providing care. To correct this violation Family Services United conducted a COVID-19 Update training for direct support professionals, individuals, and program manager on 4/23/2021 and 4/28/2021. All attendees signed a COVID-19 consent form. The staff were instructed that despite the CDC recommendations, ODP requires a mask indoors [covering the nose and mouth be worn during the entirety of service provision and not doing so is undignified and disrespectful in that it creates a risk for transmitting the COVID-19 virus.] 04/28/2021 Implemented
6400.34(a)Individual #1 was informed and explained her individual rights on 3/13/2019 and then again on 4/10/2020. Individual #1 was informed and explained individual rights on 4/10/2020. The rights document did not include the following rights: 6400.32b, an individual has the right to civil and legal rights afforded by law, including the right to vote, speak freely, practice the religion of his choice and practice no religion; 6400.32e, the right to make choices and accept risks; 6400.32g, to control his own schedule and activities; 6400.32j, the right to voice concerns about the services the individual receives; 6400.32k, the right to participate in the development and implementation of the individual plan; 6400.32L, the right to receive scheduled and unscheduled visitors, and to communicate and meet privately with whom the individual chooses, at any time; 6400.32p, the right to choose persons with whom to share a bedroom; 6400.32q, to furnish and decorate the Individual's bedroom and the common areas of the home; 6400.32r, to lock the individual's bedroom door; 6400.32s, to have a key, access card, keypad code or other entry mechanism to lock and unlock entrance door of the home; 6400.32t, to access food at any time; 6400.32u, to make health care decisions; 6400.32v, right may only be modified accordance with 6400.185.[Repeated violation 3/4/2020]The home 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 home and annually thereafter.Family Services United (FSU) recognizes the importance of regulation 6400.34(a) ¿ The home 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 home and annually thereafter. As an agency we will ensure that individuals are educated on their rights per regulation. Individual #1 was informed and received explanation of individual rights on admission (3/13/2019) and on 4/10/2020. Individual #1 and all other individuals residing at FSU signed the updated rights on 2/24/2021 in which the state representative received copies of the signature page only and not the resident rights for sample individuals via SharePoint. 02/24/2021 Implemented
6400.181(f)The program specialist did not provide Individual #1's assessment, completed 11/17/2020 to the individual plan team members for an individual plan meeting on 12/7/2020.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Family Services United (FSU) will ensure that assessments are submitted within the specified timeframe per regulations to the entire team. The program specialist is responsible for submitting the assessment to the team at least 30 days prior to an individual plan meeting. FSU program specialist will discuss with team that ISP meetings will be scheduled at least 30 days after the anniversary dates. Residential director will oversee the entire process to ensure compliance is met. The assessment 30-day window will be placed on the residential director and program specialist calendar as a reminder. The residential director conducted a training refresher with program specialist on April 23,2021. Immediately, the residential director, or designee, shall train all staff responsible for completing any portion of the individual assessment, coordinating the completion of any portion of the assessment, or ensuring the completion of the individual assessment on the required components of an individual assessment, including required content and timelines, as indicated by 6400.181(a)-(f). 04/23/2021 Implemented
SIN-00203737 Renewal 04/12/2022 Compliant - Finalized
SIN-00172123 Renewal 03/04/2020 Compliant - Finalized