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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.34 | On 4/30/2025 from 11:58AM until 12:47PM, during the physical site inspection, the door to the vacant bedroom next to Individual #1's bedroom on the first floor of the home was locked and Licensing Representative was not granted access to the bedroom. When asked to unlock the door, Direct Service Worker #1, reported that the key was at the office and the door could not be opened. No attempts were made to obtain the key and provide access to the bedroom. | The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients. | How we plan to correct the non-compliance:
What specific change will be made: Immediate corrective action was taken to retrieve the key for the locked bedroom. The room was accessed, inspected, and confirmed to be in compliance. The key has since been returned to the home and secured in an accessible but locked location for staff use. A duplicate key is now stored on-site in a designated emergency key box.
Who will make the change: The Program Specialist coordinated with the Facility Compliance Manager to retrieve and return the key, confirm room compliance, and establish new access protocols.
When will the change be made: The correction was completed on May 1, 2025.
How will the change be made: The room was opened and inspected. All vacant rooms in the home were verified as accessible, a spare key was place in the home, so that access can be granted. |
05/01/2025
| Implemented |
| 6400.62(a) | On 4/30/2025 at 12:11PM, a spray bottle of Windex and a bottle of Lysol Advanced Power Clinging Gel were unlocked and accessible in the cabinet under the sink in the bathroom on the first floor of the home. Individual #1's assessment, completed 7/31/2024 states that Individual #1 needs total assistance with poisonous substances. | Poisonous materials shall be kept locked or made inaccessible to individuals. | How we plan to correct the non-compliance:
What happened / Why did it happen:
On April 30, 2025, a spray bottle of Windex and a bottle of Lysol Advanced Power Clinging Gel were found unlocked and accessible in the bathroom cabinet on the first floor of the home. Individual #1s assessment dated 7/31/2024 states that he requires total assistance with poisonous substances. This violation occurred because the home did not have a designated locked storage area for cleaning supplies, and staff failed to follow the supervision level outlined in the individual's assessment.
What specific change was made to fix the problem:
On May 1, 2025, a cabinet with a secure lock was installed in the home specifically for storing all cleaning products and toxic substances. The Windex and Lysol were relocated to the locked cabinet immediately. The Program Specialist reviewed the individuals assessment with staff, and the Residential Manager confirmed that no hazardous materials remain accessible.
Who made the change and when:
The Facility Compliance Manager installed the locking cabinet, and the Residential Manager secured all poisonous materials on May 1, 2025.
How was the issue corrected:
All toxic products were moved into the newly installed locking cabinet. All staff were verbally and formally instructed that all cleaning supplies must be kept in this cabinet at all times, with no exceptions. |
05/01/2025
| Implemented |
| 6400.70 | On 4/30/2025 at 12:21PM, a cellular telephone provided by the home was on a shelf in the living room of the home and required a passcode to operate; therefore, rendering it inaccessible to Individual #1. Staff interviews revealed that staff return the cellular telephone to the office each evening. There is no landline telephone service in the home. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| How we plan to correct the non-compliance:
What happened / Why did it happen:
During the inspection on April 30, 2025, it was observed that the home did not have an operable, noncoin-operated landline telephone. Instead, a cellular phone was used, which required a passcode to access and was not consistently available in the home. Staff interviews revealed the cell phone was returned to the office each night, making it inaccessible for both staff and individuals during overnight hours. This occurred due to reliance on mobile devices without considering regulatory requirements for fixed, accessible communication equipment.
What specific change was made to fix the problem:
On May 1, 2025, an operable landline telephone with an outside line was installed in a central and accessible area of the home. The cell phone previously used for communication was removed from the home to eliminate confusion and noncompliant practices. Emergency contact numbers were posted next to the landline.
Who made the change and when:
The Facility Compliance Manager coordinated installation of the landline and removed the cell phone from the home on May 1, 2025.
How was the issue corrected:
The new phone was tested to confirm it could make and receive calls independently and without restriction. It remains in the home at all times and is easily accessible to individuals and staff. |
05/02/2025
| Implemented |
| 6400.71 | On 4/30/2025 at 12:11PM, the telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the cellular telephone on the shelf in the living room of the home. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| What specific change will be made: The cell phone previously located in the living room was removed from the home. A landline house phone was installed in a central location, and the telephone numbers for the nearest hospital, police department, fire department, ambulance, and poison control center were posted clearly next to the phone.
Who will make the change: The Facility Compliance Manager installed the landline and posted the emergency numbers.
When will the change be made: The correction was completed on May 1, 2025.
How will the change be made: Emergency numbers were printed in large, visible font and securely posted next to the phone for easy reference by staff and individuals in the home. |
05/01/2025
| Implemented |
| 6400.72(b) | On 4/30/2025 at 12:14PM, there were three, one-inch holes in the screen in the window in Individual #1's bedroom. | Screens, windows and doors shall be in good repair. | What happened / Why did it happen:
On April 30, 2025, the window screen in Individual #1s bedroom was found to have three one-inch holes, violating the requirement that window screens be maintained in good repair. The damage was caused by the individual poking the screen, and staff failed to identify and report the damage during routine checks.
What specific change was made to fix the problem:
On May 1, 2025, the screen was patched, and it is now free from holes and fully intact. A screen repair kit was placed in the home for quick response to future incidents. Staff were notified of the behavior contributing to the damage and directed to monitor this area routinely.
Who made the change and when:
The Facility Compliance Manager completed the patch repair and verified the screen was restored on May 1, 2025. |
05/01/2025
| Implemented |
| 6400.73(a) | On 4/30/2025 at 12:04PM, there was no railing on the three, exterior cement stairs on each side of the exit on the side of the home. On 4/30/2025 at 12:06PM, there was no railing on the seven, exterior cement stairs outside the exit from the basement of the home. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | How we plan to correct the non-compliance:
What specific change will be made: Railings were installed on both sets of exterior cement stairs on the side and rear exits of the home to provide safe egress and meet regulatory requirements. The three-step side stair and the seven-step basement stair both now have sturdy, code-compliant railings.
Who will make the change: The Facility Compliance Manager coordinated the installation of both railings.
When will the change be made: The correction was completed on May 6, 2025.
How will the change be made: Metal exterior railings were securely mounted to the concrete steps, and all installations were inspected for safety and durability. |
05/06/2025
| Implemented |
| 6400.144 | Individual #1's record in the home contained a letter dated 6/7/2024, from Children's Hospital of Pittsburgh, Primary Care Center recommending the following, moderately thick/honey thick liquids. On 4/30/2025 at 12:00PM, Licensing Representative witnessed staff serving Individual #1 a small bottle of thin apple juice. Direct Service Worker #1 reported that the recommendations changed to soft liquids, but was unsure of when this change occurred. A screenshot of a telephone encounter following a FL Modified Barium Swallow test dated 9/5/2024 was provided with a recommendations to, "consider obtaining a Provale cup (5cc) to use with thin liquid; follow up with PCP for physician-led GOC discussions and to determine any further medical work-up as needed." There was no documentation of a follow-up visit with Individual #1's Primary Care Physician. | 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.
| Provider¿s Plan of Correction
What Happened / Why It Happened:
On April 30, 2025, at 12:00 PM, a Licensing Representative observed Individual #1 being served thin apple juice, despite a documented recommendation dated June 7, 2024, from Childrens Hospital of Pittsburgh prescribing moderately thick/honey-thick liquids.
The on-duty staff believed the recommendation had changed, citing a phone encounter dated September 5, 2024, which suggested using a Provale cup with thin liquids and directed a follow-up with the Primary Care Physician (PCP). However, there was no written physician order or documentation confirming a change to thin liquids, and no record of a completed follow-up visit.
Root Cause:
The change in dietary instruction was assumed based on a phone encounter, without formal physician verification. The required PCP follow-up was scheduled but not completed, and the staff lacked clear, documented direction on the individual¿s current swallowing plan.
Providers Plan of Correction:
A PCP appointment was previously scheduled to confirm current swallowing orders, but it was canceled by the medical provider. Appointment has been rescheduled for 5/27/2025 at 3 pm to obtain clear orders for solid and liquid intake.
In the interim, the Provale cup (5cc) at the home will be used per clinical guidance, and staff have been instructed to use it with all thin liquids until formal clarification is received. |
05/28/2025
| Implemented |
| 6400.214(b) | On 4/30/2025 at 12:44PM, the most recent copies of Individual #1's physical examination, dental examination and psychological evaluations were not kept at the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| What happened / Why did it happen:
During the inspection on April 30, 2025, the most recent copies of Individual #1s physical examination, dental examination, and psychological evaluation were not present in the home. This occurred because the documents were stored at the administrative office only, and the team failed to ensure a full set of records was duplicated and maintained at the individual's residence, as required.
What specific change was made to fix the problem:
On May 1, 2025, the Program Specialist printed and delivered updated copies of all required documents to the home. These documents were reviewed for completeness and placed in the individual's on-site file.
Who made the change and when:
The Program Specialist completed the correction and filed all required records on May 1, 2025.
How was the issue corrected:
The individual's file in the home now contains the current physical, dental, and psychological evaluations. The documents were verified and organized in accordance with agency file structure. |
05/01/2025
| Implemented |
| 6400.32(r)(3) | On 4/30/2024 at 12:10PM, there was a keyed locking mechanism on the door leading to Individual #1's bedroom. Staff interviews revealed that Individual #1 is not able to use the key to independently lock and unlock the door. | Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance. | How we plan to correct the non-compliance:
What happened / Why did it happen:
On April 30, 2024, a keyed locking mechanism was observed on the door to Individual #1s bedroom. Staff confirmed during interviews that Individual #1 was unable to independently use the key to lock or unlock the door. This violated the individuals rights to privacy and independence and posed a potential safety risk. The lock had originally been installed by maintenance without full consideration of the individual's ability to use it, and the oversight was not caught during internal checks.
What specific change was made to fix the problem:
The locking mechanism was completely removed from the bedroom door. It was replaced with a non-locking knob, ensuring the individual now has unrestricted and independent access to their bedroom.
Who made the change and when:
The Facility Compliance Manager removed the lock and installed a non-locking knob on May 1, 2025.
How was the issue corrected:
The door was inspected to confirm that no locking mechanism remains. Staff were advised to report any future changes to door hardware and were reminded that individuals must be able to independently operate all locks in their personal living spaces. |
05/01/2025
| Implemented |
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