Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00281057 Renewal 01/05/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104The fire department notification letter dated 1/1/2026 did not give an accurate description of the mobility needs of individuals residing at this address. The letter states "the current occupants are ambulatory and able to safely evacuate in case of an emergency without further assistance needed". Individual #1 requires verbal prompts to safely evacuate, as indicated in Individual #1's assessment, dated 12/15/25.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Updated notification letters for Alternative Living Concepts were provided to the local fire department to ensure emergency responders have accurate, current information to support safe evacuation during an emergency. Revised fire department notification letters now include: The individual's ambulatory status and whether verbal prompting and/or physical guidance is required during evacuation. 01/13/2026 Implemented
6400.113(a)Individual #1 has an admission date of 10/16/25 and did not have fire safety training completed until 10/29/25. This exceeds the requirement that the training occur upon admission. 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. Effective 01/13/2026, Alternative Living Concepts has implemented procedures to ensure that fire safety training for individuals is completed upon admission, in the individual's primary language or mode of communication, and documented accordingly. The Compliance Managers will be responsible for verifying that fire safety training is completed at the time of move-in. This includes instruction on: · General fire safety · Evacuation procedures · Responsibilities during fire drills · Safe areas inside and outside of the home · Smoking safety procedures, if applicable Completion of the training will be documented in the individual's record and uploaded into the electronic health record system. 01/13/2026 Implemented
6400.141(c)(14)Individual #1's physical examination completed on 10/3/25 has a section for medical information pertinent to diagnosis, however it was left blank. [Repeat Violation 1/29/25 et. al.]The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Alternative Living Concepts has revised its internal review process for individual medical appointment documentation to ensure compliance with 55 Pa. Code § 6400.141(c)(14). This revised process ensures that medical information pertinent to diagnosis and treatment in the event of an emergency is complete and documented in accordance with regulatory requirements. Effective immediately, the Medical Records Coordinator will no longer be responsible for reviewing physical examination documentation for completeness. Responsibility for review has been reassigned to executive and administrative leadership. A two-step review process has been implemented as follows: 1. ALC's Administrative Coordinator will review all individual medical appointment paperwork, including physical examinations, to ensure all required medical information is completed by the physician. 2. ALC's CEO will conduct a secondary/ final review to confirm that all required sections are accurately and fully documented prior to final acceptance. 01/12/2026 Implemented
SIN-00259952 Renewal 01/29/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Support Professional #1's date-of-hire is 4/27/24. The agency completed a Pennsylvania criminal history check to the State Police on 4/12/24, revealing a criminal history record involving damage to attended vehicle property. However, the agency did not provide documentation of a criminal record review outlining their consideration for hiring Direct Support Professional #1 based on the following factors: the nature of the crime; the facts surrounding the conviction; the time elapsed since the conviction; the evidence of Direct Support Prfoessional#1's rehabilitation; and the nature and requirements of the job.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. As of 2-9-2025, ALC has developed and implemented the Determination of Hire form . This form will ensure that the decision to hire an employee with a criminal record is documented and reviewed with the prospective employee. 02/09/2025 Implemented
6400.64(a)At 11:34 AM on 1/30/25, the ceiling on the inside of the microwave was stained with food remnants and its interior surface finish was delaminating. At 11:35 AM, there were streaks of yellow-stained grease, measuring approximately one-half inches in length. At 11:37 AM, there were several circular grease splatters in multiple areas on the ceiling of the kitchen. At 11:44 AM, there were several brown water spots in multiple areas on the ceiling in the bathroom located in the hallway on the home's first floor.Clean and sanitary conditions shall be maintained in the home. As of 1/30/2025: The old microwave, with food remnant stained ceilings and delaminating interior surfaces, was removed from the home and properly disposed. A brand new microwave has been purchased and placed into the home.(see attached receipt of purchase) The yellow-stained grease streaks, measuring approximately one-half inch in length, has been cleaned. -Multiple circular grease splatters on the kitchen ceiling have been cleaned. -The several brown water spots on the ceiling in the bathroom located in the hallway on the home's first floor, have been cleaned. DSP will use ALIS to document that the microwave is cleaned after each use. 01/30/2025 Implemented
6400.64(f)At 11:15 AM on 1/30/25, there was one tall kitchen bag that was tied and laying on the ground next to the trash receptacles outside. At 11:17 AM, one outside trash receptacle was full of miscellaneous garbage and did not contain a lid. At 11:42 AM, located at the rear exit from the basement of the home, there was an inordinate amount of miscellaneous articles of trash laying on the ground outside.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The following discoveries were made on the home's weekly scheduled garbage pickup date of the following: -tied tall kitchen bag laying on the ground next to the trash receptacle, -the trash receptacle without a lid full of miscellaneous garbage, and -the inordinate amount if miscellaneous articles of trash laying on the ground outside near the rear exit of the basement of the home. The trash receptacle that was outside without a lid was disposed of. All remaining trash receptacles have attached lids. The garbage was picked up about 30mins after the discoveries were documented. Going forward, Compliance managers will ensure all outside trash receptacles are in compliance with regulation 6400.64(f). 02/05/2025 Implemented
6400.101At 11:39 AM on 1/30/25, there was sliding latch lock on the interior of the basement door that leads to the attached garage. The garage did not have an exterior swing door. Therefore, an entrapment area or blocked egress exists.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. As of 2-1-2025 The sliding latch lock on the interior of the basement door causing an entrapment area or blocked egress exists was removed. 02/01/2025 Implemented
6400.141(c)(3)Individual #1's date-of-admission is 5/10/24, and their date-of-birth is 9/20/68. Neither of Individual #1's physical examinations completed on 5/3/24 and 11/1/24, nor their content of records included documentation of a tetanus-diphtheria immunization having ever been received.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. Individual #1 did not receive a TDap immunization prior to admission. Individual #1's PCP does not offer the TDap vaccine to Medicaid participants. Therefore, we spoke with individual #1's legal guardian to inform them of the regulatory requirement that we need to follow. The legal guardian agreed to change his PCP to: United Physicians-305 ¿ 7th Street, New Kensington, PA 15068. Individual #1 is scheduled to establish care and receive the TDap vaccine on 2-27-2025 Going forward , ALC has implemented our electronic health record system called Assisted Living Intelligent Solutions also known as ALIS. ALIS will be used to ensure all immunizations, as outlined by the regulations, are in compliance. 02/18/2025 Implemented
6400.141(c)(14)Individual #1's most recent physical examination completed on 11/1/24, did not address medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. ALC has implemented our electronic health record system called Assisted Living Intelligent Solutions also known as ALIS. Medical Records coordinator and Administrative coordinator will perform the 2-step review process. This will ensure that all medical information pertinent to diagnosis and treatment in case of an emergency is documented 02/18/2025 Implemented
6400.142(d)Individual #1's date-of-admission is 5/10/24, and their date-of-birth is 9/20/68. Their initial and current dental examination completed on 10/28/24, did not include a teeth cleaning or a gums and dentures check.The dental examination shall include teeth cleaning or checking gums and dentures. Individual #1's current provider is not a Medicaid provider and was not able to complete the full dental exam. As of 2-11-2025, an application was submitted to Accessible Dental for individual #1 to establish dental care and receive a complete dental exam. (see attached email confirmation) 02/11/2025 Implemented
6400.15(b)The agency used the Self-Inspection and Declaration Tool, modified June 2018 to measure and record compliance at the home on December 30, 2024, which does not contain all the elements in the current Department's licensing inspection instrument released on February 20, 2020.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.ALC has disposed of all copies of the self inspection and declaration tool modified June-2018 and replaced them with the correct version modified Feb-2020 as located in the 6400 Regulatory compliance guide printed March15,2023. The compliance managers, who are responsible for completing the self inspection and declaration tool, were trained 2-10-2025 that going forward, the self inspection and declaration tool modified Feb-2020 is the correct form to be used when conducting home inspections. 02/10/2025 Implemented
6400.18(i)Enterprise Incident Management # 9475735 for neglect, involving failure to provide needed supervision, was discovered on 8/29/24 at 12:30 PM and finalized on 10/3/24 at 5:11 PM. The due date for finalization was 9/26/24, and no extensions were filed.The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension.The point person will check all incidents on a daily basis. This will ensure that all incidents are finalized within 30days of the date of discovery. 02/20/2025 Implemented
6400.165(g)Individual #1's date-of-admission is 5/10/24, and they are prescribed medication to treat symptoms of a psychiatric illness. The medication review completed on 9/27/24, did not document the medication that was reviewed by the licensed physician.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.The medication review document for individual #1 for 9/27/24, was developed to display the medication name in "red" when viewing the document on a computer. This caused the medication names to print out "blank" since our printer is black and white only. Therefore, the medication review form has been reformatted to be in "black" ink only. This will avoid any printing errors in the future. 02/18/2025 Implemented
6400.182(c)Individual #1's Individual Support Plan, last updated on 12/4/24, was not revised to reflect their current needs as based on their current assessment, completed on 6/12/24, in the following health and safety skill domains: Regarding poisonous materials, Individual #1's Individual Support Plan stated that they would not ingest poisons but did not address their ability to safely use such substances or indicate if supervision is required. Individual #1's assessment indicated that they can both avoid and safely use poisonous substances with staff supervision; and regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #1's Individual Support Plan left this skill domain unaddressed entirely, while their assessment indicated Individual #1 can independently sense and quickly move away from such heat sources.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The assessment information for individual #1 is correct. Individual #1's Supports Coordinator was notified of the of the missing information to be updated in the ISP. 02/20/2025 Implemented
SIN-00238724 Renewal 02/06/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual #1 had a physical examination completed on 2/28/2022 and then again on 3/27/2023.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Effective 2/12/2024 The medical records coordinator will work with the administrative coordinator to ensure that individual #1's future physical examination appointments are within the regulated time frame. 02/12/2024 Implemented
SIN-00219193 Renewal 02/13/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65The bathroom in the hallway outside the bedrooms did not have an operable window and the mechanical ventilation system was inoperable.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. The agency has an appointment scheduled with BC Electric for March 10, 2023, to install a new vent fan in the bathroom. 03/10/2023 Implemented
6400.142(a)Individual #1 had a dental examination on 08/02/21, and then again on 11/14/22.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. The individual refused several appointments, all of which were documented. The agency will continue to document refusals of the agency refusal of service form, which includes the date of the refusal, services refused, and the out come, including the date of the rescheduled appointment. In addition, to ensure follow up appointments are scheduled within the regulatory compliance guidelines, The agency has re- implemented the individual data tracking schedule, in which the agency will collect all individual records and dates and place them into Google Calendar. The renewal completion due date will be set for 30 days prior to the expiration date of the current documents. For example, if an individual's dental exam expires on 04/30/23, the renewal completion due date will be 03/30/23. The schedule will be placed into google calendar, which all admin staff are connected via email. The administrative coordinator and staff supervisors will be responsible for the review of all staff documents. 03/13/2023 Implemented
6400.165(g)The psychiatric medication reviews completed 8/29/22, 10/19/22, and 12/14/22 for Individual #1 did not include the name and necessary dosage of the medication(s), and the reason for prescribing the medication(s). [Repeat Violation, 3/2/2022]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.The provider has changed the individual's psychiatric medication provider, as the previous medical provider continuously refused to complete the requested form, despite written instructions on the forms sent with the individual to the appointment. Documentation of the mentioned issue is in the individual's file. 03/02/2023 Implemented
SIN-00202480 Renewal 03/02/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(g)Individual #1 is prescribed medication to treat the symptoms of a diagnosed psychiatric illness; however, individual #1 did not have a record of psychiatric medication review being completed prior to 9/7/2021.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.The agency CEO has sent several request (verbal phone conversation) to the psychiatric doctor to receive proof of med reviews for 2021 - in which the response was "they will eventually send them when they find them". On another occasion, the medical office stated the records were at another office and they would get back to us. As of April 20, 2022, the psychiatric office has not located or answered ALC's request. The agency has developed an "information request form". The form includes the following: 1. Date of request 2. Staff making request 3. information requested 4. reason for request 5. who staff made contact with 6. Results of the request Going forward, all information request will be documented on this form and placed in the individual's file. ["Information Request Form" received on 5/19/22 and reviewed on 5/20/22. "Individual Data Tracking" system received 5/19/22 and reviewed 5/20/22. Weekly reviews by Administrative Liaison received 5/19/22 and reviewed 5/20/22. DPOC by HDKP, HSLS, on 5/20/22]. 03/29/2021 Implemented
SIN-00185650 Renewal 03/31/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106A furnace inspection was completed on 1/03/2020 and then again on 2/12/2021.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. It is now ALC policy that all furnace inspections be scheduled 30 days prior to the expiration of the current furnace inspection date. An ¿ALC Agency Schedule Calendar¿ has been created and is connected to the emails of the CEO and administrative assistant. The administrative assistant will be responsible for scheduling the furnace inspections with ARS. ¿ALC Agency Schedule Calendar¿ includes a December 5th 2021 schedule reminder (including two days & one day before) for the administrative assistant to contact ARS to schedule the next inspection for January 5, 2022. The confirmed scheduled appointment will be placed into the ¿ALC Agency Schedule Calendar¿. 04/12/2021 Implemented
6400.141(c)(4)Individual #1, date of admission 3/27/17, had a vision screening 12/29/2020 and not one prior. Individual #1 has no record of having a hearing screening completed.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The individual attended a hearing and vision appointment today, April 13, 2021. The documentation of the hearing and vision exam will be obtained from the primary care physician and placed into the individual¿s file. 04/13/2021 Implemented
6400.151(c)(3)Direct Service Worker #1 had a physical examination completed on 3/18/2021 which did not include a signed statement that the staff person is free from communicable diseases. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. The staff¿s physical has been updated to reflect the ¿free from a communicable disease¿ statement. The physical was updated by the MedExpress medical personnel, where the staff completed his exam and TB. 04/01/2021 Implemented
SIN-00169859 Renewal 02/06/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(5)Individual #1, date of admission 10/4/19, had an immunization Tetanus Diphtheria booster on 9/1/09 then again 10/23/19.The physical examination shall include: Immunizations and screening tests for individuals 17 years of age or younger, as recommended by the Standards of Child Health Care of the American Academy of Pediatrics, Post Office Box 1034, Evanston, Illinois 60204. The appointment was scheduled for 10/23/19 for the individual to receive TD. This appointment was scheduled prior to her admission to ALC on 10.4.19. Agency took individual to appointment on 10/23/19, where she received her TD. Going forward, the TD has been added to our admission list, to ensure new admissions have required vaccinations. Agency will ensure individuals receive vaccinations according to doctor recommendations and timelines. [Immediately, the CEO shall educate all staff persons on their responsibilities to ensure all individuals are supported as needed to ensure timely completion physical examination to include all required information including immunizations. Immediately, upon completion and at least quarterly for 1 year, the CEO or Designee shall audit all individuals current physical examinations to ensure timely completion with all required information and individuals health needs are arranged and provided for. Documentation of audits shall be kept. (DPOC by AES, HSLS on 3/3/20)] 10/23/2019 Implemented
6400.143(a)Individual #1 refused the gynecological examination during a physical examination, completed 2/27/19. Individual #1's record did not included continued attempts to train the individual about the need for health care.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record.We have a letter from the individual's doctor deferring the gynecological exam, due to anxiety and lack of sexual activity. Please see attached. Going forward, agency has added gynecological exam to the admissions list, to ensure exams are current and/or scheduled during admission. Agency will continue exams annually, or as recommended my physician. [Immediately, the CEO shall develop and implement policies and procedures to address if an individual refuses a medical or dental examination and treatment. Documentation of the policies and procedures shall be kept. Within 30 days of receipt of the plan of correction, the CEO shall educate all staff persons on their responsibilities to ensure all individuals are educated about the need for health care if an individual refuses a medical or dental examination or treatment. Documentation of the training shall be kept. are supported as needed to ensure timely completion physical examination to include all required information including immunizations. Immediately, upon completion and at least quarterly for 1 year, the CEO or Designee shall audit all individuals' records to ensure documentation of the refusal and continued attempts to train the individual about the need for health care is in the individuals' records. (DPOC by AES,HSLS on 3/3/20)] 02/18/2020 Implemented