| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.14(c) | The home has been structurally renovated and altered since the initial fire safety occupancy permit was issued. There have been alterations to the home's plumbing system and a wall was constructed between the dining room and living room. | If a building is structurally renovated or altered after the initial fire safety
occupancy permit is issued, the home shall have a new occupancy permit or written
approval if required from the Department of Labor and Industry, the Department
of Health, the Department of Public Safety of the city of Pittsburgh, the
Department of Licensing and Inspection of the city of Philadelphia or the Department
of Community Development of the city of Scranton. | On 8/8/2024 the CEO reached to city of Pittsburgh to request for another occupancy permit inspection. On 8/15/2024 the house was inspected, and we were asked to remove one of the plywood's we used to cover the living window and the bedroom window which we did on 8/16/2024. The CEO reached back to the city so that they can come back to reinspect the house. On 09/18/2024 the inspector came, and he said everything looks great after few hours he sent an email stated that he can't reissue the occupancy permit. On 9/19/2024 we reached back to him to come back and explain to us what we need to do to the house again to get an occupancy permit we haven't got any response from him as at 09/25/2024.
On 9/23/2024 fire safety inspection was conducted, the fire officer issued us a letter that everything was okay.
[As of 11/4/2024 the agency has not provided any proof or documentation that the community home has a current valid occupancy permit. DPOC by HDKP, HSLS, on 11/4/2024.] |
09/20/2024
| Not Implemented |
| 6400.43(b)(1) | Chief Executive Officer (CEO) failed to ensure the implementation of the agency's policies and procedures by allowing Individual #1 to be subjected to the prohibited procedure of seclusion, violating Individual #1's right to be treated with dignity and respect, right to privacy of person and possessions, right of access to and security of personal possessions, right to participate in the development and implementation of the individual plan, right to unrestricted and private access to telecommunications, and right to lock the individual's bedroom door. These Individual Rights were modified without the review and approval of the Human Rights Team prior to implementation. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | On 07/08/2024 individual # 1 Cellphone was taken by their grandmother because she owns the phone. On 07/03/2024 The CEO reached out to the behavior specialist to have the behavior support plan updated and complete. On 08/08/2024 We had Human Rights Team meeting to revise the plan and seclusion/exclusion room was removed from the plan. The CEO will make sure the individual is involved and informed consent is obtained. [Immediately the CEO, or designee, will schedule a training related to ODP Bulletin 00-21-01 -- Guidance for Human Rights Teams and Human Rights Committees for all executive, management, and supervisory employees. Documentation shall be maintained. DPOC by HDKP, HSLS, on 11/4/2024. ] |
09/20/2024
| Not Implemented |
| 6400.43(b)(3) | Chief Executive Officer (CEO) failed to ensure the safety and protection of the individuals by allowing Individual #1 to be subjected to the prohibited procedure of seclusion, violating Individual #1's right to be treated with dignity and respect, right to privacy of person and possessions, right of access to and security of personal possessions, right to participate in the development and implementation of the individual plan, right to unrestricted and private access to telecommunications, and right to lock the individual's bedroom door. These Individual Rights were modified without the review and approval of the Human Rights Team prior to implementation. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | On 07/08/2024 individual # 1 Cellphone was taken by their grandmother because she owns the phone. On 07/03/2024 The CEO reached out to the behavior specialist to have the behavior support plan updated and complete. On 08/08/2024 We had Human Rights Team meeting to revise the plan and seclusion/exclusion room was removed from the plan. The CEO will make sure the individual is involved and informed consent is obtained. [Immediately the CEO, or designee, will schedule a training related to ODP Bulletin 00-21-01 -- Guidance for Human Rights Teams and Human Rights Committees for all executive, management, and supervisory employees. Documentation shall be maintained. DPOC by HDKP, HSLS, on 11/4/2024. ] |
09/20/2024
| Not Implemented |
| 6400.43(b)(4) | Chief Executive Officer (CEO) failed to ensure compliance with this chapter of regulations by allowing Individual #1 to be subjected to the prohibited procedure of seclusion, violating Individual #1's right to be treated with dignity and respect, right to privacy of person and possessions, right of access to and security of personal possessions, right to participate in the development and implementation of the individual plan, right to unrestricted and private access to telecommunications, and right to lock the individual's bedroom door. These Individual Rights were modified without the review and approval of the Human Rights Team prior to implementation. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. | On 07/08/2024 individual # 1 Cellphone was taken by their grandmother because she owns the phone. On 07/03/2024 The CEO reached out to the behavior specialist to have the behavior support plan updated and complete. On 08/08/2024 We had Human Rights Team meeting to revise the plan and seclusion/exclusion was removed from the plan. The CEO will make sure the individual is involved and informed consent is obtained. [Immediately the CEO, or designee, will schedule a training related to ODP Bulletin 00-21-01 -- Guidance for Human Rights Teams and Human Rights Committees for all executive, management, and supervisory employees. Documentation shall be maintained. DPOC by HDKP, HSLS, on 11/4/2024. ] |
09/20/2024
| Not Implemented |
| 6400.66 | The second-floor of the home was not adequately lit. There was a small, dim light on the ceiling, in the corner, above the stairs. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| On 7/10/2024 Second floor light replaced in Hallway. The light is well lit for safety |
07/13/2024
| Implemented |
| 6400.73(a) | The handrail on the steps leading to the front entrance of the home was loose, moving approximately 1 inch from side to side. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | On 7/11/2024, the handrail on the steps leading to front entrance of the home was repaired. The handrail is secured |
07/13/2024
| Implemented |
| 6400.76(c) | The sofas in the living room and the exclusion room were designed and constructed from plywood by the provider. The sofas had cushions made for outdoor patio furniture. | Furniture shall be comfortable and home-like. | On 8/12/2024, The furniture was replaced, the plywood sofa was modified to look more home like by adding more cushions and pillows also added a recycliner , table, lamp, area rug and various decorations all approved by individual# 1 |
08/12/2024
| Implemented |
| 6400.80(b) | At 10:00 AM there were paper wrappers and several pieces of plywood scattered about the front yard. There was an empty plastic water bottle and paper wrappers behind the bushes at the side of the home adjacent to the driveway. There was also broken glass covering the rear portion of the driveway leading to the rear entrance of the home. The agency vehicle's rear window was busted out, exposing shards of glass on the outer edges of the rear window of the vehicle, posing a laceration hazard. The sidewalk in front of the home, measuring approximately 40 feet in length, had uneven and missing sections of concrete where patches of grass were growing in the walkway, posing a tripping hazard. There was a section of concrete, measuring approximately 6 inches by 8 inches, broken off the left corner of the first step leading to the front entrance of the home. There is a raised cinder block parking pad with a 6 ½ foot drop off, posing a fall hazard behind the driveway at the rear entrance of the home. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | On 7/09/2024 all debris was removed from front and back of home. On 7/21/2024, the uneven section of concrete leading to the front entrance was repaired and the cinder block in the rear of home has been removed. |
07/13/2024
| Implemented |
| 6400.81(j) | Individual #1's bedroom did not have a door. The bedroom door was removed, and a curtain was installed to replace the door. | A bedroom shall have doors at all entrances for privacy. | On 8/10/2024 the CEO ordered a new bedroom door for individual #1 The door was delivered on 8/16/2024 and it has been installed properly for use.
On 8/16/2024 the Program director trained all staff including the CEO on physical site requirements will include the need for bedroom door and the restrictive procedure Process.
The CEO will make sure the Individual #1 bedroom shall have a door in order to ensure privacy
The CEO will be responsible to review all training sign in sheet every quarterly and it will be documented |
08/16/2024
| Implemented |
| 6400.81(k)(5) | Individual #1's bedroom closet did not have clothing racks and shelves. | In bedrooms, each individual shall have the following: Closet or wardrobe space with clothing racks and shelves accessible to the individual. | The program specialist will make sure Individual #1 closet has shelves for their clothing cubes that they may access for storage of any clothes or toiletries. |
07/13/2024
| Implemented |
| 6400.189(a) | Based upon a review of progress notes, staff and individual interviews, the home provides limited outings and documentation to indicate the individual's access to meaningful opportunities and community activities. | (a) Day services such as competitive community-integrated employment, education, vocational training, volunteering, civic-minded and other meaningful opportunities shall be provided to the individual.
| On 8/13/2024 the Program specialist will retrain the staff in the importance of community outings and documentation.
On 8/12/2024 The Program Specialist created a monthly activity calendar with the individual to make sure the individual is engaged in the community and meaningful activities. |
08/13/2024
| Implemented |
| 6400.214(b) | Individual #1's most current physical examination was not in the home. Individual #1's most current assessment was not in the home. Individual #1's most current dental hygiene plan was not in the home. Individual #1's most current behavioral support plan was not in the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| On 7/11/2024 Program Specialist places a copy of Individual #1 physical exam, an assessment, dental hygiene plan and behavioral support plan at the home for staff review and emergency situations |
07/13/2024
| Implemented |
| 6400.32(c) | Individual #1 has lived in a home that has been substantially altered. These alterations have resulted in Individual #1's loss of privacy of person and possessions, as the bedroom and bathroom doors have been removed prior to approval by the Human Rights Team. Individual #1 has had access to their personal cell phone removed for short and long periods of time prior to the approval by the Human Rights Team. Individual #1 has been subjected to seclusion, a prohibited procedure, as evidenced by the "Positive Behavior Support Plan with Restrictive Procedures," dated 1/30/2024, stating "This room will be an exclusion room where [Individual #1] will be escorted to for calming." | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | On 8/16/2024 Individual #1's privacy was restored by replacing the doors on both the bathroom and the bedroom. If individual #1 breaks the doors again, the HRT will meet within 24 hours to discuss his privacy and the risk of injury to himself if the doors are replaced. curtains will be placed on the doors if the team determines it is the least restrictive environment for Individual #1.
On 7/8/2024 Individual # 1 grandmother took his phone so it cannot be removed by staff.
On 7/19/2024 the human right team met to revise the restrictive procedure plan and remove seclusion/exclusion room. [Immediately the CEO, or designee, will schedule a training related to Individual Rights by an outside source. Documentation shall be maintained. DPOC by HDKP, HSLS, on 11/4/2024. ] |
08/13/2024
| Not Implemented |
| 6400.32(d) | The second-floor bathroom toilet did not contain a toilet seat. The toilet also had a plywood encasement constructed over the tank of the toilet with a hole drilled through the top of the encasement for the individual to flush the toilet. Individual #1's bedroom windows and second-floor bathroom had large sections of plywood covering the windows, permitting a small area of light to enter the home from the top portion of the window and a view to the outside of the home through a small peephole. The window in the exclusion room on the first-floor had a large piece of plywood covering it with a small square section cut out (measuring approximately 8 inches by 8 inches) to permit light into the room and a view to the outside of the home. The sofas in the living room and the exclusion room were designed and constructed from plywood by the agency. The sofas cushions were made for outdoor patio furniture. | An individual shall be treated with dignity and respect. | On 8/10/2024 The individual # 1 second floor bathroom toilet seat was replaced. Individual plywood encasement constructed was added to his behavior support plan. 8/10/2024 Another living furniture was purchased for individual # 1. On 8/22/2024 2 of individual # 1 living room window covered with plywood was removed and replaced with plexiglass. One of Individual# 1 bedroom window that was covered with plywood was removed and replaced with plexiglass. Individual # 1-bathroom window was cut in square section to permit light and to view the outside of the home. [Immediately the CEO, or designee, will schedule a training related to Individual Rights by an outside source. Documentation shall be maintained. DPOC by HDKP, HDLS, on 11/4/2024. ] |
08/22/2024
| Not Implemented |
| 6400.32(h) | Individual #1's bathroom door and bedroom door were removed, which does not afford the individual privacy of person and possessions. | An individual has the right to privacy of person and possessions. | On 8/16/2024 The Individual #1's privacy was restored by replacing the doors on both the bathroom and the bedroom. If individual #1 breaks the doors again, the HRT will meet within 24 hours to discuss Individual #1's privacy and the risk of injury to Individual #1 if the doors are replaced. Curtains will be placed on the doors if the team determines it is the least restrictive environment for Individual #1. Individual
#1 will be consulted about the curtains before it happens and if s/he wishes, s/he will pick out a style that suits them. [Immediately the CEO, or designee, will schedule a training related to Individual Rights by an outside source. Documentation shall be maintained. DPOC by HDKP, HSLS, on 11/4/2024. ] |
08/16/2024
| Not Implemented |
| 6400.32(i) | Individual #1's clothes and toiletries are locked in the activity room adjacent to their bedroom. | An individual has the right of access to and security of the individual's possessions. | On 7/11/2024 The Individual #1 clothing and toiletries have been placed in fabric cubes which were placed in the bedroom closet.
On 7/19/2024 HRT discussed and considered it the least restrictive way to continue to give Individual #1 access to clothing and to assure they are safe in room. [Immediately the CEO, or designee, will schedule a training related to Individual Rights by an outside source. Documentation shall be maintained. DPOC by HDKP, HSLS, on 11/4/2024. ] |
08/13/2024
| Not Implemented |
| 6400.32(k) | Individual #1 did not participate in the development and implementation of the individual plan, behavior support plan, and the restrictive procedures plan. | An individual has the right to participate in the development and implementation of the individual plan. | On 8/9/2024 The Individual # 1 participated in planning of strategies and implementation of the PBSP with RPP's and has signed off on the signature page. [Immediately the CEO, or designee, will schedule a training related to Individual Rights by an outside source. Documentation shall be maintained. DPOC by HDKP, HSLS, on 11/4/2024. ] |
08/13/2024
| Not Implemented |
| 6400.32(n) | Based upon individual and staff interviews, the home was removing Individual #1's private cell phone and placing the phone in a locked box to prevent Individual #1 from accessing the phone. | An individual has the right to unrestricted and private access to telecommunications. | On 7/8/2024 The Individual #1 mother removed cellphone from Individual #1 possession. Individual # 1 no longer has the cellphone. [Immediately the CEO, or designee, will schedule a training related to Individual Rights by an outside source. Documentation shall be maintained. DPOC by HDKP, HSLS, on 11/4/2024. ] |
08/13/2024
| Not Implemented |
| 6400.32(r) | Individual #1 does not have a bedroom door and is unable to exercise the right to lock the bedroom door. | An individual has the right to lock the individual's bedroom door. | On 8/16/2024 The Individual #1's bedroom has a door with a lock. [Immediately the CEO, or designee, will schedule a training related to Individual Rights by an outside source. Documentation shall be maintained. DPOC by HDKP, HSLS, on 11/4/2024. ] |
08/16/2024
| Not Implemented |
| 6400.52(c)(5) | Direct Support Professional #1, date of hire 02/16/22, did not receive the safe and appropriate use of behavior supports training for Individual #1. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | On 8/13/2024 The program specialist and behavior specialist trained Direct Support Professional #1and all staff on Behavioral support plan and Crisis Prevention Intervention and they were also trained on safe and appropriate use of behavior supports.
8/13/2024 the program specialist trained the team lead in charge of annual training topics on requirements for annual training. |
08/13/2024
| Implemented |
| 6400.52(c)(6) | Direct Support Professional #1, date of hire 02/16/22, did not receive training on the implementation of Individual #1's individual plan. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | On 8/13/2024 The program specialist and behavior specialist trained Direct Support Professional #1and all staff on Behavioral support plan and Crisis Prevention Intervention and they were also trained on safe and appropriate use of behavior supports.
8/13/2024 the program specialist trained the team lead in charge of annual training topics on requirements for annual training. |
08/13/2024
| Implemented |
| 6400.186 | Based upon a review of progress notes, activity schedules, staff and individual interviews, the home provides limited outings and documentation to indicate the individual's access to meaningful opportunities and community activities. The current Individual Support Plan indicates "it is essential that staff keep the individual active, busy and engaged···plan fun activities throughout the day, especially on weekends. The activities can be at home and/or the community." | The home shall implement the individual plan, including revisions. | On 8/13/2024 the Program specialist retrained the staff on the importance of community outings and documentation. On 8/12/2024 The Program Specialist created a monthly activity calendar with the individual to make sure the individual is engaged in the community and meaningful activities. |
08/13/2024
| Implemented |
| 6400.194(b) | The Human Rights Team records from 01/15/23 and 07/15/23 do not include job titles/positions, or qualifications of those in attendance; therefore, compliance could not be measured. | The human rights team shall include a professional who has a recognized degree, certification or license relating to behavioral support, who did not develop the behavior support component of the individual plan. | The CEO will ensure the human rights team shall include a professional who has a recognized degree, certification or license relating to behavioral support, who did not develop the behavior support component of the individual plan. [Immediately the CEO, or designee, will schedule a training related to ODP Bulletin 00-21-01 -- Guidance for Human Rights Teams and Human Rights Committees for all executive, management, and supervisory employees. Documentation shall be maintained. DPOC by HDKP, HSLS, on 11/4/2024. ] |
09/20/2024
| Not Implemented |
| 6400.195(c)(1) | Individual #1's Behavior Support Plan does not address the specific behavior to be addressed. The Behavior Support Plan merely lists a range of broad behaviors "aggression/destruction, physical violence, verbal aggression, property destruction, self-injurious behaviors, urinating and defecating in vents and on beds, crossing physical boundaries, inappropriate touching, repeated questioning, and waking early." | The behavior support component of the individual plan shall include: The specific behavior to be addressed. | On 7/19/2024 the individual # 1 positive behavior support plan was updated to have specific behavior well defined and examples within the updated positive behavior support plan and restrictive procedure plan. [Immediately the CEO, or designee, will schedule a training related to ODP Bulletin 00-21-01 -- Guidance for Human Rights Teams and Human Rights Committees for all executive, management, and supervisory employees. Documentation shall be maintained. DPOC by HDKP, HSLS, on 11/4/2024. ] |
09/20/2024
| Not Implemented |
| 6400.195(c)(2) | Individual #1's Behavior Support Plan does not include an assessment of the behavior including the suspected reason for the behavior. | The behavior support component of the individual plan shall include: An assessment of the behavior, including the suspected reason for the behavior. | On 7/19/2024 the individual#1 positive behavior support plan and restrictive procedure plan was updated to include an assessment of the behavior, including the suspected reason of the behavior. [Immediately the CEO, or designee, will schedule a training related to ODP Bulletin 00-21-01 -- Guidance for Human Rights Teams and Human Rights Committees for all executive, management, and supervisory employees. Documentation shall be maintained. DPOC by HDKP, HSLS, on 11/4/2024. ] |
09/20/2024
| Not Implemented |
| 6400.195(c)(3) | Individual #1's Behavior Support Plan does not indicate the outcome desired. | The behavior support component of the individual plan shall include: The outcome desired. | On 7/19/2024 individual # 1 positive behavior support plan with Restrictive procedure plan has been revised to indicate the desired outcome. [Immediately the CEO, or designee, will schedule a training related to ODP Bulletin 00-21-01 -- Guidance for Human Rights Teams and Human Rights Committees for all executive, management, and supervisory employees. Documentation shall be maintained. DPOC by HDKP, HSLS, on 11/4/2024. ] |
09/20/2024
| Not Implemented |
| 6400.195(c)(5) | Individual #1's Behavior Support Plan does not include specific methods for facilitating positive behavior changes. General statements in the plan include "use positive and encouraging communication techniques, reinforce healthy boundaries, teach and support feeling identification. Establish a relationship, engage in activities, develop and follow a simple schedule, write and review social stories, and teach replacement skills." | The behavior support component of the individual plan shall include: Methods for facilitating positive behaviors such as changes in the individual's physical and social environment, changes in the individual's routine, improving communications, recognizing and treating physical and behavior health conditions, voluntary physical exercise, redirection, praise, modeling, conflict resolution, de-escalation and teaching skills. | On 7/10/2024 the individual # 1 positive behavior support plan has been updated with more detailed specific methods for facilitating positive behavior changes. [Immediately the CEO, or designee, will schedule a training related to ODP Bulletin 00-21-01 -- Guidance for Human Rights Teams and Human Rights Committees for all executive, management, and supervisory employees. Documentation shall be maintained. DPOC by HDKP, HSLS, on 11/1/2024. ] |
09/20/2024
| Not Implemented |
| 6400.195(c)(8) | Individual #1's Behavior Support Plan does not indicate the name of the staff person responsible for monitoring and documenting progress with the behavior support component of the individual plan. | The behavior support component of the individual plan shall include: The name of the staff person responsible for monitoring and documenting progress with the behavior support component of the individual plan. | On 7/19/2024 the individual #1 positive behavior support plan was updated to indicate the persons responsible for monitoring and documenting progress with the positive behavior support plan. [Immediately the CEO, or designee, will schedule a training related to ODP Bulletin 00-21-01 -- Guidance for Human Rights Teams and Human Rights Committees for all executive, management, and supervisory employees. Documentation shall be maintained. DPOC by HDKP, HSLS, on 11/4/2024. ] |
09/20/2024
| Not Implemented |
| 6400.196(a) | Direct Service Workers who work directly with Individual #1 and implemented the behavior support component of the individual plan were not trained in the use of the specific techniques or procedures that are used. The training document provided is titled "BK ISP training for staff," dated 6/20/2024, conducted by Vivian Branch does not cover the Restrictive Procedures being utilized. Individual #1's "Positive Behavior Support Plan with Restrictive Procedures," dated 1/30/2024, states that "staff may need to physically intervene with a manual restraint or two person escort." There is no documentation of staff persons being trained on manual restraints or two-person escorts. | A staff person who implements or manages a behavior support component of an individual plan shall be trained in the use of the specific techniques or procedures that are used. | On 8/13/2024, behavior specialist & Program director conducted a training on positive behavior support Plan with specific strategies and procedures are explained and modeled with least restricted procedures and updated changes. |
08/13/2024
| Implemented |
| 6400.207(1) | The most current behavior support plan with restrictive procedures, updated last on 06/24/24, indicates (page 9, number 8) the door on the exclusion/calming room remains locked. The lock on the door between the exclusion room was removed at the direction of another oversight agency prior to the department's on-site investigation on 07/09/24. Staff and individual interviews confirm prior to the removal of the exclusion room door lock, Individual #1 was involuntarily confined to the exclusion area when having behavioral episodes. Staff observed the individual from the dining area through plexiglass. | The following procedures are prohibited: Seclusion, defined as involuntary confinement of an individual in a room or area from which the individual is physically prevented or verbally directed from leaving. Seclusion includes physically holding a door shut or using a foot pressure lock. | The Positive behavior support plan with Restrictive procedure plan was revised in July and approved by the Human right team at the meeting on July 19, 2024. The plan no longer has the calming room, or any type of seclusion mentioned. Individual #1 is not confined to any room in the house at any time. [Immediately the CEO, or designee, shall schedule a training for all staff related to Prohibited Procedures, as outlined in the regulations 6400.207(1)-(5), 6400.208(c), 6400.208(d), and 6400.210(a). Documentation shall be maintained. DPOC by HDKP, HSLS, on 11/4/2024.] |
09/20/2024
| Not Implemented |