Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00243329 Renewal 04/24/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.84The facility had an annual onsite fire safety inspection by a fire safety expert on 08/09/22, and then again on 08/30/23. This exceeds the annual requirement.The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.The most current annual fire safety inspection by a fire safety expert, conducted 8/30/23, was discussed between the 2380 supervisor and the Director of Maintenance. Both understood and agreed that the 365 day deadline for the next annual inspection was Thursday, 8/22/2024; therefore, the inspection has to be scheduled by or on the 365 day deadline. The director of maintenance emailed the city inspector to see if he could schedule an inspection date for later in the year (our renewal date) or find out when the city would start scheduling for that time (our renewal date). The supervisor also set an annual calendar reminder for two months in advance of the 365 day deadline to schedule and confirm (if needed) all upcoming annual fire safety inspections. All emails will be on file for reference. ****Inspection is confirmed for on July 29th at 930am with the Deputy Fire Marshal of the Pittsburgh Bureau of Fire. Documentation emailed after online submission to Licensing Supervisor. 05/01/2024 Implemented
2380.91(a)Individual #1 and Individual #2 were instructed 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 facility on 09/02/22 and then again on 09/20/23. This exceeds the annual requirement.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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 facility.The 2380 Supervisor scheduled a Fire Safety Training with the city¿s Public Education Fire Instructor over the phone at the beginning of August 2023 for the only date available in their schedule for training in September 2023. The training was for both clients and staff requirements. The date available was over the 365 day annual deadline for staff and clients to receive training. The supervisor should have scheduled for a date prior to or on the 365 day deadline, and if not able to, then adequately documented the process to show her efforts to get the training scheduled under the 365 day deadline and why she accepted the date documented for the 9/2023 training. The supervisor understands and verbally educated all staff members that Fire Safety Training for clients (and staff) must be by the 365 day/annual date of the previous training. The supervisor understands and verbally educated all staff members that the individual dates the clients receive their annual training must also be double checked to verify each client¿s training date is, in fact, within the 365 day deadline and not effected by the 15-day grace period. The supervisor also understands that if there must be any deviation from conducting a training after the 365 day deadline, it must be documented electronically, in great detail, to show the efforts made to schedule training within the deadline. The supervisor sent an email Friday, April 26, 2024 at 1:07 PM, to the Administrative Specialist, who schedules the fires safety training for the Pittsburgh Bureau of Fire with the subject: Request to have Fire Safety Training at our agency in September (2024). The email was to secure a fire safety training date in the first week of September 2024. The supervisor will continue to correspond with Harper via email until a training date, within or by the 365 annual training date is confirmed. All emails will be on file for reference. ***As of 5/1/24 the supervisor has not yet received an email /call back from the PBF. Supervisor will continue to pursue until date is scheduled. 05/01/2024 Implemented
2380.36(b)Director #1 and Program Specialist #2 were trained in fire safety by a fire safety expert on 09/09/22, and then again on 09/20/23. This exceeds the annual requirement.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The 2390 Supervisor scheduled a Fire Safety Training with the city¿s Public Education Fire Instructor over the phone at the beginning of August 2023 for the only date available in their schedule for training in September 2023. The training was for both clients and staff requirements. The date available was over the 365 day annual deadline for staff and clients to receive training. The supervisor should have scheduled for a date prior to or on the 365 day deadline, and if not able to, then adequately documented the process to show her efforts to get the training scheduled under the 365 day deadline and why she accepted the date documented for the 9/2023 training. The supervisor understands and verbally educated all staff members that Fire Safety Training for clients (and staff) must be by the 365 day/annual date of the previous training. The supervisor understands and verbally educated all staff members that the individual dates the clients receive their annual training must also be double checked to verify each client¿s training date is, in fact, within the 365 day deadline and not effected by the 15-day grace period. The supervisor also understands that if there must be any deviation from conducting a training after the 365 day deadline, it must be documented electronically, in great detail, to show the efforts made to schedule training within the deadline. The supervisor sent an email Friday, April 26, 2024 at 1:07 PM, to the Administrative Specialist, who schedules the fires safety training for the Pittsburgh Bureau of Fire with the subject: Request to have Fire Safety Training at our agency in September (2024). The email was to secure a fire safety training date in the first week of September 2024. The supervisor will continue to correspond with Harper via email until a training date, within or by the 365 annual training date is confirmed. All emails will be on file for reference. ***As of 5/1/24 the supervisor has not yet received an email /call back from the PBF. Supervisor will continue to pursue until date is scheduled. 05/01/2024 Implemented
SIN-00224927 Renewal 05/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1 had a physical examination completed 5/28/2021 and then again 6/29/2022.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.¿ The Licensing Due Date table was reviewed to confirm that the current annual physical exam and upcoming annual physical exam were documented correctly and coincided with the client¿s ISP. ¿ Any discrepancies on the table were corrected by the Program Specialist and the Supervisor of Day Programs. 06/09/2023 Implemented
2380.111(c)(4)Individual #1's physical examinations completed 8/16/2021 and 8/09/2022 did not include a vision and hearing screening. The physician documented not applicable. Individual #4 physical examinations completed 8/12/2021 and 8/15/2022 documented the individual is legally blind and has impaired hearing. There was no documentation of the results of the vision and hearing screenings, nor any follow up with a specialist.The physical examination shall include: Vision and hearing screening, as recommended by the physician.¿ The client physical exam forms were reviewed confirm the vision and hearing sections of the physical exam were filled out entirely. If needed, any copies of the physician-recommended follow-up exams were attached (e.g., a report from their ophthalmologist). ¿ Any discrepancies in this section were corrected/noted by the Program Specialist and/or the Supervisor of Day Programs. PS will contact the individual's Supports Coordinator and request said information be sent over asap. 06/09/2023 Implemented
2380.113(c)(2)Direct Service Worker #1, date of hire 11/08/2021, had an initial Tuberculin skin test completed 11/19/2021.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.¿ Staff records were reviewed by Supervisor to confirm that new hires had a physical exam within 12 months prior to employment of which included a Tuberculin skin test with noted results. 06/09/2023 Implemented
2380.181(a)Individual #1 had an assessment completed 9/27/2021 and then again 10/17/2022.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.¿ The Licensing Due Date table was reviewed to confirm that a client¿s current annual assessment date and the upcoming annual assessment date were documented correctly, as well as the assessment packet due date. ¿ Any discrepancies on the table were corrected by the Program Specialist and the Supervisor of Day Programs. 06/09/2023 Implemented
2380.181(e)(4)Individual #1's assessment completed 10/17/2022 states the individual can be unsupervised for up to 5 minutes. Individual #1's individual support plan, last updated 5/04/2023 states the individual must always be in visual contact of staff and has a tendency to find small bits of paper or crumbs of food and ingest them. Individual #2's assessment completed 12/16/2022 states the individual can be unsupervised up to 5 minutes. Individual #2's individual support plan, last updated 4/25/2023, states the individual is supervised at all times when at his day program, and he is not able to be left unattended for any length of time. Individual #3's assessment completed 9/14/2022 states the individual can be unsupervised for up to 10 minutes. individual #3's individual support plan, last updated 11/21/2022, states the individual is supported at all times while in the facility and in the community [Repeated Violation- 6/15/2022].The assessment must include the following information: The individual¿s need for supervision.¿ The clients¿ latest assessment was reviewed to confirm that all statements regarding an individual¿s supervision during program were consistent with that of the statement in the ISP. ¿ Any discrepancies in this section were corrected by the Program Specialist and an email was sent to notify the individual¿s Supports Coordinator. 06/09/2023 Implemented
2380.181(f)Individual #2 had an assessment completed 12/16/2022, which was sent to the plan team members 12/16/2022, for the individual plan meeting that occurred 1/10/2023. Individual #4 had an assessment completed 2/15/2023, which was sent to the plan team members 2/15/2023, for the individual plan meeting which occurred 3/14/2023.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.¿ The Licensing Due Date table was reviewed to confirm that a client¿s current annual assessment packet due date was documented correctly as 45-30 days out from the annual assessment meeting date. ¿ Any discrepancies on the table were corrected by the Program Specialist and the Supervisor of Day Programs. 06/09/2023 Implemented
SIN-00206608 Renewal 06/14/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(4)Individual #1's 9/30/21 assessment does not address their need for supervision.The assessment must include the following information: The individual's need for supervision.On 6/21/2022, The Supervisor of Day Programs asked the CTP Program Specialist to address Individual #1's 2021 Assessment and the [omitted] information on the individual's need for supervision in the subsection comments of the Safety Skills section. The PS will revise the individual's comments immediately to include the need for supervision as it relates to the individual's daily program activities and personal safety due to physical limitations with vision, hearing, and mobility. Effective 6/22/2022, the PS will review each individual's annual assessment, specifically the Safety Skills section, prior to sending it to the Supports Coordinator for the annual ISP meeting. Should the PS find any information that does not relay the individual's need for supervision clearly, the PS will update the section accordingly and notify the Supervisor of Day Programs that they have also printed out a copy for the individual's binder and sent a request to the SC asking that the revisions are entered into the individual's ISP for discussion during the meeting. All communications on this subject will be printed and kept in the individual's binder. 06/22/2022 Implemented
SIN-00188995 Renewal 06/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.182(c)Individual #1's individual support plan, last updated 6/08/21 does not include the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources, ability to safely use or avoid poisonous materials.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Supervisor of Habilitative Services sent an email to Individual #1's SC on 6/28/2021 asking her to add information related to the danger of heat sources and poisonous materials to his current ISP. See attachment. 06/29/2021 Implemented
SIN-00122336 Renewal 10/04/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)In the cabinet in the laundry area near the bathrooms were three bottles of Clorox disinfectant wipes, three cans of Lysol disinfectant spray and a bottle of Tide laundry detergent each with a label that read to contact poison control or doctor for treatment if ingested which was unlocked and accessible to the individual.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The maintenance person for the agency added a Hasp Lock to the cabinet located in the laundry area. This is a more visible lock that will ensure that the cabinet is always locked. All staff were re-trained on this regulation 53(a) and the new locking system. [Immediately, the CEO or designee shall educate all staff to monitor for poisonous materials and aforementioned locked cabinet throughout the course of their daily duties to ensure all poisonous materials are locked or inaccessible to individuals at all time when not in use. (AS 10/17/17)] 10/12/2017 Implemented
2380.181(a)Individual #1 had an annual assessment completed 2/5/16 and then again 3/7/17. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.Each Program Specialist developed a list of current assessment dates to ensure that all assessments are completed within one year. Each Program Specialist were re-trained in regulation 181(a). All binders that were not apart of recent inspection were reviewed for compliance with this regulation. All were found compliant with this regulation.[At least quarterly for 1 year, the CEO or designee shall review a 25% sample of individual assessments and the aforementioned tracking system to ensure individuals' assessments are completed, timely. Documentation of reviews shall be kept.(AS 10/17/17)] 10/12/2017 Implemented
2380.181(f)The program specialist provided Individual #1's annual assessment completed 3/7/17 to plan team members on 3/8/17 for an annual ISP meeting on 3/7/17. The program specialist provided Individual #2's annual assessment completed 2/13/17 to plan team members on 2/20/17 for an annual ISP meeting on 3/16/17.The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).Each Program Specialist were re-trained on regulation 181(f) to ensure that all annual assessments are completed at least 30 days prior to the ISP meeting. All binders that were not apart of recent inspection were reviewed for compliance with this regulation. All were found to be compliant with this regulation. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure the program specialist provides all individuals' assessment to all plan team members, timely. At least quarterly for 1 year, the CEO shall review a 25% sample of correspondence documentation showing the program specialist provided individual's assessment to all the plan team members, timely. Documentation of reviews shall be kept. (AS 10/17/17)] 10/12/2017 Implemented
SIN-00163227 Renewal 09/17/2019 Compliant - Finalized
SIN-00142947 Renewal 10/03/2018 Compliant - Finalized
SIN-00102325 Initial review 10/24/2016 Compliant - Finalized