Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00268468 Renewal 06/10/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individual #1's current assessment, completed on 1/13/25, indicated they are unable to both safely use or avoid poisonous materials. Individual #1's Service Plan, last updated 5/12/25, explained that "[they] are unable to identify poisonous substances and that "These items have to be locked to ensure [their] safety." At 11:27 AM on 6/11/25, in the bedroom hallway closet located directly outside of Individual #1's bedroom, there was an unlocked one quart can of Behr Primer & Paint. At 11:34 AM, underneath the bathroom sink located in the basement, there were two one-pound cans of Clorox Disinfectant Wipes with directions to "call Poison Control for treatment."Poisonous materials shall be kept locked or made inaccessible to individuals. All unsecured poisonous materials were immediately removed and placed in locked storage areas. A walkthrough of the home was conducted to ensure no other hazardous substances were accessible. Staff responsible were retrained on proper storage protocols on 6/11/2025 06/15/2025 Implemented
6400.65At 11:32 AM on 6/11/25, the half-bathroom located in the home's basement did not have a mechanical exhaust fan or an operable window for ventilation.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. CEO purchased and added exhaust fan to bathroom. Picture were sent via email to licensing inspector 06/28/2025 Implemented
6400.68(a)At 11:23 AM on 6/11/25, the hot water temperature at the tub in the bathroom located on the home's main level measured 87.6 degrees Fahrenheit. This is the bathroom in which Individual #1 showers and bathes.A home shall have hot and cold running water under pressure. Hot water heated was adjusted to desired temp of 120 06/28/2025 Implemented
6400.101At 11:39 AM on 6/11/25, the interior door in the basement leading to the attached garage was equipped with a deadbolt lock, requiring a key to disengage if rom the garage side. The attached garage does not have an exterior swing door to prevent entrapment.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Deadbolt lock was removed and replaced with a no locking mechanism lock. Pictures were sent via email to licensing inspector 06/28/2025 Implemented
6400.141(c)(2)On Individual #1's current physical examination, completed 6/20/24, the physician noted, "unable to perform review of health systems and hearing/ vision screenings due to the patient being uncooperative." Therefore, Individual #1's current physical examination did not include a general physical examination. The agency did not provide any documentation regarding follow-up attempts to have a general physical examination completed for Individual #1.The physical examination shall include: A general physical examination. The individuals primary care provider was contacted to clarify whether a general physical exam was completed and request updated documentation. The updated physical exam has been placed in the individual's record. 07/03/2025 Implemented
6400.141(c)(4)Individual #1 had vision and hearing screenings performed on their physical examination, completed 3/19/24, but not on their current physical examination, conducted 4/16/25. Individual #1's content of records did not include any other vision and hearing examinations that had been completed since 3/19/24. [Repeat Violation- 7/9/24 et al]The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The individual was immediately scheduled for both hearing and vison screenings upon identification of oversight. Screenings are scheduled as follows hearing exam 7/14/2025 at 9AM at UPMC Shadyside and Vision scheduled for 7/24/2025 at 8:30am at Blind and vison rehab services. 07/01/2025 Implemented
6400.141(c)(7)Individual #1's date-of-birth is 4/16/93. Their current gynecological examination was completed on 8/2/24. However, Individual #1's content of records did not include documentation of a gynecological examination having been completed in 2023. Therefore, annual compliance could not be measured.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. The individuals 2023 gynecological form was scheduled under a previous program specialist and due to it not being clear but dated as August 2023. The current program specialist called to verify due date in Summer 2024 and the Indvidual was scheduled in August 2024 and received proper documentation. 07/03/2025 Implemented
6400.181(e)(10)Individual #1's current assessment, completed on 1/13/25, did not include a lifetime medical history, as the corresponding field read, "See attached." However, Individual #1's lifetime medical history, rather, was attached to their previous assessment, completed on 1/19/24. The agency did not provide documentation showing that Individual #1's lifetime medical history or most recent physical examination had been sent with their current assessment to plan team members.The assessment must include the following information: A lifetime medical history. The program specialist reviewed the Indvidual's medical records and in fact discovered the lifetime medical records were not attached to most recent assessment. The assessment was updated to include the missing information and reissued to the ISP team. 07/03/2025 Implemented
6400.181(e)(11)Individual #1's current assessment, completed on 1/13/25, did not include an applicable psychological evaluation, as the corresponding field read, "See attached." However, Individual #1's psychological evaluation, rather, was attached to their previous assessment, completed on 1/19/24. The agency did not provide documentation showing that Individual #1's psychological evaluation had been sent with their current assessment to plan team members.The assessment must include the following information: Psychological evaluations, if applicable. The file was reviewed and confirmed to be missing the psychological evaluation from the 2025 assessment. this information has been updated to reflect the 2025 assessment to have the psych evaluation attached. And the psych eval was sent to the plan team on 7/3/2025 07/03/2025 Implemented
6400.24According to the written fire drill record submitted from 1/11/25 to 5/8/25, during the drill conducted on 3/16/25, the vertical-opening garage door was utilized as an exit route. However, this type of vertical-opening door is not recognized as a fire safety exit in accordance with the PA Construction Code under 34 PA Code 50.24(a) which reads: a) Doors used in connection with exits, exit discharge, or exit access shall be of substantial construction, installed in a workmanlike manner, fitted with reliable hardware, and shall be of the side-hinged, vertical hung, swinging type. [Repeat Violation- 7/9/24 et al]The home shall comply with applicable Federal and State statutes and regulations and local ordinances.The use of the garage door as a fire exit was immediately discontinued. A compliant primary and secondary emergency exit route was reviewed and re-established for the home. A corrective fire drill was conducted on 6/28/2025. Documentation of the corrected drill was completed and filed. 06/28/2025 Implemented
6400.32(r)(1)Individual #1 signed a form on 1/14/25, indicating that they wanted to have their bedroom door equipped with a lock. At 11:20 AM on 6/11/25, Individual #1's bedroom door was equipped with a privacy lock with a turn latch on the interior and a straight-edge, thumbnail access point on the exterior. This locking assembly does not provide Individual #1 with a designated mechanism in which to lock and unlock their bedroom door independently.Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.An individual has the right to lock the individual's bedroom door. All individuals locks were updated with key and given to individual. Picture was sent via email to licensing inspector. 06/28/2025 Implemented
6400.32(r)(4)At 11:20 AM on 6/11/25, Individual #1's bedroom door was equipped with a privacy lock with a turn latch on the interior and a straight-edge, thumbnail access point on the exterior. This bedroom door lock mechanism does not allow easy and immediate access by the individual and staff persons in the event of an emergency.The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency.An individual has the right to lock the individual's bedroom door. All individuals locks were updated with key and given to individual. Picture was sent via email to licensing inspector. This individual door does not have a lock as she is unable to use a key lock Independently. 06/28/2025 Implemented
6400.52(c)(1)Direct Service Provider #1 did not complete annual training for the 2024 calendar year in the following required content areas: individual choice and supporting individuals to develop and maintain relationships, as their record did not include training-source content or certificates of completion addressing these required topics.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The individual has completed a targeted training make up plan totaling twenty-four hours between 7-1 25-7/3/25. Documentation of completed training has been added to the personnel file. 07/03/2025 Implemented
6400.52(c)(5)Direct Service Provider #1 did not complete annual training for the 2024 calendar year in the following required content area: individual-specific reviews of the safe and appropriate use of behavior support plans.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.The missed BSP training was completed on 6/12/25 and documentation has been added to the staff personnel file. A review of all staff BSP training records was conducted to verify compliance and identify any additional gaps. 07/03/2025 Implemented
6400.163(d)At 11:12 AM on 6/11/25, unlocked and accessible in the home's first aid kit, there were the following: two packets of Aspirin, each containing two 325 MG tablets; two packets of Acetaminophen, each containing two 500 MG tablets; and two packets of Ibuprofen, each containing two 500 MG tablets.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.Medications were removed from first aid kit and removed from the site. 06/28/2025 Implemented
6400.165(b)On 6/11/25, Individual #1's following prescribed medication, Sodium Flour Gel 1.1%--For Prevident 5000 Dry Mouth---Apply to toothbrush and use to brush teeth every night at bedtime for oral health (Do not rinse, eat, drink for at least 30 minutes after use.)---was listed on Individual #1's June 2025 Medication Administration Record but was not at the home. [Repeat Violation- 7/9/24 et al]A prescription order shall be kept current.The program specialist immediately investigated the discrepancy. A call was made to the pharmacy to verify that the medication was missed in delivery. The medication was delivered on the night of 6/11/2025 06/11/2025 Implemented
6400.165(g)Individual #1 is prescribed medication to treat symptoms of a psychiatric illness. Individual #1 had reviews of those medications conducted by a licensed physician on 9/9/24, then again on 12/27/24, and subsequently thereafter on 4/14/25. [Repeat Violation- 7/9/24 et al]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.All Psychiatric reviews will be scheduled to be completed by psychiatric provider. The Psychiatric medication review appointment summary form has been updated to reflect the reasons for prescribing the medication as well as the need to continue the medication and necessary dosage. Files are being audited to ensure compliance and corrections made where necessary. 07/01/2025 Implemented