Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00293518 Renewal 07/21/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101On 7/21/2026 at 12:57 PM there was a turn lock on the exterior door, leading from the staff office to the garage, a thumb nail turn mechanism on the doorknob on the garage-side of the door, and no egress from the garage to the outside of the home. This causes a blocked egress and potential entrapment risk. On 7/21/2026 at 12:59 PM there was a turn lock on the exterior door, leading from the basement to the staff office, a thumb nail turn mechanism on the doorknob on the staff office-side of the door, and no egress from the staff office to the outside of the home. This causes a blocked egress and potential entrapment risk.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. On July 22, 2026, CEO & Manager took off the turn lock door knobs that were in the garage and office. These were replaced with new door knobs that do not have locks on them. This provides safe exit in the event of an emergency for Individuals and Staff. 07/22/2026 Implemented
6400.216(a)On 7/21/2026 at 12:59 PM there was a turn lock on the exterior door, leading from the basement to the staff office, which allowed access into the staff office. The following records were able to be accessed in the staff office, including but not limited to: Individual #1's progress notes from June 2021 to June 2026, Individual #1's daily monitoring notes from June 2021 to December 2021, Individual #2's progress notes from January 2024 to June 2026, and individuals' medication administration records from 2020 to 2025. An individual's records shall be kept locked when unattended. On 7/25/2026, Provider brought in a new large locking filing cabinet. All documents with Individual #1, #2, & others was filed into the new locking filing cabinet. These documents included progress notes, med admin records, and other documents with personal information on them. 07/25/2026 Implemented
6400.32(r)(1)On 7/21/2026 at 1:36 PM Individual #1 had a turn lock on the interior bedroom door and a thumb nail turn lock mechanism on the exterior of their bedroom door. This does not provide the individual with a unique locking mechanism to lock and unlock the door.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.On 7/31/2026, Provider changed Individual #1 door knob to a locked/key entry door knob. Individual was given a key. A labeled, spare key was put in the staff office for use in the event the Individual loses his key, or in the case of an emergency. In addition, the other unoccupied bedroom door knob was also changed to a keyed locked door knob. 07/31/2026 Implemented
6400.52(a)(3)Program Specialist #2 completed 20.5 annual training hours in the annual training year, dated 7/01/2025 through and including 6/30/2026.The following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists.On 8/16/2026, a new training syllabus was created for all existing staff, except for new hires. This syllabus has a minimum of 24 hours annual training hours on it that must be maintained in order to keep compliance and employed. The same day, Program Specialist had meeting with CEO & Manager to be sure that all sides are aware of the issue to prevent it from happening again. 08/16/2026 Implemented
6400.163(a)On 7/21/2026 at 1:33 PM a bottle of Clobetasol Propionate topical solution 0.05%, a bottle of Extra Strength Magnesium 400mg soft gels dietary supplement, a bottle of Fish Oil 1200mg soft gels dietary supplement, and a bottle of Mega Men Essentials One Daily Multi dietary supplement caplets were observed in Individual #1's bedroom, without labels issued by a pharmacy.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.On 7/21/2026, the extra Strength Magnesium 400mg soft gels, Fish Oil 1200mg soft gels, and Mega Men Essentials One Daily Multi supplements that were observed by inspector in Individual #1's room were disposed of by CEO with Individual #1's consent. 07/21/2026 Implemented
6400.163(d)Individual #1 is assessed to be unable to self-administer medications. On 7/21/2026 at 1:19 PM there were two first aid kits containing the following medications that were unlocked and accessible to Individual #1: Five packets, each containing 2 tablets, of Non-Aspirin Acetaminophen 325mg, Aspirin 325mg, and Antacid 420mg. On 7/21/2026 at 1:31 PM there was a first aid kit in the second-floor hallway closet, to the right of the bathroom, containing the following medications that were unlocked and accessible to Individual #1: Four packets, each containing 2 tablets, of Non-Aspirin Acetaminophen 325mg, three packets, each containing 2 tablets, of Aspirin 325mg, and five packets, each containing 2 tablets, of Antacid 420mg. At 1:26 PM Individual #1's Hydrocortisone ointment 2.5%, prescribed 8/04/2025, with instructions to "Apply topically to affected areas only as needed 2 times a day for 2 weeks. Discontinue when clear." was observed in the bathroom cabinet, unlocked and accessible. At 1:26 PM Individual #1's Ketoconazole Cream 2%, prescribed 2/04/2026, with instructions to "Apply on rash on face and scalp 2 times a day." was observed in the bathroom cabinet, unlocked and accessible. On 5/12/2026 Individual #1 was prescribed 2 tablets of Fluconazole 200mg Tablet, with instructions to "Take 1 tablet by mouth now and then take another tablet in 7 days." On 7/21/2026 at 1:33 PM the medication was observed in Individual #1's bedroom with 1 tablet remaining in the bottle, unlocked and accessible. At 1:33 PM a bottle of Clobetasol Propionate topical solution 0.05%, a bottle of Extra Strength Magnesium 400mg soft gels dietary supplement, a bottle of Fish Oil 1200mg soft gels dietary supplement, and a bottle of Mega Men Essentials One Daily Multi dietary supplement caplets were observed in Individual #1's bedroom, unlocked and accessible.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.On July 21st, 2026, Provider removed Aspirin, Non- Aspirin, & Antacid from First Aid Kits and locked up with Individual 1's medications. Also Individual #1's Hydrocortisone ointment, Ketoconazole Cream 2%, Fluconazole 200mg Tablet, and Clobetasol Propionate topical solution 0.05% that were found in their room by Inspector were locked away with their other medications, pending approval and reason why they had them from this new Dermatologist. At time of the inspection, Individual #1 was called on the phone to find out how and where they was seeing a Dermatologist. Individual stated that he would go to those appointments on their own free time or with his CPS provider. Provider had no knowledge of these appointments or medications. Individual #1 supplements were locked away as well, and later discarded once seeing the expiration date on them. 07/22/2026 Implemented
6400.163(h)On 7/21/2026 at 1:31 PM there was a first aid kit in the second-floor hallway closet, to the right of the bathroom, containing the following expired medications: four packets, each containing 2 tablets, of Non-Aspirin Acetaminophen 325mg which expired in January 2025, three packets, each containing 2 tablets, of Aspirin 325mg which expired in September 2023, and five packets, each containing 2 tablets, of Antacid 420mg which expired May 2024. On 2/04/2026 Individual #1's was prescribed Ketoconazole 2% shampoo, with instructions to "Apply topically daily. Use to wash hair.", which was discontinued 5/12/2026 when the prescription order changed to pro re nata. On 7/21/2026 at 1:25 PM the medication was observed in the shower. At 1:26 PM Individual #1's Hydrocortisone ointment 2.5%, prescribed 8/04/2025, with instructions to "Apply topically to affected areas only as needed 2 times a day for 2 weeks. Discontinue when clear." was observed in the bathroom cabinet. At 1:33 PM the following expired medications were observed in Individual #1's bedroom: a bottle of Extra Strength Magnesium 400mg soft gels dietary supplement which expired October 2025, a bottle of Fish Oil 1200mg soft gels dietary supplement which expired May 2024, and a bottle of Mega Men Essentials One Daily Multi dietary supplement caplets which expired in May 2024.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.On 7/22/2026 Provider disposed of following First Aid Kit expired medications: four packets of Non-Aspirin Acetaminophen 325mg, three packets of Aspirin 325mg, and five packets of Antacid 420mg. On 7/22/2026 Individual #1's prescribed Ketoconazole 2% shampoo and Hydrocortisone ointment 2.5% that were expired were disposed of. Also the same day, Individual #1's unprescribed suppletments Magnesium 400mg soft gels, Fish Oil 1200mg soft gels, and Mega Men Essentials One Daily caplets were expired and disposed of. These expired medications were taken to CVS in Penn Hills for proper discarding. 07/22/2026 Implemented
6400.165(c)On 5/12/2026 Individual #1 was prescribed Ketoconazole 2% shampoo, with instructions to "Apply topically twice per week for 8 weeks, then as needed. On 7/21/2026 the medication was not on the July 2026 medication administration record, and administration of the medication was not being documented.A prescription medication shall be administered as prescribed.On July 21, 2026, while inspectors were there, Individual #1's prescribed Ketoconazole Shampoo was locked away with their other medications. Also at this time Individual #1 was contacted by Staff to find out when and how they got this medication. Individual stated they would see and schedule these appts with Dermatologist on own free time or with CPS. Individual gave staff the Doctors information. Staff called and notified Dr office to call Provider for future scheduling appointments and prescribing medications as Individual cannot self administer meds. Dr office agreed. Dr office notified us at this time to discontinue any meds they prescribed until Individual #1's next appointment on August 28th, at 11:40am. This appointment is on calendar for staff to take individual. 07/22/2026 Implemented
6400.166(a)(4)On 5/12/2026 Individual #1 was prescribed Ketoconazole 2% shampoo, with instructions to "Apply topically twice per week for 8 weeks, then as needed. On 7/21/2026 Individual #1's July 2026 medication administration record did not include the name of the medication. On 2/04/2026 Individual #1 was prescribed Ketoconazole Cream 2% with instructions to "Apply on rash on face and scalp 2 times a day." On 7/21/2026 Individual #1's July 2026 medication administration record did not include the name of the medication. On 7/21/2026 at 1:33 PM Clobetasol Propionate topical solution 0.05% was observed in Individual #1's bedroom. Individual #1's July 2026 medication administration record did not include the name of the medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.On July 21, 2026, while inspectors were there, it was noticed that Individual #1 had multiple medications without a name of medication on it. These medications were also not on the MAR. These prescribed meds were Ketoconazole Shampoo, Ketoconazole Cream, and Clobetasol Propionate topical solution was locked away with their other medications. Also at this time Individual #1 was contacted by Staff to find out when and how they got this medication. Individual stated they would see and schedule these appts with Dermatologist on own free time or with CPS. Individual gave staff the Doctors information. Staff called and notified Dr office to call Provider for future scheduling appointments and prescribing medications as Individual cannot self administer meds. Dr office agreed. Dr office notified us at this time to discontinue any meds they prescribed until Individual #1's next appointment on August 28th, at 11:40am. This appointment is on calendar for staff to take individual. 07/21/2026 Implemented
6400.166(a)(5)On 5/12/2026 Individual #1 was prescribed Ketoconazole 2% shampoo, with instructions to "Apply topically twice per week for 8 weeks, then as needed. On 7/21/2026 Individual #1's July 2026 medication administration record did not include strength of the medication. On 2/04/2026 Individual #1 was prescribed Ketoconazole Cream 2% with instructions to "Apply on rash on face and scalp 2 times a day." On 7/21/2026 Individual #1's July 2026 medication administration record did not include strength of the medication. On 7/21/2026 at 1:33 PM Clobetasol Propionate topical solution 0.05% was observed in Individual #1's bedroom. Individual #1's July 2026 medication administration record did not include strength of the medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.On July 21, 2026, while inspectors were there, it was noticed that Individual #1 had multiple medications without the strength of medication on the physical bottles as well as the MAR. These prescribed meds were Ketoconazole Shampoo, Ketoconazole Cream, and Clobetasol Propionate topical solution was locked away with their other medications. Also at this time Individual #1 was contacted by Staff to find out when and how they got this medication. Individual stated they would see and schedule these appts with Dermatologist on own free time or with CPS. Individual gave staff the Doctors information. Staff called and notified Dr office to call Provider for future scheduling appointments and prescribing medications as Individual cannot self administer meds. Dr office agreed. Dr office notified us at this time to discontinue any meds they prescribed until Individual #1's next appointment on August 28th, at 11:40am. This appointment is on calendar for staff to take individual. 07/21/2026 Implemented
6400.166(a)(7)On 5/12/2026 Individual #1 was prescribed Ketoconazole 2% shampoo, with instructions to "Apply topically twice per week for 8 weeks, then as needed. On 7/21/2026 Individual #1's July 2026 medication administration record did not include dose of the medication. On 2/04/2026 Individual #1 was prescribed Ketoconazole Cream 2% with instructions to "Apply on rash on face and scalp 2 times a day." On 7/21/2026 Individual #1's July 2026 medication administration record did not include dose of the medication. On 7/21/2026 at 1:33 PM Clobetasol Propionate topical solution 0.05% was observed in Individual #1's bedroom. 2026 Individual #1's July 2026 medication administration record did not include dose of the medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.On July 21, 2026, while inspectors were there, it was noticed that Individual #1 had multiple medications without the dose of medication on the physical bottles as well as the MAR. These prescribed meds were Ketoconazole Shampoo, Ketoconazole Cream, and Clobetasol Propionate topical solution was locked away with their other medications. Also at this time Individual #1 was contacted by Staff to find out when and how they got this medication. Individual stated they would see and schedule these appts with Dermatologist on own free time or with CPS. Individual gave staff the Doctors information. Staff called and notified Dr office to call Provider for future scheduling appointments and prescribing medications as Individual cannot self administer meds. Dr office agreed. Dr office notified us at this time to discontinue any meds they prescribed until Individual #1's next appointment on August 28th, at 11:40am. This appointment is on calendar for staff to take individual. 07/21/2026 Implemented
6400.166(a)(8)On 5/12/2026 Individual #1 was prescribed Ketoconazole 2% shampoo, with instructions to "Apply topically twice per week for 8 weeks, then as needed. On 7/21/2026 Individual #1's July 2026 medication administration record did not include route of administration. On 2/04/2026 Individual #1 was prescribed Ketoconazole Cream 2% with instructions to "Apply on rash on face and scalp 2 times a day." On 7/21/2026 Individual #1's July 2026 medication administration record did not include route of administration. On 7/21/2026 at 1:33 PM Clobetasol Propionate topical solution 0.05% was observed in Individual #1's bedroom. Individual #1's July 2026 medication administration record did not include route of administration.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.On July 21, 2026, while inspectors were there, it was noticed that Individual #1 had multiple medications without the proper route of administration on the physical bottles as well as the MAR. These prescribed meds were Ketoconazole Shampoo, Ketoconazole Cream, and Clobetasol Propionate topical solution was locked away with their other medications. Also at this time Individual #1 was contacted by Staff to find out when and how they got this medication. Individual stated they would see and schedule these appts with Dermatologist on own free time or with CPS. Individual gave staff the Doctors information. Staff called and notified Dr office to call Provider for future scheduling appointments and prescribing medications as Individual cannot self administer meds. Dr office agreed. Dr office notified us at this time to discontinue any meds they prescribed until Individual #1's next appointment on August 28th, at 11:40am. This appointment is on calendar for staff to take individual. 07/21/2026 Implemented
6400.166(a)(9)On 5/12/2026 Individual #1 was prescribed Ketoconazole 2% shampoo, with instructions to "Apply topically twice per week for 8 weeks, then as needed. On 7/21/2026 Individual #1's July 2026 medication administration record did not include frequency of administration. On 2/04/2026 Individual #1 was prescribed Ketoconazole Cream 2% with instructions to "Apply on rash on face and scalp 2 times a day." On 7/21/2026 Individual #1's July 2026 medication administration record did not include frequency of administration. On 7/21/2026 at 1:33 PM Clobetasol Propionate topical solution 0.05% was observed in Individual #1's bedroom. 2026 Individual #1's July 2026 medication administration record did not include frequency of administration.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.On July 21, 2026, while inspectors were there, it was noticed that Individual #1 had multiple medications without the frequency of administration on the physical bottles or the MAR. These prescribed meds were Ketoconazole Shampoo, Ketoconazole Cream, and Clobetasol Propionate topical solution was locked away with their other medications. Also at this time Individual #1 was contacted by Staff to find out when and how they got this medication. Individual stated they would see and schedule these appts with Dermatologist on own free time or with CPS. Individual gave staff the Doctors information. Staff called and notified Dr office to call Provider for future scheduling appointments and prescribing medications as Individual cannot self administer meds. Dr office agreed. Dr office notified us at this time to discontinue any meds they prescribed until Individual #1's next appointment on August 28th, at 11:40am. This appointment is on calendar for staff to take individual. 07/21/2026 Implemented
6400.166(a)(11)On 5/12/2026 Individual #1 was prescribed Ketoconazole 2% shampoo, with instructions to "Apply topically twice per week for 8 weeks, then as needed. On 7/21/2026 Individual #1's July 2026 medication administration record did not include diagnosis or purpose for the medication. On 2/04/2026 Individual #1 was prescribed Ketoconazole Cream 2% with instructions to "Apply on rash on face and scalp 2 times a day." On 7/21/2026 Individual #1's July 2026 medication administration record did not include diagnosis or purpose for the medication. On 7/21/2026 at 1:33 PM Clobetasol Propionate topical solution 0.05% was observed in Individual #1's bedroom. Individual #1's July 2026 medication administration record did not include diagnosis or purpose for the medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.On July 21, 2026, while inspectors were there, it was noticed that Individual #1 had multiple medications without the diagnosis on the physical bottles or the MAR. These prescribed meds were Ketoconazole Shampoo, Ketoconazole Cream, and Clobetasol Propionate topical solution was locked away with their other medications. Also at this time Individual #1 was contacted by Staff to find out when and how they got this medication. Individual stated they would see and schedule these appts with Dermatologist on own free time or with CPS. Individual gave staff the Doctors information. Staff called and notified Dr office to call Provider for future scheduling appointments and prescribing medications as Individual cannot self administer meds. Dr office agreed. Dr office notified us at this time to discontinue any meds they prescribed until Individual #1's next appointment on August 28th, at 11:40am. This appointment is on calendar for staff to take individual. 07/21/2026 Implemented
6400.167(a)(1)On 5/12/2026 Individual #1 was prescribed 2 tablets of Fluconazole 200mg Tablet, with instructions to "Take 1 tablet by mouth now and then take another tablet in 7 days." On 7/21/2026 at 1:33 PM the medication was observed in Individual #1's bedroom with 1 tablet remaining in the bottle.Medication errors include the following: Failure to administer a medication.On July 21, 2026, while inspectors were there, it was noticed that Individual #1 had the medication Fluconazole, and that Individual had missed an administration of the medication . This prescribed med was locked away with their other medications immediately. Also at this time Individual #1 was contacted by Staff to find out when and how they got this medication. Individual stated they would see and schedule these appts with Dermatologist on own free time or with CPS. Individual gave staff the Doctors information. Staff called and notified Dr office to call Provider for future scheduling appointments and prescribing medications as Individual cannot self administer meds. Dr office agreed. Dr office notified us at this time to discontinue any meds they prescribed until Individual #1's next appointment on August 28th, at 11:40am. This appointment is on calendar for staff to take individual. 07/21/2026 Implemented
6400.182(c)Individual #1's individual support plan, last updated 6/12/2026, documents "[Individual #1] requires support from residential staff with the following: managing money, paying bills on time, budgeting for and purchasing food. Individual #1's behavior support plan, last updated 9/24/2025, documents "On a weekly basis [Individual #1] will work with residential staff to budget money to pay bills 100% of the time, over a 3-month period. Individual #1's assessment, completed 8/07/2025, documents staff assist [Individual #1] with in-person bank transactions to help stay on track with budgeting. [Individual #1] has a rep payee and receives checks in the mail on a weekly basis. Individual is able to make purchases independently. Due to [Individual #1's] addiction to gambling and soliciting sex, individual has agreed that staff/management only provide so much money at a time. Staff will take individual to reload bus pass, as in the past when given the money to complete this task, individual would be irresponsible and not obtain bus pass. [The individual] has a lengthy history of going to the casino or using the slot machines in corner stores to gamble and spending all of the allowance in just a couple of hours. On 7/21/2026 Chief Executive Officer #1 advised Individual #1 is independent in spending money provided by the representative payee, and the agency is not assisting the individual with managing finances nor keep a financial ledger to assist with budgeting. Individual #1's assessment, completed 8/07/2025, documents the individual requires staff who has been certified to pass medication to ensure medication is taken daily, and that the individual is taking the correct dose. Individual #1's individual support plan, last updated 6/12/2026, documents "[Individual #1] generally is independent and self-administration but requires occasional verbal reminders to take medication at the correct time, to obtain refills, and to schedule and attend medical appointments where medication needs will be reviewed. If individual is prescribed a new medication that is not an oral capsule or tablet, [Individual #1] will need assistance in administering medication until individual is familiar with the method."The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.On 8/21/2026, CEO revised Individual #1's annual assessment. These changes were submitted to Individual's SC & BSC on 8/22/2026. The changes addressed the change that occurred in April 2026. It revolves around their current state of the Individuals ability to handle money and who s/he has put in place to help them with their financial struggles. 08/22/2026 Implemented
SIN-00274532 Renewal 09/26/2025 Compliant - Finalized