Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00247227 Renewal 07/01/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)The most recent fire drill held during sleep hours was on 7/6/23.A fire drill shall be held during sleeping hours at least every 6 months. The House Manager and Program Specialist will be retrained on 6400.1129e) regulation. A fire drill should be conducted during sleep hours every 6 months. The asleep fire drill will be conducted by the house manager between the hours of 11:00 PM and 7:00 AM every six months. The Program Specialist will assure the House Manager is in compliance by reviewing and scheduling the asleep fire drills. 07/12/2024 Implemented
6400.112(f)The front door was used to exit route every month from 7/25/23 through 6/6/24.Alternate exit routes shall be used during fire drills. The Program Specialist and House Manager will be retrained on 6400.112(f), Alternate exit routes shall be used during fire drills. The Program Specialist will evaluate the individual each time the secondary exit is used to assure safe ambulation down basement steps. The Program Specialist will schedule the secondary exit fire drill and will be present for the fire drill. 07/12/2024 Implemented
SIN-00231436 Unannounced Monitoring 08/29/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.45(e)On 8/19/23 Direct Services Worker (DSW) #1 left individual #1 unsupervised in a vehicle outside of DSW #1's personal residence for a period of time solely for the convenience of DSW #1.An individual may not be left unsupervised solely for the convenience of the home or the direct service worker.On 8/24/2023 DSW#1 was interviewed by Program Specialist ( FM ) on the events of 8/19/2023. DSW#1 stated he stopped at his residence and left the individual unattended in the agency vehicle while getting his phone charger. Program Specialist at this terminated the employment of DSW#1 for violation of company policy. On 9/28/2023 - All staff operating agency vehicles were retrained on the Transportation/Vehicle Policy. 09/26/2023 Implemented
6400.186Individual #1's Individual Support Plan, last updated 7/28/23, states that "[Individual #1] should be within line of sight of staff at all times." On 8/23/23 the awake overnight staff did not maintain line of sight supervision with Individual #1 by allowing them to close their bedroom door. Individual #1 exited the home through a bedroom window.The home shall implement the individual plan, including revisions.On 9/18/2023 staff was re-trained on Individual #1's ISP and the definition of "Line of Site". The staff will maintain "Line of Site" during awake hours as well as asleep hours. 09/26/2023 Implemented
6400.195(a)On 8/26/23 the agency removed the bedroom door of Individual #1 as part of a restrictive procedure. The agency failed to ensure that the restrictive procedure was written and approved by the human rights team prior to use of the restrictive procedure.For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures.On 8/29/2023 the door of individual #1's bedroom was put back on. HNA with the direction of Beaver County removed the door on 8/26/2023 with impression the removal of the door would not be restrictive due to the ISP stating individual #1 must in in "Line of Site" thus forfeiting privacy behind closed doors. 09/27/2023 Implemented
SIN-00228003 Renewal 07/20/2023 Compliant - Finalized