| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.21(b) | The Agency commenced operation of Community Home, 167 Howard St. Pittsburgh, PA 15235 for Individual #1 prior to the submission of an application and approval from the Department from 8/3/2023 through 2/26/2024. The Agency commenced operation of Community Home, 7134 Jonathan Place Pittsburgh, PA 15208 for Individual #1 prior to the submission of an application and approval from the Department from 3/4/2024 through 3/6/2024. | The legal entity responsible for a facility or agency subject to licensure under Article X of the Public Welfare Code (62 P. S. § § 1001¿1080) shall submit an application for a certificate of compliance prior to commencing operation of the facility or agency and may not commence operation until notified that a certificate of compliance will be issued. | In order to correct this violation, Family Services United conducted an internal review to identify gaps in the compliance process that led to the commencement of operations without obtaining prior approval. We created a checklist to ensure strict adherence to regulations outlined in Article X of the Public Welfare Code regarding the submission and approval of applications for a certificate of compliance. |
04/17/2024
| Implemented |
| 6400.62(a) | At 10:52AM on 3/6/2024, a spray bottle of Clorox Disinfectant Cleaner with Bleach, an aerosol can of Lysol Disinfectant Spray and multiple containers of All detergent pods were unlocked and accessible in a cabinet in the kitchen of the home. | Poisonous materials shall be kept locked or made inaccessible to individuals. | On 03/07/2024 all poisonous materials were removed from the bathroom, kitchen, and all areas of the home where accessible to individuals. As of 03/07/2024 all poisonous materials are and will be stored in the kitchen cabinet with Cabinet Handle Locks, inaccessible to individuals. Individual #1 assessment and ISP have conflicting information regarding the individual¿s ability to use poisons in a safe manner. The individuals¿ team will discuss and make any revisions to ensure ISP/ assessment is up to date and has accurate information. |
03/07/2024
| Not Implemented |
| 6400.64(a) | At 10:28AM on 3/6/2024, two cardboard boxes containing bags of trash, plastic and other trash were on the floor at the landing of the stairs where you enter the apartment. | Clean and sanitary conditions shall be maintained in the home. | Boxes and packaging plastic were in the home from indiviudal #1 moving into the home. The individual was unpacking throughout the week. On March 6, 2024, all boxes and package material were placed outside of the home. |
04/17/2024
| Not Implemented |
| 6400.70 | At 10:10AM on 3/6/2024, the telephone in the home did not have an operable outside line of service. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| Immediately, the telephone cord was plugged into the modem. During inspection, the telephone cord was plugged into an old, inoperable telephone jack. |
03/06/2024
| Not Implemented |
| 6400.101 | At 10:43AM on 3/6/2024, a metal gate was at the top of the steps in the attic of the home causing an obstructed egress. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Immediately, the metal gate at the top of the steps in the attic of the home was removed. All other homes were assessed for gates in the home. No other homes contained gates. |
04/15/2024
| Not Implemented |
| 6400.110(b) | At 10:57AM on 3/6/2024, the closest smoke detector was 17 feet 7 inches from Individual #1's bedroom door. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | Immediately, the smoke detector was moved 2 feet 7 inches closer to Individual #1's bedroom. All other homes were assessed and found to be in compliance of this regulation. |
04/17/2024
| Implemented |
| 6400.173 | At 10:33AM on 3/6/2024, there was no food in the home. | The quantity of food served for each individual shall meet minimum daily requirements as recommended by the United States Department of Agriculture, unless otherwise recommended in writing by a licensed physician.
| During inspection, Individual #1 was not home due to his refrigerator malfunctioning. The refrigerator was replaced on March 6, 2024. Individual #1 returned home with his food, his medications, and his house chart on March 7, 2024. |
04/17/2024
| Implemented |
| 6400.214(b) | The most recent copies of Individual #1's record documents were not present at the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Immediately, on March 6, 2024, an updated copy of the physical examination was placed in the home. All other charts in the homes were reassessed for physical examinations. The charts with missing physical examination were sited. |
03/06/2024
| Not Implemented |