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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.101 | On 9/17/2025 at approximately 12:21 PM there was a thumb turn lock on the basement-side of the door, leading from the basement to the garage, and no exit from the garage to the outside of the home. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The Facilities Manager changed the key hole lock on a basement door to the garage upon discovery on 9/17/25. The Facilities Manager and assistant rechecked all remaining doors within Emmaus Community of Pittsburgh by 9/30/25, and found them all to be within compliance. |
10/11/2025
| Implemented |
| 6400.144 | Individual #1's individual support plan, last updated 9/04/2025, states "as per a swallow study completed on 2/20/2024, recommended soft solid foods and thin liquid diet with a frequent use of liquid wash 1-3 bites of food." Individual #1's appointment form completed 2/20/2024, states the individual will be prescribed a soft diet due to difficulty swallowing a cracker. He did not have any difficulty swallowing liquid." On 9/17/2025 at approximately 11:58 AM Program Specialist #1 stated the staff are following a low cholesterol, low sodium diet and are cutting his food due to his declining health status. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| This individual was having acute pain in his neck area due to believed arthritis. During this time Emmaus was attempting to feed the individual as much as possible, due to low weight, and his refusal for nutrition. The family was also in agreement. The Program Specialist was aware of the individual's dietary recommendations. The 2024 dietary recommendations stand as the accurate guiding information for soft foods. This is more due to his lack of teeth, than it is pertaining to swallowing issues. |
10/11/2025
| Implemented |
| 6400.182(c) | Individual #1's individual support plan, last updated 9/04/2025, states staff need to check and assist the individuals water temperature. Individual #1's assessment completed 6/06/2025, states the individual can independently adjust water temperature. Individual #1's individual support plan, last updated 9/04/2025, states during awake hours [the individual] can be left unsupervised for 1 hour at a time throughout the day as long as staff is in the home. [The individual] will seek help as needed by approaching staff but not by phone." Individual #1's assessment completed 6/06/2025, states he can be alone in the home for up to 1 hour. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Due to acute health issues with this individual, needs and care were changing frequently. On 10/2/25, this individual changed to a Needs Group 5. Meetings were held throughout the month of August 2025 into September 2025. Although, there were differences between the Assessment and the ISP, all the staff provided the care necessary for this person's safety, health and wellbeing. This individual is able to have alone time with staff within the home, for example if they are in the office and the resident is in the living room or their bedroom. They also are able to have alone time for instances when the staff are going to the bathroom and /or taking out the garbage, talking on the phone, etc. This person does not require in-line of sight at all times. This change was discussed verbally with his SC and will be placed into the ISP document for more clarity. This individual is able to regulate his own water temperatures in the shower and at sinks. This will be clarified in the ISP via the SC. The Program Specialist, RA, Assistant Director of IDD and Director of IDD will ensure that the ISP and Assessment will match ASAP. |
10/11/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(e) | A fire drill was held during sleeping hours on 10/06/23, and then again on 05/17/24. This exceeds the at least every 6-months requirement. | A fire drill shall be held during sleeping hours at least every 6 months. | On 10/4/24 a meeting was held with the Director and Assistant Director of IDD Services, and Residential Advisors where the violation was explained. The RA that works at this particular home was also present at the Exit meeting on 9/26/24, therefore, she is aware of this regulation. A new Unannounced Fire Drill form was created on 10/3/24. This new form was distributed to the RA's today, 10/4/24. On this form a line was created for person Reviewed signature along with the date. The RA's will complete overnight drills every 6 months regularly, per year. Unannounced overnight fire drills will be done by the 15th of the months designated by the RA/ Director of IDD and Assistant Director of IDD. This particular drill will be delivered shortly thereafter to the main office, so that it can be approved. If not approved by the Director of Assistant Director of IDD, it will be re-done by the corresponding RA of that location, for correct completion. |
10/04/2024
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.166(a)(11) | The medication administration record for November 2021 for Individual #1 did not list the diagnosis or purpose for any prescribed medications. | 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. | Immediately on 11/23/21, the Emmaus Healthcare and Quality Management Coordinator made the corrections to the current November MAR based on the recommendation from Licensing Representative. This was also so indicated onto the MAR for December 2021 as well. Quality Management Coordinator also talked to our Pharmacy, PDC on 12/3/21. Quality Management Coordinator is retrieving new medication for January on 12/27/21 and will reassure that all MARs have the corresponding diagnoses for all medications. Pharmacy also has a menu option when calling for MAR Corrections. This was discussed with all Emmaus RA's on 12/9/21, at a Program Meeting. All RA's are aware to communicate to Physicians about indicating the diagnosis onto prescription information for the corresponding medication label in the future. |
12/23/2021
| Implemented |
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