Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00269238 Renewal 07/08/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66There was not a light outside of the bedroom hall egress.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Maintenance was immediately contacted upon discovery ,and an external light was installed outside of the bedroom hallway on 7/10/25. See attachment #1. 07/28/2025 Implemented
SIN-00225233 Renewal 06/21/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual #1 received a physical examination on 07/09/21 and not again until 08/31/22.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The provider realizes that this violation cannot be corrected. Individual #1 received his physical on 8/31/22. 07/11/2023 Implemented
6400.142(a)Individual #1 received an annual dental cleaning and examination on 04/28/22 and not again in 04/23. Appointment is scheduled for 06/29/23.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. The provider realizes that this violation cannot be corrected. Individual #1 had his dental appointment on 6/29/23. (see attachment #3) 07/11/2023 Implemented
6400.145(1)Emergency medical plan identified for this home is not person specific. The Emergency Medical Plan states that staff will utilize the closest hospital to the home unless emergency personnel or a licensed physician indicates otherwise. This hospital or source of health care must be based on the preference of the individual or their substitute decision maker unless honoring the request puts the individual at risk of harm.The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. Individual number 1s Emergency Medical Plan was completed (see attachment #7) 07/11/2023 Implemented
6400.181(d)Individual #1's annual assessment was not signed by the program specialist.The program specialist shall sign and date the assessment. Individual #1 annual assessment was signed and dated by program specialist and individual on 7/5/23 (see attachment #4) 07/06/2023 Implemented
6400.34(a)Individual #1 was informed of rights on 05/19/21 and not again until 08/09/22.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The provider realizes this violation cannot be corrected. Rights were reviewed with the individual on 8/9/22 and will be again on 8/9/23. 07/06/2023 Implemented
6400.46(b)Staff # 1 did not receive annual training in Fire Safety in training year 03/22-02/23.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The provider realizes that this violation cannot be corrected. Staff #1 completed her annual fire safety on 6/2/23, which puts her in compliance for this year. Attached is a copy of her training certificate. See attachment # 6. 07/06/2023 Implemented
6400.52(c)(6)Staff #1 did not receive annual training in individual plan implementation. Staff #3 did not receive annual training in Individual plan implementation.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.The provider realizes that this violation cannot be corrected. Staff did receive training in individual plan implementation on 10/4/22. 07/06/2023 Implemented
6400.181(f)Individual #1's assessment was sent to ISP team on 01/19/23. The ISP meeting was held on 12/02/22. The assessment must be sent to team members 30 days prior to the ISP meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The provider realizes that this violation cannot be corrected. 07/06/2023 Implemented
SIN-00208738 Renewal 07/11/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)Repeat 08/03/21-A fire drill was held on 02/10/22 which took 6 minutes 48 seconds to evacuate. There was no additional fire drill held where individuals would have evacuated within the 2 minute 45 second extended evacuation time. A fire drill was held on 11/03/21 which took 7 minutes and 41 seconds. There was no additional fire drill held where individuals would have evacuated within the 2 minute 45 second extended evacuation time. An unannounced fire drill shall be held at least once a month. Merakey Allegheny Valley School recognizes that this citation cannot be corrected for this specific documentation. 07/28/2022 Implemented
6400.112(e)A fire drill was held on 02/10/22 at 3:00 am which took 6 minutes 48 seconds to evacuate. There was no additional sleep fire drill held in February where individuals evacuated within the 2 minute 45 second extended evacuation time. A fire drill was held on 11/03/21 at 3:45 am which took 7 minutes and 41 seconds. There was no additional fire drill held where individuals would have evacuated within the 2 minute 45 second extended evacuation time.A fire drill shall be held during sleeping hours at least every 6 months. Merakey Allegheny Valley School recognizes that this citation cannot be corrected for this specific documentation. 07/28/2022 Implemented
6400.207(5)(I)Individual # 1 has bed rails on his bed which restricts movement and requires a restrictive procedure plan.A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Post-surgical or wound care.A team meeting was held for Individual #1 on 8/4/22. The team agreed to discontinue the use of bilateral bedrails with padding and implement the use of a single outside positioning wedge, with the approval of Individual #1¿s PCP. See attachment number 8, which is the Mini IDT. The verbal order to discontinue the bedrails and implement the single outside positioning wedge was received on 8/4/22. The written order was documented on 8/8/22. See attachment number 9, which includes both the verbal and written order. On 8/4/22, the bilateral bed rails with padding were removed from Individual #1¿s bed, and the single outside positioning wedge was implemented. A memo was provided to staff on 8/4/22 about the following: 1) Individual #1¿s bilateral bedrails with padding were discontinued on 8/4/22; 2) A single positioning wedge should be applied to the outside of Individual #1¿s bed whenever he is in bed; and 3) For the next two weeks, staff should complete 15-minute checks when Individual #1 is in bed, and document Individual #1¿s movement on the 15-minute positioning check sheet provided. See attachment number 10, which is the memo. See attachment number 11, which is the 15-minute positioning check sheet. 08/04/2022 Implemented
SIN-00190981 Renewal 08/03/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)There was no fire drill completed for the month of February 2021. An unannounced fire drill shall be held at least once a month. To prevent a recurrence of this violation, the Residential Director conducted a training for all House Managers on 8/19/21 on regulation 6400.112(a) which included a discussion on the House Manager's responsibility to ensure that an unannounced fire drill is held at least once a month. Staff receiving this training signed a Staff Signature (SA) Sheet. This SA Sheet serves as acknowledgement staff received and understand the training provided. See attached SA Sheet. (attachment #1). 08/19/2021 Implemented
6400.113(a)Individual #1, #2, #3, and #4 had fire safety training on 2/28/2020 and not again until 7/30/2021. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. To prevent a recurrence of this violation, the Residential Director conducted a training for all House Managers on 8/19/21 on regulation 6400.113(a) which included a discussion on the House Manager's responsibility to ensure that all individuals are trained annually in the individual's primary language or mode of communication of general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the home. See attached Staff Signature (SA) Sheet. (attachment #2) 08/19/2021 Implemented
SIN-00102579 Renewal 10/24/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106Furnace was cleaned/inspected on 8/3/15 and not again until 8/23/16. Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Allegheny Valley School/NHS acknowledges that the furnace at 920 South 61st Street should have been cleaned within 365 days. To prevent a reoccurrence of this event, a certified letter (Attachment 1, 2, and 3) was sent to G.F. Bowman who holds the preventive maintenance contract for Allegheny Valley School. The letter clearly states the time frame needed between furnace cleanings. The Maintenance Supervisor will follow up with the company to confirm all furnace cleanings fall in the correct time frame. The Maintenance Supervisor will validate with that the furnace cleanings are scheduled within the correct time frame with the Administrator. Documentation of the furnace cleaning will be kept in the House Fire Book when completed. 11/18/2016 Implemented
SIN-00068690 Renewal 10/14/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Poisons where to be locked in this home but during inspection laundry and cleaning supplies where accessible to indivudals. Poisonous materials shall be kept locked or made inaccessible to individuals. Allegheny Valley School, Central Region 6400 Group Homes, makes its best effort to operate in full compliance with Federal and State Law. Nothing included in this Plan of Correction is an admission otherwise. Central Region 6400 Group Homes has submitted this Plan of Correction in order to comply with its regulatory obligation and does not waive any objections to the merits or form of any allegations contained herein. Please note that Central Region 6400 Group Homes may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them. On November 11, 2014 the House Managers were trained on ¿Safe Handling and Storage of Poisonous Materials¿; please see attachment #7 and #8. The House Manager immediately placed all laundry supplies in a locked cabinet under the kitchen sink. The House Manager, who is also the safety officer, will complete a daily walk through for their site. The Administrator will conduct monthly audits to check that all poisonous substances are locked and stored appropriately. All poisonous substances that are in areas accessible to the individuals are to be labeled with a Mr. Yuk sticker and placed in a locked area. In addition, yearly safety audits will be conducted by the Performance Quality Improvement Coordinator. Please see attachment #24 for an audit conducted on November 6, 2014. No issues have been found in any group homes since the inspection. 11/11/2014 Implemented
6400.67(b)The ramp off the back door had non-skid surface that was almost gone causing it to be slippery. The carpet was rippled/bubbled throughout the home. This is considered a tripping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.Allegheny Valley School Central Region 6400 Group Homes makes its best effort to operate in full compliance with Federal and State Law. Nothing included in this Plan of Correction is an admission otherwise. Central Region 6400 Group Homes has submitted this Plan of Correction in order to comply with its regulatory obligation and does not waive any objections to the merits or form of any allegations contained herein. Please note that Central Region 6400 Group Homes may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them. The House Manager placed a maintenance work order for the replacement of the anti skid strip on the ramp. The strip was replaced on October 17, 2014, please see attachment #1. The carpet will be replaced in early April, please see attachment #2. In addition the House Managers were trained on ¿Safety Precautions and Maintenance Work Orders¿ on November 11, 2014, please see attachment #3 and #4. Safety audits will be conducted yearly on the group homes by the Performance Quality Improvement Coordinator. Please see the attached audit from November 6, 2014 attachment #5 and #6. House Managers, who also act as the safety officer for the home, will do a daily walk through of their respective homes and report any issues to the administrator. Monthly visits by the Administrator will be conducted to monitor for any safety issues at the site. When a home is discovered to have carpets/flooring that pose a safety risk, the Administrator and/or the Region Director will be notified. If the carpet/flooring needs to be replaced the administrator will contact the Region Director to have the home placed on the Capital Development Improvement list. When any safety issue is noted by the House Manager or Administrator, a maintenance work order will be placed immediately to correct the issue. No safety issues were noted at this time in the remaining group homes. 04/30/2015 Implemented
SIN-00247307 Renewal 07/08/2024 Compliant - Finalized
SIN-00224003 Unannounced Monitoring 05/04/2023 Compliant - Finalized
SIN-00175329 Renewal 08/25/2020 Compliant - Finalized
SIN-00141582 Renewal 10/04/2018 Compliant - Finalized
SIN-00121498 Renewal 10/17/2017 Compliant - Finalized
SIN-00041067 Renewal 11/19/2012 Compliant - Finalized