Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00247312 Renewal 07/08/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individual # 1 had fire safety training on 06/07/23 and did not receive fire safety training in 2024 as of 07/08/24. 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. A fire safety training packet was completed immediately on 7/9/24 upon notification that it was not completed annually (see attachment #3) 07/18/2024 Implemented
6400.34(a)Individual # 1 was informed of their rights on 06/27/22 and not again until 07/17/23.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.A consent packet was completed immediately on 7/9/24 upon notification that it was not completed annually (see attachment #3 07/18/2024 Implemented
SIN-00225238 Renewal 06/21/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The closet door in Individual #2's room gets stuck at the top and does not close the whole way.Floors, walls, ceilings and other surfaces shall be in good repair. A work order to have the closet door repaired was submitted the same day as the walkthrough on June 22 2023, see attachment # 19. The closet door was fixed on 06/22/2023. 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. All Individuals Emergency Medical Plan were completed (see attachment #24) 07/06/2023 Implemented
6400.214(b)Individual #1's physical was dated 10/21/21 and Individual #2's physical was dated 07/09/21 at the home. The most recent physical exam was not at the home. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Individual #1s and #2s current physical were printed out and placed in the home immediately after the walkthrough when it was identified that it was missing. 07/11/2023 Implemented
SIN-00208743 Renewal 07/11/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The broom closet doorknob is broken and has sharp edges.Floors, walls, ceilings and other surfaces shall be in good repair. A maintenance work order was submitted on July 14th, 2022. The broom closet doorknob was replaced on July 14th, 2022. 07/28/2022 Implemented
6400.112(e)Repeat 08/03/21- A fire drill was held on 08?21/21 which took 5 minutes and 22 seconds and on 11/18/21 which took 04:37sec. The extended evacuation time for the home is 03 minutes and 20 seconds. Successful fire drills were not conducted for 08/21 or 11/21.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
6400.112(e)An asleep fire drill was held on 08/21/21 which took 5 minutes and 22 seconds and on 11/18/21 which took 04:37sec. The extended evacuation time for the home is 03 minutes and 20 seconds. Successful asleep fire drills were not conducted for 08/21 or 11/21.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
SIN-00161512 Renewal 10/01/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1's January and July 2019 financial petty cash ledgers, maintained by the home, recorded that $45 was deposited into his account one time per month, but did not record a date of deposit.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. Merakey Allegheny Valley School acknowledges that Individual #1's January and July 2019 financial petty cash ledgers, maintained at , recorded deposit without dating the ledger. The House Manager received training on 10-9-19 on the proper documentation of Financial Logs (Attachments 31 and 32). (Attachments 33 and 34) show the correct documentation for Individual# 1 financial log. The Administrator will monitor compliance monthly. 01/03/2020 Implemented
6400.216(a)An unlocked mail bin that contained individual's personal mail and identifying information, was found unlocked, accessible, and unattended on top of the filing cabinet in the office. The office did not have a door that could be locked. A communication book was also found unlocked, accessible, and unattended on a book shelf in the kitchen area, near the dining room. Contents of the communication book included Individual #3's doctor's summary from a 2016 medical visit, and an additional medical summary from Individual's #1-#4 from 2015. An individual's records shall be kept locked when unattended. Merakey Allegheny Valley School acknowledges that individual's personal information was found unlocked at home. The information was moved to the locked file cabinet and locked medication cabinet at the home in the office. The House Manager acknowledged that all personal information was locked (Attachment 30) on 1/10/2020. The Administrator will monitor the home monthly for compliance. 01/10/2020 Implemented
SIN-00102583 Renewal 10/24/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106Furnace was cleaned/inspected on 8/3/2015 and not again until 8/23/2016,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 1506 Spring Garden Drive 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-00085328 Renewal 10/14/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Poisons at this site where not locked. Hand soap was left unlocked in the bathroom and the kitchen. Poisonous materials shall be kept locked or made inaccessible to individuals. NHS acknowledges that the mentioned products should have been in a locked area of the home. There are locked closets for the storage of poisonous materials in each of the homes, and the products are now locked in those areas. To assure there is no recurrence of this event the House Managers were retrained on their responsibility to monitor storage of poisonous material (Staff Attendance Sheet with memo Attachment #1). Additionally, the direct care teams for all homes were reminded to properly handle and store poisonous materials (Staff Attendance Sheet with memo Attachment #14). The compliance to this requirement will be validated during monthly supervision with the Administrator. The House Manager will bring a completed site checklist, which includes review of toxic products for discussion and review to the monthly House Manager meetings (Safety Audit Attachment # 15). 12/21/2015 Implemented
6400.181(e)(13)(v)Individual #1's assessment did not include progress and growth over the last 365 calendar days and current level in socialization.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. To assure there is no recurrence of this event, the Program Specialist will be retrained by the Social Services Supervisor regarding the progress and growth comments in the assessment (Staff Attendance Sheet Attachment #18). Completed assessments will be reviewed by the Social Service Supervisor for thoroughness and accuracy in progress and growth. If concerns arise during the review, the Program Specialist will be notified and appropriate revisions will be made to the document. The Program Specialist completed a revision to the progress and growth section of the assessment (Attachment #21). 12/31/2015 Implemented
6400.181(e)(13)(vi)Individual #1's assessment did not include progress and growth over the last 365 calendar days and current level in recreation.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. To assure there is no recurrence of this event, the Program Specialist will be retrained by the Social Services Supervisor regarding the progress and growth comments in the assessment (Staff Attendance Sheet Attachment #18). Completed assessments will be reviewed by the Social Service Supervisor for thoroughness and accuracy in progress and growth. If concerns arise during the review, the Program Specialist will be notified and appropriate revisions will be made to the document. The Program Specialist completed a revision to the progress and growth section of the assessment (Attachment #21). 12/31/2015 Implemented
6400.181(e)(13)(ix)Individual #1's assessment did not include progress and growth over the last 365 calendar days and current level in community-integration. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.To assure there is no recurrence of this event, the Program Specialist will be retrained by the Social Services Supervisor regarding the progress and growth comments in the assessment (Staff Attendance Sheet Attachment #18). Completed assessments will be reviewed by the Social Service Supervisor for thoroughness and accuracy in progress and growth. If concerns arise during the review, the Program Specialist will be notified and appropriate revisions will be made to the document. The Program Specialist completed a revision to the progress and growth section of the assessment (Attachment #21). 12/31/2015 Implemented
6400.186(c)(2)Individual #1's ISP reviews did not review the following plans:diabetes, osteoprois, pressure sores, fall risk, dysphasia, and mrsa. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. To assure there is no recurrence of this event, the Program Specialist will be retrained by the Social Services Supervisor regarding review of all parts of the ISP. This included the importance of reviewing all aspects of the individual¿s ISP and commenting in the 3 month review (Staff Attendance Sheet Attachment # 20). 3 month reviews will be reviewed by the Social Services Supervisor starting on 12/3/2015 through 3/3/2016. If concerns arise during the review, the Program Specialist will be notified by the Social Services Supervisor and the concerns will be addressed. 03/03/2016 Implemented
SIN-00068695 Renewal 10/14/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)All poisons were to be locked or inaccessible to the individual's in this home. The laundry area doors were not locked and contained cleaners and laundry soap that was accessible to the individual's.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
SIN-00190986 Renewal 08/03/2021 Compliant - Finalized
SIN-00121503 Renewal 10/17/2017 Compliant - Finalized
SIN-00041072 Renewal 11/19/2012 Compliant - Finalized