Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00262719 Renewal 03/18/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101On 3/19/25 at 11:19AM, there was a padlock, on the hallway side of the door between the hallway and the attic of the home posing an obstructed egress from the attic, when engaged.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The padlock on the door between the hallway and the attic was removed on 3-25-25 and was replaced with a standard locking doorknob that can be opened from the inside. 04/24/2025 Implemented
6400.111(f)On 3/19/2025 at 11:22AM, the two fire extinguishers, in the attic of the home, were most recently inspected in June 2023. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The two fire extinguishers in the attic of the home were replaced with 2 fire extinguishers inspected in March 2025. The fire extinguishers that did not have current tags were removed from the home. 04/24/2025 Implemented
6400.181(e)(4)Individual #1's assessment, completed 11/12/2024 did not include the individual's need for supervision at the home. [Repeated violation: 3/19/2024 et al] The assessment must include the following information: The individual's need for supervision. Individual #1's assessment was updated to address the individual's need for supervision at the home on 3-25-25, and the updated assessment was sent to all team members. 04/24/2025 Implemented
6400.216(a)On 3/19/25 at 11:16AM, the medical records and other personal health information for Individual #1, Individual #2, and Individual #3 were unlocked and unattended in the office of the home. An individual's records shall be kept locked when unattended. A locking doorknob that can be opened from the inside was installed on the office door on 3-19-25, to ensure that the individual records will be kept locked when unattended. 04/24/2025 Implemented
6400.46(d)Program Specialist #1 completed training on first aid, Heimlich techniques and cardio-pulmonary resuscitation on 10/02/2022 and then again 3/12/2025.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.Program Specialist # 1 completed the CPR/First Aid training late on 3-12-25 and will be due again on 3-12-27. 04/24/2025 Implemented
6400.165(a)Individual #1 was administered Coricidin Maximum Strength 30ml on 11/01/2024, 11/04/2024, 11/11/2024, and 11/25/2024. Individual #1 does not have a prescription for this medication by an authorized prescriber.A prescription medication shall be prescribed in writing by an authorized prescriber.A new written order was obtained from the PCP for Individual # 1 on 4-2-25 for recommended over the counter medications for common medical concerns as documented on the completed Recommended Over the Counter Medication form signed by the PCP. 04/24/2025 Implemented
6400.165(f)Individual #1 was prescribed Escitalopram for anxiety on 1/06/2025 and does not have written protocol as part of Individual #1's plan to address the social emotional environmental needs of the individual.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.A Social Emotional Environmental Plan (SEEP) was written for Individual #1 on 3-14-2025 and was sent to all team members on 3-25-25 04/24/2025 Implemented
SIN-00222371 Renewal 04/04/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.51(b)(1)Direct Service Worker #1, date of hire 03/15/23, began working with individuals on 3/15/23. The orientation did not include the completion of the following required training topics: the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Direct Service Worker #1 completed the training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships on 4/18/23. 05/26/2023 Implemented
6400.51(b)(3)Direct Service Worker #1, date of hire 03/15/23, began working with individuals on 3/15/23. The orientation did not include the completion of the following required training topics: individual rights.The orientation must encompass the following areas: Individual rights.Direct Service Worker #1 completed the training on individual rights on 4/18/23. . 05/26/2023 Implemented
SIN-00171474 Renewal 02/19/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)Individual #1's physical examination completed on 7/18/19, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual #1's physical examination date 7/18/19 was updated to address medical information pertinent to diagnosis and treatment in case of an emergency. Immediately, the program specialist shall review all individuals' current physical examination to ensure all required areas are completed and there are not any required areas left blank. At least quarterly for 1 year, a designated management staff person shall review a 25% sample of completed physical examination to ensure aforementioned process is working and that required areas of physical examinations are completed for the health and safety of the individuals. This training will be completed by 3-24-2020. The Program Specialist will retrain all staff within 30 days. [Documentation of trainings and audits shall be kept. (DPOC by AES,HSLS on 3/17/20)] 04/23/2020 Implemented
6400.212(b)Individual #1's assessment completed 12/19/19 by the program specialist was not signed or dated by the program specialist. Entries in an individual's record shall be legible, dated and signed by the person making the entry. The Supervisor went over the assessment with the Program Specialist and was trained on the assessment procedure and reiterated about a signature.. A spreadsheet has been developed denoting when the annual assessments are due. At least quarterly for 1 year, a designated management staff person shall review a 25% sample the assessments to review and aforementioned tracking systems to ensure timely completion by the program specialist(s). Documentation of reviews shall be kept. This training will be completed by 3-24-2020. The Program Specialist will retrain all staff within 30 days 04/23/2020 Implemented
6400.62(b)On 2/20/20 at 11:58AM, a one quart bottle of Clorox Clean Up with precautions reading "contact poison control if ingested", was in an unlocked cabinet under the sink in the kitchen of the home. Individual #1's ISP, last updated 2/12/2020 states [Individual #1] is not exposed to poisonous substances at home. [S/he] does have issues with clumsiness. [S/he] is not known for ingesting poisonous or inedible items. All poisonous substance are kept locked at home.Poisonous materials may be kept unlocked if all individuals living in the home are able to safely use or avoid poisonous materials. Documentation of each individual's ability to safely use or avoid poisonous materials shall be in each individual's assessment.All staff were educated and trained on ISP trained and importance of locking poisonous substance according to 55 PA Code Chapter 6400.62(b) for the health and safety of the individuals living at the Lilac CLA. The Program specialist did a safety check of the substances after the training and made sure any chemicals were locked up. Since the client was assessed to be not able to distinguish between poisonous or non-poisonous substances. Signs will also be posted in the house to remind staff to lock poisonous materials up after being used. All Program Specialist will be trained on the protocol for locking poisonous/hazardous materials unless all individuals are assessed with the ability to safely use or avoid poisonous materials shall be in each individual's assessment. This training will be completed by 3-24-2020. The Program Specialist will retrain all staff within 30 days and will post signs regarding locking all poisonous materials in affected homes. Documentation will be kept. 04/23/2020 Implemented
6400.166(b)Clonazepam 2 MG Tablet, take 1 tablet by mouth 3 times a day; Clonidine HCL 0.1MG tablet, take 1 tablet by mouth at bedtime; Diproex Sod DR 500MG Tab, take 2 tablets by mouth at bedtime; Flovent HFA 110 MXCG Inhaler, Inhale 1 puff by mouth 2 times a day and Risperidone 4MG tablet, take 1 tablet by mouth 2 times a day prescribed to Individual #1 were not initialed as administered at 8:00 PM on 2/19/2020 at 8:00 PM.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The Program Specialist/Medication Trainer reviewed the 5 rights of medication administration with the staff that did not initial and put the count down on the MAR. The trainer had the staff sign off that the training was completed. At least weekly for 1 month and then continuing monthly, a designated staff person shall review all individuals' current medication records and current medications to ensure all individual are being administered medications as prescribed and documented as required for the health and safety of the individuals. Documentation of reviews shall be kept. 04/23/2020 Implemented
SIN-00112649 Renewal 04/20/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(c)A psychiatric medication review for Individual #1 completed 8-24-16, did not include the medications and necessary dosages. Individual #1 had a psychiatric medication review on 10-14-16 and the next review on 2-24-17. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Pittsburgh Mercy staff sent the Medical Appointment Summary to the physician and requested the Physician include the list of medications, dosages and the need to continue those medications for the 8-24-16 appointment. The Doctor signed off on the form as evidenced by the form emailed to ODP. All Program Specialists will review forms for thorough completion prior to filing. All Program Specialist and staff who accompany individuals to appointments will be retrained on the requirement to include the list of medications, dosages and need to continue for all Psychiatric Medication Reviews by 5-26-17. Evidence of the training will be submitted to ODP. All Program Specialists will be responsible to ensure that Psychiatric Medication Reviews are completed every three months and will develop a spreadsheet to assist with tracking appointments. All Program Specialists will be trained on this requirement by 5-26-17. Evidence of the training will be sent to ODP. [At least quarterly for 1 year, a designated staff person shall review a 25% sample of psychiatric medication review documentation to ensure timeliness and all required information is included. Documentation of the reviews shall be kept. (AS 5/18/17)] 05/26/2017 Implemented
SIN-00059400 Renewal 01/22/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(b)The rights form signed by individual #1 on 1/4/14, did not state the full rights per regulations 33(g) regarding visitors and 33(k) regarding religion. Per 6400. 33(g), "An individual has the right to receive scheduled and unscheduled visitors,communicate, associate and meet privately with family and persons of the individual's own choice." Individual #1's signed statement included that, "I have the right to have visitors in my home and talk to people I want unless my health or safety is at risk." Per 6400 .33(k), " An individual has the right to practice the religion or faith of the individual's choice." Individual #1's signed statement included that, " I have the right to attend religious services of my choice."(b) Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. The individual rights statement form was revised to reflect the exact wording of state regulation 6400.31(b)33(g), 33(k).The individual#1 reviewed signed a new rights statment on 03/21/2014, attachment A. All other individuals in residntial programs will sign the revised statement by 4/30/14. The program specialist is responsible for the completion of this corrective action. All agency ID services residential staff will be trained on the changes to the form by 04/30/2014. The program specialist is responsible for ensuring completion of the staff training. 04/30/2014 Implemented
6400.63(a)Heat radiators in the home ranged from 137 degrees Fahrenheit to 154 degrees Fahrenheit. Individual #2's assessment indicated that s/he cannot independently move away from heat sources. Furthermore, the radiator in Individual #2's room measures 141.9 degrees Fahrenheit.(a) Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. The radiator cover was repaired so that the cover was not touching the radiator on 02/01/2014. The Program Specialist will ensure that all heat sources are equipped with protective guards that are in good condition. 02/01/2014 Implemented
6400.64(a)An unlabeled bar of soap was in the shower/tub which is shared by 4 individuals living in the home. (a) Clean and sanitary conditions shall be maintained in the home. The unlabeled bar of soap was immediately removed on 1-23-14. The staff will monitor the tub/shower after each individual showers to ensure that all personal hygiene products have been removed. The program specialist is responsible to ensure compliance with 6400 regulations. 01/23/2014 Implemented