Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00243330 Renewal 04/25/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.82(b)Facility had an annual onsite fire safety inspection by the local fire department on 08/09/22, and then again on 08/30/23. This exceeds the annual requirement.Facilities shall have an annual onsite fire safety inspection by the local fire department or other fire safety authority or shall notify the local fire department or other fire safety authority in writing annually of address of the facility and the number and disabilities of the clients served. Documentation of the fire safety inspection or the written notification shall be kept on file.The most current annual fire safety inspection by a fire safety expert, conducted 8/30/23, was discussed between the 2390 supervisor and the Director of Maintenance. Both understood and agreed that the 365 day deadline for the next annual inspection was Thursday, 8/22/2024; therefore, the inspection has to be scheduled by or on the 365 day deadline. The director of maintenance emailed the city inspector to see if he could schedule an inspection date for later in the year (our renewal date) or find out when the city would start scheduling for that time (our renewal date). The supervisor also set an annual calendar reminder for two months in advance of the 365 day deadline to schedule and confirm (if needed) all upcoming annual fire safety inspections. All emails will be on file for reference. ****Inspection is confirmed for on July 29th at 930am with the Deputy Fire Marshal of the Pittsburgh Bureau of Fire. Documentation emailed after online submission to Licensing Supervisor. 05/01/2024 Implemented
2390.87Individual #1 was instructed in general fire safety and in the use of fire extinguishers on 09/02/22, and then again on 09/20/23. This exceeds the annual requirement.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.The 2390 Supervisor scheduled a Fire Safety Training with the city¿s Public Education Fire Instructor over the phone at the beginning of August 2023 for the only date available in their schedule for training in September 2023. The training was for both clients and staff requirements. The date available was over the 365 day annual deadline for staff and clients to receive training. The supervisor should have scheduled for a date prior to or on the 365 day deadline, and if not able to, then adequately documented the process to show her efforts to get the training scheduled under the 365 day deadline and why she accepted the date documented for the 9/2023 training. The supervisor understands and verbally educated all staff members that Fire Safety Training for clients (and staff) must be by the 365 day/annual date of the previous training. The supervisor understands and verbally educated all staff members that the individual dates the clients receive their annual training must also be double checked to verify each client¿s training date is, in fact, within the 365 day deadline and not effected by the 15-day grace period. The supervisor also understands that if there must be any deviation from conducting a training after the 365 day deadline, it must be documented electronically, in great detail, to show the efforts made to schedule training within the deadline. The supervisor sent an email Friday, April 26, 2024 at 1:07 PM, to the Administrative Specialist, who schedules the fires safety training for the Pittsburgh Bureau of Fire with the subject: Request to have Fire Safety Training at our agency in September (2024). The email was to secure a fire safety training date in the first week of September 2024. The supervisor will continue to correspond with Harper via email until a training date, within or by the 365 annual training date is confirmed. All emails will be on file for reference. ***As of 5/1/24 the supervisor has not yet received an email /call back from the PBF. Supervisor will continue to pursue until date is scheduled. 05/01/2024 Implemented
SIN-00224925 Renewal 05/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Individual #1 was out on leave beginning 3/13/2020 and did not return until 4/07/2022. Individual #1's fire safety training was completed 9/02/2020 and then again 9/02/2022 [Repeated Violation- 6/15/2022].Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.¿ The client files for the annual Fires Safety training were reviewed to confirm that each individual in program completed said training upon admission and annually thereafter. ¿ Any client absent the day of the training will receive training from the Program Specialist the first day they return to program based on their weekly schedule. Any clients that are not scheduled to be present the day of training per their weekly schedule will receive said training the day prior to the annual training date according to their weekly schedule. 06/08/2023 Implemented
2390.151(e)(4)Individual #3's assessment completed 1/10/2023 states the individual can be unsupervised for up to 10 minutes. Individual #3's individual support plan, last updated 3/09/2023, states the individual is always supervised while at the program and monitored during participation to make sure he isn't being taken advantage of by others. The assessment must include the following information: The client's need for supervision.¿ The client ISPs were reviewed to confirm that all statements regarding an individual¿s supervision during program were consistent with that of the statement in the ISP. ¿ Any discrepancies in this section were corrected by the Program Specialist and an email was sent to notify the individual¿s Supports Coordinator. 06/08/2023 Implemented
2390.151(f)Individual #2 had an assessment completed 2/08/2023, which was sent to the plan team members 2/09/2023, for the individual plan meeting which occurred 3/09/2023. Individual #3 had an assessment completed 1/10/2023, which was sent to the plan team members 1/06/2023 prior to it being completed.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting.¿ The Important Clients Dates table was reviewed to confirm that a client¿s current annual assessment packet due date was documented correctly as 45-30 days out from the annual assessment meeting date. ¿ Any discrepancies on the table were corrected by the Program Specialist and the Supervisor of Day Programs. 06/08/2023 Implemented
2390.152(c)Individual #1's assessment completed 10/07/2022 states the individual is unable to self-administer medications. Individual #1's individual support plan, last updated 5/08/2023, states the individual is able to self-medicate and also states she does not self-medicate. Individual #1's assessment completed 10/07/2022 states she can be unsupervised for 10 minutes. Individual #1's individual support plan, last updated 5/08/2023, does not address supervision needs at the program. Individual #2's assessment completed 2/08/2023 states the individual can be unsupervised for up to 10 minutes. Individual #1's individual support plan, last updated 5/22/2023, does not address supervision needs at the program.The Individual plan shall be initially developed, revised annually and revised when a client's needs change based upon a current assessment.¿ The clients¿ latest assessment was reviewed to confirm that all statements in each section of the assessment were consistent with that of the statement in the ISP. ¿ Any discrepancies on the table were corrected by the Program Specialist and the Supervisor of Day Programs. 06/08/2023 Implemented
SIN-00206607 Renewal 06/14/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Individual #1, date of admission is 6/13/22, had fire safety training on 6/15/22.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.On 6/21/2022, the Supervisor of Day Programs discussed the importance of informing a new client of Fire Safety on their first day of program and not any day thereafter, as with the case of Individual #1. Effective 6/22/2022, the Program Specialist will refer the Orientation to Program checklist while orientating a new client on their first day. The PS will check off all topics covered as they are completed, including Fire Safety. When the Fire Safety section is completed, the PS will also have the client sign a separate form stating that they have received said training. When all of the topics on the checklist are completed, the PS will turn in both the signed and dated checklist and the signed and dated Fire Safety form to the Supervisor of Day Programs to confirm completion. A copy of these forms will go into the client¿s binder for record. 06/22/2022 Implemented
2390.21(u)Individual #1, date of admission 6/13/22, was informed and explained their individual rights on 6/15/22. Individual #2 was informed and explained their individual rights on 3/25/21 and not subsequently.The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.On 6/21/2022, the Supervisor of Day Programs discussed the importance of informing a new client(s) of their Civil Rights on their first day of our program and not any day thereafter, as with the case of Individual #1. After the client receives orientation on their civil rights, the individual will then receive annual training on the date set forth by the program and not any other date thereafter as with Individual #2. Effective 6/22/2022, the Program Specialist will refer to the Orientation to Program checklist while orienting a new client on their first day. The PS will check off all topics covered as they are completed, including Civil Rights. When the Civil Rights section is completed, the PS will also have the client sign a separate form stating that they have received said training. When all of the topics on the checklist are completed, the PS will show both the signed and dated checklist and the signed and dated Civil Rights form to the Supervisor of Day Programs to confirm completion. A copy of these forms will go into the client's binder for the record. Effective 6/22/2022, the Project Specialist will review the list of individuals scheduled to be present for the annual Civil Rights training two weeks before the date. If the PS sees that an individual will not be present on the day of the scheduled annual training, then the PS will arrange a date and time to do so within the two weeks before the annual review with said individual. The PS will also notify the Supervisor of Day Programs of the change in dates. When finished with the review, the PS will have the client sign and date the annual Civil Rights training sheet, present the signed training sheet to the Supervisor to confirm completion, and make a copy of the sheet to go into the client's binder for the record. 06/22/2022 Implemented
2390.124(1)Individual #1's record did not include date of admission and place of birth.Each client's record must include the following information: The name, sex, admission date, birthdate and place, Social Security number and dates of entry, transfer and discharge.On 6/21/2022, the Supervisor of Day Programs discussed the importance of capturing all pertinent information on the client¿s Personal Data Sheet and not leaving any fields blank, as was the case with Individual #1. Effective 6/22/2022, the Program Specialist will have 30 days to ensure all information on the Personal Data Sheet is entered properly and completely. The PS may, at any time leading up to the 30-day review, turn in the completed form to the Supervisor of Day Programs to confirm completion. 06/22/2022 Implemented
SIN-00188994 Renewal 06/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.152(c)Individual #1's individual support plan, last updated 5/20/21 does not include the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources, ability to safely use or avoid poisonous materials.The Individual plan shall be initially developed, revised annually and revised when a client's needs change based upon a current assessment.Supervisor of Habilitative Services sent an email to Individual #1's SC on 6/28/2021 asking her to add information related to the danger of heat sources and poisonous materials to his current ISP. See attachment. 06/29/2021 Implemented
SIN-00122338 Renewal 10/03/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual #1 had an annual assessment completed 6/30/16 and then again 7/19/17.Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.Each Program Specialist developed a list of current Assessment dates to ensure that all assessments are completed within 1 year. All binders that were not apart of recent inspection were reviewed for compliance with this regulation and 3 were out of compliant. All Program Specialists were re-trained on this regulation 151a. [At least quarterly for 1 year the CEO shall audit the aforementioned tracking system and a 25% sample of assessments to ensure all individuals have assessments completed, timely. Documentation of audits shall be kept. (AS 10/11/17)] 10/10/2017 Implemented
SIN-00122880 Renewal 10/03/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual #1 had an annual assessment completed 6/30/16 and then again 7/19/17.Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.Each Program Specialist developed a list of current Assessment dates to ensure that all assessments are completed within 1 year. All binders that were not apart of recent inspection were reviewed for compliance with this regulation and 3 were out of compliant. All Program Specialists were re-trained on this regulation 151a. [At least quarterly for 1 year the CEO shall audit the aforementioned tracking system and a 25% sample of assessments to ensure all individuals have assessments completed, timely. Documentation of audits shall be kept. (AS 10/11/17)] 10/10/2017 Implemented
SIN-00162868 Renewal 09/17/2019 Compliant - Finalized
SIN-00142784 Renewal 10/02/2018 Compliant - Finalized
SIN-00102326 Initial review 10/24/2016 Compliant - Finalized