Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00221762 Renewal 03/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Individual #1, Individual #2, Individual #3, Individual #4, Individual #5, Program Specialist #1, Direct Service Worker #2, Direct Service Worker #3, Direct Service Work #4, and Direct Service Worker #5 were trained in general fire safety 10/12/2021 and then again 10/31/2022.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.Moving forward, and under the direction of the program director and program coordinator, all consumers and all staff will be trained in general fire safety and in the use of fire extinguishers annually, utilizing a tickler notification. Tickler notification will be set to alert program leadership six weeks before the previous year¿s training date. 04/06/2023 Implemented
2390.21(u)Individual #1, Individual #2, Individual #3, Individual #4, and Individual #5 were informed of client rights 10/12/2021 and then again 10/31/2022.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.Moving forward, and under the direction of the program director and program coordinator, all consumers will be trained in client rights and the process to report a rights violation, utilizing a tickler notification. Tickler notification will be set to alert program leadership six weeks before the previous year¿s training date. 04/06/2023 Implemented
SIN-00204329 Renewal 04/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(f)Individual 1's assessment, dated 11/23/2021, was not provided to the individual plan team members prior to the 2/21/2022 ISP meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting.Moving forward and under the direction of the program coordinator; all consumer assessments will be provided to the individual team members at least 30 calendar days prior to the individual¿s meeting. Staff training reviewing these expectations will be completed. [Staff training for "Plan of Correction 2022," dated 5/13/22, was received on 5/19/22 and reviewed on 5/20/22. Tracking document to ensure Assessments are provided to the plan team at least 30 days prior to the annual ISP meeting received on 5/19/22 and reviewed 5/20/222. DPOC by HDKP, HSLS, on 5/20/22]. 05/12/2022 Implemented
SIN-00187102 Renewal 05/04/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.85(b)-2The fire drills conducted from 1/21/2020 to 3/3/2021 did not use different hypothetical locations of the fire.Hypothetical locations of the fire shall be different for each drill.Moving forward and under the direction of the program director, the program coordinator will create a new fire drill log which includes an area for documenting the hypothetical location of the drill¿s fire. 05/07/2021 Implemented
SIN-00171550 Renewal 02/27/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.85(a)-2The written record for the fire drill held on 8/19/19 does not include the amount of time it took for evacuation. The written record for the fire drill held on 9/20/19 does not include the amount of time it took for evacuation.A written record shall be kept of the date, hypothetical location of fire and the amount of time it took for evacuation.55 PA Code Chapter 2390.85(a)-2 Description: The written record for the fire drill held on 8/19/19 does not include the amount of time it took for evacuation. The written record for the fire drill held on 9/20/19 does not include the amount of time it took for evacuation. Correction Required: A written record shall be kept of the date, hypothetical location of the fire, and the amount of time it took for evacuation. Plan of Correction: Moving forward, UPMC Vocational Training Center, under the leadership of the program coordinator, will ensure that each fire drill record shall include information regarding the date of drill, hypothetical location of the fire, and the amount of time it took for evacuation as completed by the conducting safety officer. During the fire drill, program coordinator will monitor drill begin time and drill end time during evacuation; post-fire drill, program coordinator will meet with the safety officer conducting the fire drill to ensure that begin times, end times, and amount of time for evacuation are congruent. At this time, Program coordinator will also ensure that the fire drill record has been filled out to completion by the safety officer conducting the drill. If program coordinator is not present during a fire drill, program specialists will monitor begin times, end times, and amount of time for evacuation as well as verify these times with safety officer and ensure the record is filled out to completion. Training outlining the specifics of this plan of correction will be completed with all program staff by 3.13.2020. [Documentation of the aforementioned trainings shall be kept. Documentation of the aforementioned audits of the fire drill records shall be kept. (DPOC by AES,HSLS on 3/10/20)] 03/09/2020 Implemented
2390.151(e)(5)Individual #1's initial assessment, dated 11/8/19, does not address the individual's ability to self-administer medications. This section of the assessment states "N/A." The assessment must include the following information: The client's ability to self-administer medications.55 PA Code Chapter 2390.151(e)(5) Description: Individual #1¿s initial assessment, dated 11/8/19, does not address the individual¿s ability to self-administer medications. This section of the assessment states ¿N/A.¿ Correction Required: The assessment must include the following information: The client¿s ability to self-administer medications. Plan of Correction: Moving forward, UPMC Vocational Training Center, under the leadership of the program coordinator, will assess each client¿s ability to self-administer medications via simulating medication self-administration or contacting the client¿s support groups (family members, residential staff, or therapy team members) to gather information regarding the client¿s ability to self-administer medications. To immediately correct the issue cited, Program Specialists will review Individual #1¿s assessment (in addition to all current clients¿ assessments) and reassess clients¿ abilities to self-administer medications using the methods described above; Program Specialists will also utilize these methods to assess all new clients¿ abilities to self-administer medications in the future, assessment review will be completed by 3.13.2020. Program Specialists, under guidance of program coordinator and program director, will review and be retrained in current state regulations and guidelines regarding assessing medication self-administration by 3.13.2020. Program Specialists will document the completion of all current clients¿ assessments to ensure that they are in agreement with current state regulations. and complete medication self-administration retraining by 3/13/2020. [Documentation of aforementioned training shall be kept. At least quarterly for 1 year, the CEO or designee shall audit a 5% sample of individuals' current assessments to ensure all required information is included and accurate. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 3/10/20)] 03/09/2020 Implemented
SIN-00071545 Renewal 02/27/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)The assessment for Individual #2, admitted 9/10/14, was not completed until 12/15/14. 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.Under the direction of the Program Manager, (Allen Meade Gregory), effective 3/24/2015, the Program Coordinator, (Ian Bonnet), will ensure consumer initial assessments are completed within 1 year prior to or 60 calendar days after admission to the facility. Effective 3/24/2015, the Program Coordinator will utilize an excel spreadsheet tickler to indicate assessment completion due dates. Effective 3/24/2015, all staff were re-educated re: 2390.151 (a) requirements. REFER TO ATTACHED DOCUMENTATION. 03/25/2015 Implemented
2390.151(f)The assessment for Individual #1, dated 2/27/15, was sent on 2/27/15 to plan team members for an ISP meeting date on 3/19/15. The assessment for Individual #4, dated 6/2/14 was sent to plan team members on 6/2/14 for an ISP meeting on 6/6/14.The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).Under the direction of the Program Manager, (Allen Meade Gregory), effective 3/24/2015, the Program Coordinator, (Ian Bonnet), will ensure all assessments are communicated to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting. Effective 3/24/2015, the Program Coordinator will utilize an excel spreadsheet tickler to indicate due dates. Effective 3/24/2015 all staff were re-educated re: 2390.151(f) requirements. REFER TO ATTACHED DOCUMENTATION. 03/25/2015 Implemented
2390.156(d)The 3 month review for Individual #3, dated 1/2014 through 3/2014 and 2/2014 through 4/2014, were sent to plan team members on 6/12/14. The 3 month review for Individual #5, dated 5/2014 through 7/2014, was sent to the team on 9/3/14. The program specialist shall provide the ISP review documentation, including recommendations if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.Under the direction of the Program Manager (Allen Meade Gregory),effective 3/24/15 the Program Coordinator (Ian Bonnet), will ensure all ISP review documentation is provided to the SC or plan lead as applicable, and plan team members within 30 calendar days after the ISP review meeting. Effective 3/24/15, the Program Coordinator will utilize an excel spreadsheet tickler to indicate due dates for consumer ISP reviews and date documentation is sent. Effective 3/24/15, all staff were re-educated re: 2390.156(d) requirements. REFER TO ATTACHED DOCUMENTATION. 03/25/2015 Implemented
SIN-00057955 Renewal 03/12/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.59The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not posted by the telephone on the desk near the large conference room and the telephone on the desk near the front entrance of the facility. Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephoneUnder the direction of the Clinical Administrator, the Program Director or designee will develop a list of telephone numbers of the nearest hospital, police and fire departments, ambulance and poison control center. This list will be posted by the telephone on the desk near the large conference room and the telephone on the desk near the front entrance of the facility (completed 3.12.14). In addition, all staff will be retrained on this requirement (completed 3.12.14) All new staff will be trained on posting of emergency numbers during orientation. Posting of emergency numbers will also be added to the annual fire safety training. Documents attached 03/21/2014 Implemented
2390.82(a)The facility's "Emergency Relocation Policy" does not include the means of transportation used in an emergency.(a) Written emergency evacuation procedures including at a minimum client and staff responsibilities, means of transportation in an emergency, emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency shall be posted in work areas.Under the direction of the Clinical Administrator, the Program Director or designee, will revise the facility's "Emergency Relocation Procedure" to include means of transportation in an emergency and shall be posted in the main program area (completed 3.12.14). Document Attached. 03/21/2014 Implemented
2390.83(c)-2The facility's document titled, "Fire Safety Policies" does not include a written procedure for fire safety monitoring in the event that the fire alarm is inoperative. In addition, the policy states repairs "must be completed...within 4 working days;" Chapter 2390.83(c)-1 requires repairs to be completed within 48 hours of the check where the fire alarm is found to inoperable. There shall be a written procedure for fire safety monitoring in the event that the fire alarm is inoperative. Under the direction of the Clinical Administrator, the Program Director or designee, will revise the facility's "Fire Safety Procedure" for monitoring in the event that a fire alarm is inoperable (completed 3.12.14). This procedure will include: Repairs must be completed within 48 hours from the time the fire alarm system was found to be inoperable and monitoring the facility every 60 minutes, by doing a walkthrough to make certain the facility is safe. Results of the walkthrough will be documented and kept in the facilities Safety Manual. Document Attached 03/21/2014 Implemented
2390.151(e)(11)Psychological evaluations are not included in the assessments for Individual #1, admitted 6/14/13 and Individual #2, admitted 6/14/13. (e) The assessment must include the following information: (11) Psychological evaluations, if applicable.Under the direction of the Clinical Administrator, the Program Director or designee will obtain Psychologicals for Individual #1 and Individual #2 (completed 3.12.14). A quarterly review will be conducted of client records to ensure all required assessments and documents are available in the record. Documents Attached 03/21/2014 Implemented
SIN-00240348 Renewal 03/13/2024 Compliant - Finalized
SIN-00152052 Renewal 03/18/2019 Compliant - Finalized
SIN-00131741 Renewal 03/26/2018 Compliant - Finalized
SIN-00111858 Renewal 04/07/2017 Compliant - Finalized
SIN-00092451 Renewal 03/29/2016 Compliant - Finalized
SIN-00040745 Renewal 11/19/2012 Compliant - Finalized