Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00251576 Unannounced Monitoring 08/29/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)On 8/29/24 at 11:30AM, in Individual #1's bedroom there was an open container of cooked macaroni and cheese and a closed container of watermelon on top of clothing and blankets on the floor next to individual #1's bed. There was a slice of bread and crumbs on the floor in front of the nightstand next to Individual #1's bed. There were various items to include, but not limited to mounds of clothing and blankets on the floor throughout Individual #'s room.Clean and sanitary conditions shall be maintained in the home. Transitional Services Inc. recognizes the complex physical, medical, and behavioral needs of [Individual #1]. [Individual #1] is very oppositional and apprehensive towards staff assistance and requests. Effective immediately, TSI is implementing twice daily bedroom checks to ensure her bedroom is free from trash, opened food, soiled clothing, and insects. The IDD Director has informed [Individual #1] of this implementation, which was met with opposition and refusal. However, the Daily Checks are designed to give [Individual #1] three (3) attempts with a designated time frame for compliance. For example, staff will either email [Individual #1] or visit her apartment to let her know it is time for a bedroom check. If she refuses at that time, staff will inform her that they will be back in one hour for the second check. This will allow [Individual #1] to have time to independently rid her room of any of the aforementioned items. They will complete this process until her room is healthy and sanitary. All staff are currently being trained on this practice. 10/01/2024 Implemented
SIN-00222794 Renewal 04/11/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed a self-assessment on 3/20/23; however, the following 6400 regulations were left blank: 19a3, 25c, 141c10, 141c11, 141c12, 141c15, 141d, 142b, 142c, 142d, 142e, 142g, 145(2), 145(3), 165f, 165g, 166a11, 181e9, and 212.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. By May 26, 2023, CEO, Program Specialist and ID Director will obtain the necessary education/training on utilization and guidelines on the Self-assessment licensing inspection instrument that is featured in the ODP 6400 Regulatory Compliance Guide as appendix A. II. The Program Specialists and Program Director will be responsible for completing these self-assessments, including marking "NA" for any areas that do not apply to the house that they are assessing. III. Self-assessment forms will be submitted to the Director and/or CEO for their review. 05/04/2023 Not Implemented
6400.141(c)(7)Individual #1, date of birth 12/3/2002, has not had a gynecological examination.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. 1. Individual has appointment with PCP on May 8, 2023. PCP has expertise in treating adolescents transitioning into Primary Care with Disabilities. The individual has been resistant to gynecological exams. PCP is familiar to the individual and will provide education regarding the benefits of gynecological preventive exams and cervical surveillance via PAP tests. Referral to Pittsburgh Mercy Family Health Center can be option if agreeable by individual due to their specialty in providing gynecological services to ID population. 05/04/2023 Not Implemented
6400.142(a)Individual #1's most recent dental examination was completed on 8/4/2021.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. I. Individual has a scheduled appointment with Dr. Martin at Children's Hospital, the sole provider acceptable to individual, on June 16, 2023. II. Individual has been educated as to the continued feasibility of continuing with Children's Hospital for dental care due to adult status and lack of providers to provide continued care. III. Individual has accepted to discuss with staff other options. 05/04/2023 Not Implemented
6400.44(b)(2)Program Specialist #1 did not attend or participate in Individual #1's plan team meeting on 3/13/2023.The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews and implementation in accordance with this chapter.The program specialist and ID Director were in attendance for the ISP meeting, as evidenced by email communication 9 minutes prior to the start of the online meeting from the SC supervisor, and 1 minute after the start of the meeting the link was emailed out by the program specialist for other TSI staff to join the meeting. The SC supervisor has been communicated with to update the roster to include all members present and will provide for verification by May 26, 2023. 05/04/2023 Not Implemented
SIN-00221584 Unannounced Monitoring 03/21/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)There are two screws protruding upward from the bottom of the cabinet above the stove inside the kitchen. Floors, walls, ceilings and other surfaces shall be free of hazards.Screws were sawed flush with the cabinet immediately by end of business day on 3/21/23. 04/13/2023 Implemented
6400.82(e)There is not a nonslip mat in the bathtub in the bathroom of the home. Bathtubs and showers shall have a nonslip surface or mat. The Callowhill staff immediately on 3/21/23 corrected the violation by providing a thorough cleaning to address all the items listed in this violation by the end of business day and installed necessary bath mat. 04/13/2023 Implemented
SIN-00212600 Renewal 10/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill records for the fire drills completed from February 2022 through September 2022 do not address problems encountered.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. [Immediately, the CEO or designee shall audit the written fire drill documentation to ensure all required information including problems encountered is included on the documentation and revised as needed. Within 2 weeks of receipt of the plan of correction, the CEO or designee shall educate all staff person on conducting fire drills and documenting as required to ensure all required information is included including if problems are encountered and their responsibility if problems are encountered. Documentation of the trainings shall be kept. Upon completion of fire drills, a designated management staff person shall audit all fire drills to ensure fire drills are conducted as required and documented as required to ensure the safety of the individuals and if problems are encountered, they are addressed, timely. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/18/2022)] 11/01/2022 Implemented
SIN-00208229 Unannounced Monitoring 07/06/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The light on the ceiling in the hallway near the bathroom of the home is not operable. There is not another source of light in this area.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. On 7/6/21 light bulb replaced in the hallway of apartment 5. 07/06/2022 Implemented
6400.67(a)There is a one inch round hole surrounded by a twelve inch long section of paint peeling near the light fixture on the ceiling in the living room of the home.Floors, walls, ceilings and other surfaces shall be in good repair. TSI maintenance staff are in the process of repairing the ceiling in apartment 5. The ceiling has been assessed by the TSI maintenance department and have reported no evidence of a leak. 08/08/2022 Implemented
SIN-00204511 Unannounced Monitoring 05/03/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The light outside the back door of the home is not operable. There is not another source of light in that area.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. maintenance department replace lightbulb. Staff training to review protocol of reporting and documenting maintenance issues was reviewed on May 27,2022. 06/10/2022 Not Implemented
SIN-00200934 Renewal 02/28/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(b)The smoke detector in the hallway of the home was 18 feet and 4 inches from Individual #2's bedroom door.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. A smoke detector was installed in Apartment 5 within 15 feet of each individual¿s bedroom door on 3/1/2022. Staff were trained on this regulation on 3/3/2022. 03/03/2022 Not Implemented
6400.15(b)The agency did not use the current Department's licensing inspection instrument when completing a self-assessment of the home on 11/18/21. The self-assessment used was modified 6/2018 and did not included the current community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.The agency did not use the Regulatory Compliance Guide Appendix A 55Pa.Code Chapter 6400 Community Homes for Individuals with an Intellectual Disability or Autism Self Assessment Licensing Inspection Instrument to complete the annual pre licensing inspection paperwork. The Department director discarded the outdated pre licensing inspection checklist immediately. The department director immediately created a pre licensing inspection folder which now included the Regulatory Compliance Guide Appendix A 55Pa.Code Chapter 6400 Community Homes for Individuals with an Intellectual disability or Autism. The file is in hard copy form in the director's office. An electronic version is found on the agency's U drive. The ID Director will complete the tool in the month of April. 03/31/2022 Not Implemented
SIN-00143626 Renewal 10/18/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone number of the nearest hospital was not on or by the telephone in the living room of the home.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Stickers on all of the phones at the site were immediately updated to include all previous information PLUS the number of the nearest hospital - UPMC Shadyside (completed 10.19.18) Program Specialist sent an email to all program staff informing them that the number had been added to the phone stickers. This was also addressed at the staff meeting on 10.24.18 as well as at the house meeting with all persons served on 10.25.18. To ensure that this violation does not occur again in the future, the program specialist will scan/email the phone/emergency number audit to the ID director monthly. The document will be kept and filed in the on site safety binder at Callowhill. Furthermore, regulation 6400.71 will be reviewed and signed off on at the all staff ID training on 11.5.18. The training slips will be kept on file with human resources. 11/05/2018 Implemented
6400.213(10)(iv)Individual #1's record did not include notices that the plan team members have the option to decline the ISP review documentation.Documentation of ISP reviews and revisions under § 6400.186 (relating to ISP review and revision), including the following: Notices that the plan team member may decline the ISP review documentation. Immediately, Option to Decline Notices were sent to all of the team members of the person served in question (completed 10.19.18). For those that chose to decline, the signed Option to Decline for was/will be added to the individuals chart. For those that chose to continue receiving the ISP review documentation, an Option to Decline form was/will also be added to the individuals chart, stating that they (named team member) would like to continue receiving the ISP review documentation until we (TSI) are notified otherwise. To ensure the violation doesn't occur again in the future, Option to Decline Notices were sent to all team members of persons currently being served at our Callowhill site to ensure that the forms are current, up to date, and on file. Moving forward, the charts will reflect Option to Decline notices for all team members, both those who choose to decline and those who wish to continue receiving the documentation. Furthermore, during monthly chart audits, the program specialist will ensure that any new team member, including those of new admissions, will be provided with the Option to Decline form in a timely matter (within 15 days of being added to the team/admission).Lastly, regulation 6400.213 (10)(iv) will be reviewed and signed off on at the all staff ID training on 11.5.18. Signed training slips will be kept on file with Human Resources 11/05/2018 Implemented
SIN-00103402 Renewal 11/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)The individuals living in the home were not in the home when the monthly fire drills were held on 9/22/16, 6/6/16, 1/13/16, and 11/5/15. An unannounced fire drill shall be held at least once a month. What specific change will be made. Fire drills are conducted each month for the building as a whole. If no resident for a given apartment is present during a drill, another drill will be conducted for that apartment when at least one resident of that apartment is present. Who will make the change. Site staff. With the December 2016 fire drill. How will the change be made. As much as possible, fire drills will be conducted for the building when residents of all apartments are present. However, if no resident for a given apartment is present during the drill, another drill will be conducted for that apartment when at least one resident of that apartment is present. What system have you implemented to make sure that the same violation will not occur again. The building supervisor and the Health and Safety Committee will check for this condition when reviewing fire drills. What training will be provided to your staff. Staff will be re-trained on conducting fire drills with emphasis on the requirements contained in 6400.112 (a).[At least monthly for 6 months and at least quarterly thereafter, the CEO or designated management staff person will review the fire drill records to ensure all individuals participate in an unannounced drill at least once a month. Documentation of the review shall be kept. (AS 11/29/16)] 12/01/2016 Implemented
6400.141(c)(14)The physical examination dated 8/18/16 for Individual #1 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. What specific change will be made. The physician was contacted and requested to provide this information. Who will make the change. Supervisor and Site staff. When will the change be made. 11-22-16. How will the change be made. A letter was sent to the physician requesting the information in question. What system have you implemented to make sure that the same violation will not occur again. In addition to staff reviewing physical exams for completeness, the supervisor will also review all physicals for completeness for the next two months. What training will be provided to your staff. Staff will be re-trained on reviewing physical exams for completeness and the requirements contained in 6400.141(c)(14). [Upon receipt from the physician, Individual #1's physical examination shall be reviewed by the supervisor to ensure medical information pertinent to diagnosis and treatment in case of an emergency is completed as required. Immediately and upon completion, a designated management staff person shall review all individuals' current physical examinations to ensure all required information is included and there are no areas of required information left blank. Missing information shall immediately be obtained. Documentation of reviews shall be kept. (AS 11/29/16)] 12/01/2016 Implemented
SIN-00069179 Renewal 10/10/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency's certificate of compliance expired 10/22/14; however the agency completed the self-assessment on 9/15/14.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. What specific change will be made. Self-Assessments will be scheduled between 04-22 and 07-22 of each year. Who will make the change. ID Program Director. When will the change be made. For the next self-assessment (i.e., between 04-22-15 and 07-22-15). How will the change be made. In planning when to do the self-assessment it will be scheduled to occur after 04-22-15 and before 07-22-15. What system have you implemented to make sure that the same violation will not occur again. This adjustment has been built into the inspection cycle. What training will be provided to your staff. Staff was re-trained on the inspection cycle and the requirements contained in 6400.15(a). 10/27/2014 Implemented
6400.31(b)The "Rights" form, signed by Individual #1 on 1/2/14, does not state the full rights per regulations 33(e) regarding the right to privacy and 33(m) regarding not being required to work in the home. Per 6400.33(e), ¿An individual has the right to privacy in bedrooms, bathrooms and during personal care." Individual #1¿s signed statement does not include this statement. Per 6400.33(m), "An individual may not be required to work at the home, except for the upkeep of the individual¿s personal living areas and the upkeep of common living areas and grounds." Individual #1¿s signed statement included "the right to be paid by the agency for any work at the residence that benefits the agency, other than upkeep of personal and community living areas related to shared responsibilities for regular household chores." 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. Our Rights document included the following statements: ¿The right to privacy regarding myself and my possessions.¿ and ¿The right to be paid by the agency for any work that I do that benefits the agency. (This does not include regular household chores that are part of the upkeep of my personal living areas or related to my shared responsibilities for community living areas.)¿ The Rights document was revised on 10-09-14 replacing these statements with the following: ¿The right to privacy in bedrooms, bathrooms, and during personal care. This includes honoring male or female staff preferences for assistance during personal care, if I have communicated a preference for purposes of privacy and dignity.¿ and ¿The right not to be required to work at the home, except for the upkeep of my personal living areas and the upkeep of common living areas and grounds.¿ What specific change will be made. Our Rights document was revised to incorporate the language in the regulations. The revised form was reviewed with and signed by all individuals and will be the version used in future reviews of rights. Who will make the change. ID Program Director. When will the change be made. 10-09-14. How will the change be made. Our Rights document was revised to incorporate the language in the regulations. What system have you implemented to make sure that the same violation will not occur again. The revised Rights document will be used in place of the previous version. What training will be provided to your staff. Staff was re-trained on the revised Rights document and the requirements contained in 6400.31-34. 10/27/2014 Implemented
6400.141(c)(7)Individual #1, admitted 10/17/13, did not have a gynecological examination including a breast examination and Pap test.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. On this individual¿s most-recent physical exam form, the physician had marked ¿NA¿ next to the section on gynecological. What specific change will be made. Staff obtained written documentation from this individual¿s physician recommending no gynecological exam at this time. Who will make the change. Site staff. When will the change be made. 10-10-14. How will the change be made. Staff contacted the physician and explained the requirement. The physician sent written documentation recommending no gynecological exam at this time. What system have you implemented to make sure that the same violation will not occur again. During medical visits, staff will review forms for completeness before leaving the physician¿s office. If this item is incomplete, staff will ask the physician to complete it or provide them with written documentation recommending no or less frequent gynecological exams. What training will be provided to your staff. Staff was re-trained on the expectations during medical visits and the requirements contained in 6400.141(c)(7). 10/27/2014 Implemented
6400.142(d)Individual #1's dental examination, dated 4/14/14, does not include teeth cleaning.The dental examination shall include teeth cleaning or checking gums and dentures. On this individual¿s most recent Dental Exam, the dentist did not specifically note that her teeth were cleaned or that her gums were checked. What specific change will be made. On her next dental exam, the dentist will be informed of this requirement and asked to note this information. Who will make the change. Site staff. When will the change be made. On her next dental visit. How will the change be made. On her next dental exam, the dentist will be informed of this requirement and asked to note this information. What system have you implemented to make sure that the same violation will not occur again. During dental visits, staff will review forms for completeness before leaving the dentist¿s office. If this item is incomplete, staff will ask the dentist to indicate that the examination included teeth cleaning or checking gums and dentures. What training will be provided to your staff. Staff was re-trained on the expectations during dental visits and the requirements contained in 6400.142(d). 10/27/2014 Implemented
6400.142(f)Individual #1's record does not include a written plan for dental hygiene.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. On this individual¿s most recent Dental Exam, the dentist did not indicate a dental hygiene plan. What specific change will be made. On her next dental exam, the dentist will be informed of this requirement and asked to note this information. Who will make the change. Site staff. When will the change be made. On her next dental visit. How will the change be made. On her next dental exam, the dentist will be informed of this requirement and asked to note this information. What system have you implemented to make sure that the same violation will not occur again. During dental visits, staff will review forms for completeness before leaving the dentist¿s office. If this item is incomplete, staff will ask the dentist to indicate a written plan for dental hygiene. What training will be provided to your staff. Staff was re-trained on the expectations during dental visits and the requirements contained in 6400.142(f). [All individual records will be audit to ensure a dental hygeine plan is present to ensure compliance. (AS 11/7/14)] 10/27/2014 Implemented
6400.181(f)The program specialist did not provide Individual #1's assessment, completed 9/15/14, to the SC and plan team members at least 30 calendar days prior to the annual ISP meeting, scheduled for 11/4/14. (f) The program specialist shall provide the assessment to the SC, 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). What specific change will be made. The Assessment was sent to the SC & plan team members on 10-02-14. At the time of the inspection, the cover memos to team members that accompanied the Assessment had not yet been filed in the individuals chart. They have since been filed. Copies of these documents are being provided to the licensing inspector. In the future, such documents will be filed more quickly in the individual record. Who will make the change. Site staff, site supervisors. When will the change be made. 10-15-14. How will the change be made. In the future staff will assure that documentation of communication with all plan team members informing them of the assessment results are filed in the individual record in a timely manner. What system have you implemented to make sure that the same violation will not occur again. Adherence to the plan team communication process whereby there is a memo indicating what documentation was sent on what date and to whom. What training will be provided to your staff. Staff and supervisors were re-trained on the plan team communication process and the requirements contained in 6400.181(f). 10/27/2014 Implemented
6400.213(1)(i)Individual #1's record does not include identifying marks or a dated photograph.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.What specific change will be made. The face sheet has been revised to capture this information. On 10-10-14, the photograph in the chart had the date that it was taken added to the photograph. Who will make the change. ID Program Director & Site Supervisor. When will the change be made. 10-23-14. How will the change be made. This information will be indicated in the ¿Notes¿ section of the Face Sheet. As noted, the date was added to the photograph during the inspection visit. What system have you implemented to make sure that the same violation will not occur again. The revised form has replaced the original form for use in the future. What training will be provided to your staff. Staff was trained on the revised face sheet and the requirements contained in this regulation as well as the requirement to place dates on photographs. [All records will be audit to ensure identifying marks and a dated photo are present for each individual. (AS 11/7/14)] 10/27/2014 Implemented
6400.217Individual #1's most recent release of information, signed 1/2/14, is not signed by the individual. The previous release, signed 10/17/13, states that it expires after 6 months.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. What specific change will be made. Consents with a 6-month expiration date will be renewed before the expiration date. Who will make the change. Site staff. When will the change be made. 10-29-14. How will the change be made. All consents will be renewed. What system have you implemented to make sure that the same violation will not occur again. Renewal of consents will be scheduled for all individuals in April and October of each year. What training will be provided to your staff. Staff was trained on the consent cycle, the necessity of the individual¿s signature and the requirements contained in 6400.217. 10/27/2014 Implemented
SIN-00248004 Renewal 07/11/2024 Compliant - Finalized
SIN-00230023 Renewal 07/06/2023 Compliant - Finalized
SIN-00217895 Unannounced Monitoring 01/19/2023 Compliant - Finalized
SIN-00215101 Unannounced Monitoring 11/08/2022 Compliant - Finalized
SIN-00211958 Unannounced Monitoring 09/22/2022 Compliant - Finalized
SIN-00183179 Renewal 02/09/2021 Compliant - Finalized
SIN-00164034 Renewal 10/09/2019 Compliant - Finalized
SIN-00123551 Renewal 10/26/2017 Compliant - Finalized
SIN-00085622 Renewal 10/16/2015 Compliant - Finalized