Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00196555 Renewal 11/18/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self assessment of the home.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. The Senior Residential Homes Managers will complete the self-assessment of their assigned homes by December 20, 2021. The Residential Director will review each plan prior to submission. 12/20/2021 Implemented
SIN-00180325 Renewal 12/08/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace was inspected and cleaned by a professional furnace cleaning company on 8/21/19 and then again on 12/3/19. There was no documentation of a furnace inspection and cleaning in 2018.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. The Facilities Director is responsible for coordinating all annual inspections. He indicated that due to COVID restrictions it was difficult to get the company to complete them. A checklist system is in place so that the Quality and Compliance Coordinator will send a notice at least three months in advance to the Facilities Director to have the inspections scheduled. The Quality and Compliance Coordinator will also send a two month and one month warning. All updated inspections were completed on January 11, 2021 and January 12, 2021. Copies will be emailed as proof. The Facilities Director and the Senior Residential Homes Coordinators were trained by the Quality and Compliance Coordinator about the regulation and the new tracking system. 01/12/2021 Implemented
6400.112(d)The fire drill conducted 9/6/19 at 1:25am had an evacuation time of 6 minutes 10 seconds. At the time of this fire drill the agency has two current documented evacuation times by a fire safety expert in writing dated 10/6/2018, one stating 2 minutes and 30 seconds with note stating "Day Time Fire Drill with evacuation" and the other stating 7 minutes and 15 seconds with the note stating "Over Night Fire Drill with Evacuation." In addition, the signed documentation reads in part "I have made this determination based on the design and construction of the home." [Repeat violation 8/8/19]Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home.Staff were retrained by the Residential Homes Manager on safely getting people out of the home. A fire safety expert was contacted to perform an actual evening fire drill at the home. It was on January 28, 2021. The document is being provided. A reminder for the annual drill by a fire safety expert will be put on the calendar 90 days prior, 60 days prior, and 30 days prior, by the Residential Director, to ensure the inspection and letter is completed and obtained in a timely manner. [A copy of a fire extended evacuation time letter from a fire safety expert that determined an extend evacuation time of 5 minutes and 13 seconds was provided to the Department on 1/29/21. At least quarterly for 1 year, a designated management staff person will audit all fire drill records to ensure fire drills are conducted and documented as required. (AES,HSLS on 2/10/21)] 01/28/2021 Implemented
SIN-00160392 Renewal 08/08/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There was a 64 oz container of Clorox Clean Up with warning label "call poison control immediately if swallowed" was accessible in the unlocked cabinet under the sink in the kitchen of the home. Individual #1's assessment completed 10/15/18 assessed Individual #1 as requiring physical prompting around poisons.Poisonous materials shall be kept locked or made inaccessible to individuals. Staff will be retrained on what materials qualify to be locked away by the Training Coordinator. The program specialist will also reassess the individual in the home who was incorrectly assessed as needing assistance with avoiding poisonous materials. [Individual #1 assessment was revised on 8/30/19 to indicate individual #1 is able to safely recognize and avoid poisonous materials. Program specialist educated all staff person on 8/18/19 for 60 minutes on the procedures for poisonous materials. Immediately and at least quarterly, the Program specialist(s) shall audit all individuals' assessments for accuracy including the individuals' ability to safely use and avoid poisonous materials. At least monthly, a designated management staff person shall complete a walk thorough of all community homes to ensure poisonous materials are kept locked or made inaccessible to individuals. (DPOC by AES, HSLS on 9/17/19)] 09/01/2019 Implemented
6400.166(b)Vitamin B complex tablet, take 1 capsule Tuesday and Saturday prescribed to Individual #1 was not initialed as administered on Saturday, 8/3/19 at 8:00 AM.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Staff will be retrained on signing MARS by the medication trainer. [Oxybutynin CL ER 10 mg TAB, Alphagan P 0.1 % drops, and Vitamin D3 1,00 unit tab prescribed to Individual #1 were not initialed as administered on 9/1/19 at 8:00AM. Sertraline HCL 50 mg tabs prescribed to Individual #1 was not initialed as administered on 9/1/19 at 8:00PM. Immediately, the staff person responsible for these documentation errors shall be reeducated in medication administration training and observed at least 4 times while administering medication prior to administering medications without supervision by a staff person certified to administer medications. All staff persons were reeducated on administering medications on 8/16/19. At least weekly for 3 months and then continuing at least monthly, a staff person certified to administer medication shall audit all individuals' current medication administration records, current medications and physicians' orders to ensure all individuals are administered medications as prescribed and documented as required. Documentation of all medications audits shall be kept. (DPOC by AES,HSLS on 9/17/19)] 09/01/2019 Implemented
SIN-00140417 Renewal 08/21/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill record for the fire drill held on 3/26/18 at 5:00 AM did not include the exit used for evacuation.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. Residential staff will be retrained by the Residential Homes Manager on the proper completion of the fire drill form with an emphasis on reinforcing the need for all information will be filled in. In addition, the fire drill will be reviewed and signed by the Residential Homes Manager as well as the Coordinator of Residential Homes on a monthly basis. If errors are discovered the Residential Homes Manager will address this with the staff completing the form and will ensure the staff completes the missing information.[Documentation of the trainings and audits shall be kept. (DPOC by AES, HSLS on 10/2/18)] 10/05/2018 Implemented
6400.112(d)The fire drill held on 9/8/17 had an evacuation time of 4 Minutes 20 seconds. The fire drill held on 10/9/17 had an evacuation time of 2 minutes 45 seconds. The fire drill held on 3/26/18 had an evacuation time of 4 minutes 45 seconds. The fire drill held on 6/15/18 had an evacuation time of 2 minutes 46 seconds. The home did not have an extended evacuation time in writing within the past year by a fire safety expert. [Repeat Violation 9/12/18, et. al.] Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. The Coordinator of Residential Homes met with the North Versailles Borough Office Manager on 9/26/2018 regarding the necessity to secure an approval letter from a fire safety expert regarding evacuation times at this home. The fire chief will meet the Coordinator on 9/28/2018 to observe an actual fire drill and review the previous year's fire drill documentation. The approval letter will be signed at that time. [On 10/6/18, fire expert completed an inspection and a review of fire drills of at least 12 months and determined the maximum time for the home from the time the alarm sounds until the individual have evacuated to the outside of the home is 2 minutes and 30 seconds during day time and 7 minutes and 15 seconds for over night fire drills. At least monthly for 6 months and continuing at least quarterly, the CEO or designee shall audit all documentation from fire safety experts and fire drill records to ensure individuals are able to evacuate within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/9/18)] 09/28/2018 Implemented
SIN-00121255 Renewal 09/12/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)The most recent fire drill held during sleeping hours was 1/27/17. A fire drill shall be held during sleeping hours at least every 6 months. All staff will be retrained by the assigned Residential Homes Specialist in the proper completion of an unannounced fire drill. Included in this training will be a review of what constitutes an asleep fire drill including timeframe for completion and the need for the majority of individuals to be asleep.[Within 15 days of receipt of the plan of correction, a fire drill during sleep hours shall be held and documented as required. At least monthly for 6 months and continuing at least quarterly, upon completion of a fire drill, the CEO or designee shall audit the all fire drill documentation to ensure the fire drill is completed and documented as required and there are not any areas of required information left blank on the fire drill record. Documentation of audits and aforementioned trainings shall be kept. (AS 10/4/17)] 10/31/2017 Implemented
6400.163(c)Individual #1, who has a diagnosis of depression and psychosis, had psychiatric medication review on 4/7/17; the next review was 7/21/17. Individual #1's psychiatric medication review on 12/9/16 did not include the necessary dosage for Celexa. Individual #1's psychiatric medication review on 7/21/17 did not include the necessary dosage for Celexa or Risperdol.(Repeated Violation-9/23/16, et al) 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.A chart has been completed by each Residential Homes Specialist Assistant regarding medical appointments with the last and next dates of required appointments including quarterly psychotropic medication reviews. The required timeframe for scheduling these appointments will be followed and if the appointment can not be made due to the physician's schedule, documentation of the reason for the delay will be secured and kept in the individual(s) file.[Within 30 days of receipt of the plan of correction, all staff persons responsible for ensuring Individuals who are prescribed medication to treat symptoms of a diagnosed psychiatric illness shall be trained as to what is to be included in the reviews to include the reason for prescribing the medication, the need to continue the medication and the necessary dosage and to ensure all the required information is obtained. Upon completion by a licensed physician, a designated staff person shall audit the reviews to ensure all required information is included and the orders are being followed. Missing information shall be immediately obtained. At least quarterly for 1 year a designated management staff person shall review the aforementioned tracking system and a 25% sample of medication reviews to ensure timely completion with all required information. Documentation of reviews shall be kept. (AS 10/4/17) 10/13/2017 Implemented
6400.181(d)Individual #1's assessment, dated 5/30/17 had the Program Specialist #1's name typed in place of the signature.The program specialist shall sign and date the assessment. All assigned Program Specialist(s) will sign and date all assessments effective immediately. In addition, Program Specialist will manually sign all previously typed signatures on assigned assessments [Immediately, the CEO or designee shall review with all program specialist(s) the responsibilities of the program specialist position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. At least quarterly for 1 year, the CEO or designee shall review a 25% sample of individuals' assessment to ensure the program specialist sign and date the individuals' assessments as required. (AS 10/4/17)] 10/06/2017 Implemented
6400.186(b)The Program Specialist's name was typed in place of the signature on Individual #1's ISP reviews, dated 10/18/16, 1/18/17, 4/18/17 and 7/17/17.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. All upcoming ISP review documents requiring a Program Specialist signature in the will be signed in ink as indicated in this regulation. This includes previously electronically signed notes. In these cases, the Program Specialist will sign in ink above or next to the electronica signature on these [Immediately, the CEO or designee shall review with all program specialist(s) the responsibilities of the program specialist position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. At least quarterly for 1 year, the CEO or designee shall review a 25% sample of individuals' ISP reviews to ensure the program specialist sign and date the individuals' ISP reviews as required. (AS 10/4/17)] 10/13/2017 Implemented
SIN-00101156 Renewal 09/23/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill record for the drill held on 7/27/16 did not include the time of the drill. [Repeated Violation 8/27/15 et al.]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. It will be the Residential Homes Manager's responsibility to ensure that all required documentation in each home's fire drill record is completed in its entirety and information included in correct. To accomplish this goal, the review of monthly fire drills has been included on a Monthly Residential Checklist. This list is to be completed by the Homes Manager and any oversights corrected prior to the completed checklist being submitted to the Residential Associate Director by the 5th of the following month. [Immediately, the CRO will review the fire drill documentation along with 6400.112(A)-(I) and revise as needed to ensure accurate documentation of fire drills. Immediately, the CRO will develop and implement policies and procedures to ensure fire drills are conducted and documented as require including evacuating in less than 2 and 1/2 minutes and procedures to follow if required evacuation time is not met. Within 30 days and continuing at least quarterly for 1 year all staff persons shall be trained in aforementioned policies and procedures. Within 60 days of receipt of the plan of correction, a program specialist(s) shall observe a fire drill at each community home to ensure an unannounced fire drill is completed and documented as required. At least quarterly, the CEO or designated management staff shall review all fire drill records to ensure fire drills are conducted and documented as required. Documentation of trainings and monthly and quarterly reviews of all fire drills shall be kept.(AS 11/7/16)] 10/13/2016 Implemented
6400.112(d)The fire drill held on 11/9/15 had an evacuation time of 4 minutes and 10 seconds. The fire drill held on 5/31/16 had an evacuation time of 4 minutes and 50 seconds. There is not an extended evacuation time specified in writing by a fire safety expert. [Repeated Violation 8/27/15 et al.] Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Staff were timing the fire drills completion when all individuals were at the designated meeting place. The licensing inspector at the time of review indicated that evacuation time is to indicated to end when all of the individuals reach the outside. Staff will be retrained on these new instructions and conduct the October 2016 fire drill during overnight hours using these indicators. It is expected that the total evacuation time will be under the allotted 2 and 1/2 minutes. If this is not the case, the home's staffing pattern will be adjusted to include more staff support on the overnight hours. [Immediately, the CRO will review the fire drill documentation along with 6400.112(A)-(I) and revise as needed to ensure accurate documentation of fire drills. Within 30 days of receipt of the plan of correction, the CRO will develop and implement policies and procedures to ensure fire drills are conducted and documented as require including evacuating in less than 2 and 1/2 minutes and procedures to follow if required evacuation time is not met. Within 30 days and continuing at least quarterly for 1 year all staff persons shall be trained in aforementioned policies and procedures. Within 60 days of receipt of the plan of correction, a program specialist(s) shall observe a fire drill at each community home to ensure an unannounced fire drill is completed and documented as required. At least quarterly, the CEO or designated management staff shall review all fire drill records to ensure fire drills are conducted and documented as required. Documentation of trainings and monthly and quarterly reviews of all fire drills shall be kept. (AS 11/7/16)] 10/31/2016 Implemented
6400.112(i)The fire alarm was not set off during the fire drill held on 3/31/16; rather staff yelled "fire" to alert the individuals in the home. A fire alarm or smoke detector shall be set off during each fire drill.The staff who conducted the drill on 3/31/16 has been reinstructed in the proper execution of a fire drill[Immediately, the CRO will review the fire drill documentation along with 6400.112(A)-(I) and revise as needed to ensure accurate documentation of fire drills. Within 30 days of receipt of the plan of correction, the CRO will develop and implement policies and procedures to ensure fire drills are conducted and documented as require including evacuating in less than 2 and 1/2 minutes and procedures to follow if required evacuation time is not met. Within 30 days and continuing at least quarterly for 1 year all staff persons shall be trained in aforementioned policies and procedures. Within 60 days of receipt of the plan of correction, a program specialist(s) shall observe a fire drill at each community home to ensure an unannounced fire drill is completed and documented as required. At least quarterly, the CEO or designated management staff shall review all fire drill records to ensure fire drills are conducted and documented as required. Documentation of trainings and monthly and quarterly reviews of all fire drills shall be kept. (AS 11/7/16)] 10/13/2016 Implemented
SIN-00083440 Renewal 08/27/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(g)The fire safety training for Direct Support Staff #1 was completed on 9/23/13 and 11/3/14.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). The Residential Office Manager will provide each Residential Homes Manager on a monthly basis a chart indicating due dates for each staff person they supervise which includes annual fire safety training. It will be the RHM's responsibility to notify and provide access to this annual training to each staff prior to it's due date. In addition, the Office Manager will provide a quarterly report to each staff delineating training needs and due dates.[As per conversation with CEO on 10/23/15, once employee completed the required training and notifies the residential manager who notifies the office manager. The office manager will update the chart and maintain in employee record. Examples of training tracking documents were sent to the department. (AS 10/23/15)] 10/03/2015 Implemented
6400.64(e)The trash receptacles located in the kitchen, the bathroom in between the bedrooms, and the bathroom near the kitchen area all measured 19 inches in height and did not have lids. Trash receptacles over 18 inches high shall have lids. Assigned Residential Homes Manager replaced trash receptacle in the kitchen with a lid on date of inspection. In addition, this position will be responsible to ensure all trash receptacles in the home meet the regulation standards.[As per our conversation on 10/23/15, Residential Manager is responsible to oversee the process for correcting physical site issues. Direct service workers were instructed on the process to contact the Residential Manager for repairs that they are not able to correct on their own. Residential manager conducts monthly staff meetings to review areas of concern including physical site issues. If after 3 months, the Residential Manager notices that physical site areas are not being addressed promptly or reported, the Residential Manager will develop a checklist to be completed by direct service workers upon monitoring the home. The checklist will be reviewed and filed by the Residential Manager and reviewed at least quarterly by the program specialist.(AS 10/23/15)] 10/03/2015 Implemented
6400.66The light outside of the sliding doors which exit from the kitchen area on to the back deck did not work and could pose a tripping and falling hazard at night. Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. All lights will be checked on a monthly basis by the assigned awake overnight staff person and light bulbs replaced when a problem is indicated.[As per our conversation on 10/23/15, Residential Manager is responsible to oversee the process for correcting physical site issues. Direct service workers were instructed on the process to contact the Residential Manager for repairs that they are not able to correct on their own. Residential manager conducts monthly staff meetings to review areas of concern including physical site issues. If after 3 months, the Residential Manager notices that physical site areas are not being addressed promptly or reported, the Residential Manager will develop a checklist to be completed by direct service workers upon monitoring the home. The checklist will be reviewed and filed by the Residential manager and reviewed at least quarterly by the program specialist. (AS 10/23/15)] 10/03/2015 Implemented
6400.112(c)The written fire drill record for the fire drill conducted in June 2015 did not include the full date. 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. A new training was developed and implemented which includes step by step instructions on the proper completion of a fire drill. It will be the responsibility of the Residential Homes Manager to review monthly fire drills for completeness and retrain when necessary.[As per conversation with CEO on 10/23/15, All staff were trained at the staff meeting as to the new process for completing fire drill documentation and instructions are maintained in the home for staff to review when completing a fire drill form. ¿Directions on how to fill out a fire drill log¿ document was submitted to the department on 10/1/15. Residential Manager will review fire drill documentation and retrain staff at staff meetings as needed. (AS 10/23/15)] 10/03/2015 Implemented
6400.112(d)The fire drill conducted on 11/26/14 had an evacuation time of 7 minutes and 30 seconds. The fire drill conducted on 1/19/15 had an evacuation time of 3 minute and 50 seconds. The fire drill conducted on 2/25/14 had an evacuation time of 4 minutes and 20 seconds. The fire drill conducted on 4/26/15 had an evacuation time of 6 minutes and 25 seconds. The fire drill conducted on 5/22/15 had an evacuation time of 7 minutes. The fire drill conducted in June, 2015 had an evacuation time of 6 minutes and 15 seconds. The most recent evacuation time specified in writing by a fire safety expert was dated 3/7/13. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Residential Homes Manager is to deliver a letter to the local fire department which indicates the longest amount of time evacuation takes for this home. If deemed an appropriate length of time, a fire company representative will be asked to sign a letter stating their approval. This letter will be filed in the fire drill log book. This process will be repeated annually if evacuation times are over two and a half minutes.[Within 1 month of receipt, the residential home managers will review and train on the fire drill procedures and completion of fire drill records at all homes. The evacuation time must be written by a fire safety expert designating a time period. If said letter is not obtained, the individuals must evacuate within 2 1/2 minutes. Fire drill logs from September, October and November, 2015 were submitted to the department demonstrating that individuals are evacuating in less than 2 1/2 minutes. Fire drill logs will be reviewed by the CEO or designee monthly for the next 6 months ensuring individuals are evacuating within 2 1/2 minutes, if evacuation times are not within required timeframes, CEO or designee will provide training, staffing etc. to ensure individuals' safety. (AS 12/28/15)] 10/03/2015 Implemented
SIN-00232942 Renewal 09/26/2023 Compliant - Finalized
SIN-00090072 Unannounced Monitoring 02/05/2016 Compliant - Finalized