Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00156718 Renewal 06/04/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill records for the fire drills held on 6/19/18, 7/9/18, 8/22/18, 9/24/18, 10/5/18, 11/10/18, 12/28/18, 1/25/19, 3/12/19 do not address problems encountered; this section was left blank.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. Historically, we have instructed staff to document on the fire drill only if there was a problem encountered. If nothing occurred, there would be no documentation in this section. This has been our process for many years. It has not been discussed with us during any previous licensing inspection that we were not meeting the regulation or that we needed to consider making any changes. This would have been greatly appreciated, as we always value the guidance received during inspections and have made adjustments as needed. Going forward, all staff at all homes will be instructed to document ¿none¿ under ¿Problems Encountered¿ if there is no occurrence to be documented. Specialists will be trained by the Associate Director on 7/1/19. In turn, Specialists will train the Supervisors and they will train the DSPs. This training will be completed by 7/31/19. We will continue our current fire drill review process with an emphasis on no part of the documentation being left blank. The Supervisor of each home will review the Fire Drill to ensure that staff running the drill has completed the documentation in its entirety. The Supervisor will present the drill to the Specialist, who will also review the drill for accuracy and completion. The drill will then be submitted to the next reviewer, who will do the same. The Associate Director, Community Living will then complete a final review of the drill before filing. 07/31/2019 Implemented
6400.181(a)The program specialist completed the annual assessment for Individual #1 on 5/26/17 and then again on 06/15/18. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The Person¿s last Assessment was completed on 6/15/18, which was five days past the grace period. The Person¿s current Assessment has been completed on 6/10/19. Each Specialist will identify the date of the current Assessment for each Person they support, utilizing a chart provided by the Associate Director. The Specialist will update the chart when Assessments are completed. This chart will be reviewed by the Associate Director (Pittsburgh) and Senior Specialist (Greensburg) on a monthly basis to ensure that Assessments are being worked on and completed prior to their due date. Specialists will be trained by the Associate Director on 7/1/19. 07/01/2019 Implemented
SIN-00105252 Renewal 12/13/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)Individual #1's bedroom did not have a mirror.In bedrooms, each individual shall have the following: A mirror. On 12/19/16, a mirror was placed in the Individual's bedroom. [Immediately and the vice president, residential supports shall ensure all staff persons working in community homes shall be educated of the requirements in all individuals' bedrooms as per 6400.(k)(1)-(6) and to check the bedroom throughout the course of their daily duties to ensure all required items are present. Immediately and at least quarterly, the program specialist(s) shall complete an onsite walk through of the homes to ensure are required bedroom items are present. Documentation of trainings and home checks shall be kept. (AS 1/12/17)] 01/10/2017 Implemented
SIN-00079708 Unannounced Monitoring 05/08/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.18(c)On Sunday, May 3, 2015 at approximately 4:30 PM Direct Service Workers #2 and #3 returned to the home with Individuals #1, #2, and #3. Individuals #1 and #2 got out of the van and were walking to the home. Direct Service Workers #2 and #3 reported that Direct Service Worker #1 opened the front window of the home and yelled that they could not come into the home. The incident was not reported in HCSIS until May 5, 2015.The home shall orally notify the county mental retardation program of the county in which the home is located, the funding agency and the appropriate regional office of mental retardation, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs. All staff are trained annually on Incident Management . This includes recognizing and reporting abuse, neglect and exploitation as well as required time frames and procedures for reporting. This is tracked and monitored by the Training and Development Manager and is documented on each employee¿s annual training record. In this case, the events of 5/3/15 was not recognized by the WC as a reportable incident. During a conversation between the Community Home Supervisor and the weekend coordinator (subsequently the initial reporter) on 5/4/15, the CH Supervisor felt that she needed to seek further clarification as to what had occurred on 5/3/15. The initial reporter was vague in her description. After further conversations and clarifications the CH Supervisor and the CH Specialist became aware that an incident needed to be filed in HCSIS. Though the incident was not filed within 24 hours of the time it occurred, it was filed within 24 hours of the time we became aware that an incident had in fact occurred. All staff will continue to receive annual mandatory training on Incident Management ( as described above). This training will continue to be tracked and monitored by the Training and Development Manager and will continue to be documented on each employee¿s annual training record. On 5/8/15, the WC was counseled and retrained on recognizing and reporting abuse, neglect and exploitation including reporting within the required time frame. 07/26/2015 Implemented
6400.33(a)On Friday, May 1, 2015 in the evening, Individuals #1, #2, and #3 were relocated to the home from their home because of a possible bedbug problem. On Sunday, May 3, 2015 at approximately 4:30 PM, Direct Service Workers #2 and #3 returned to the home with Individuals #1, #2, and #3. Individuals #1 and #2 got out of the van and were walking to the home. Direct Service Workers #2 and #3 reported that Direct Service Worker #1 opened the front window of the home and yelled that they could not come into the home. Direct Service Workers #2 and #3 assisted Individuals #1 and #2 back into the van. They returned to the home at approximately 6:45 PM after having dinner at a fast food restaurant. Individuals #1, #2, and #3 were assisted into the home. An individual may not be neglected, abused, mistreated or subjected to corporal punishment. All staff are trained annually on Incident Management . This includes recognizing and reporting abuse, neglect and exploitation as well as required time frames and procedures for reporting. This is tracked and monitored by the Training and Development Manager and is documented on each employee¿s annual training record. As a result of this incident, the target received a 5-day unpaid suspension . Upon returning to work on 6/2/15, the Agency Code of Conduct was reviewed and signed by the target. An agency corrective action was also completed, reviewed and signed by the target on 6/2/15 upon her return to work. The Corrective action included a review of Participant Rights as listed in the Chapter 6400 Regulations and clear expectations as to her job performance in order for her to continue her employment with the agency. The corrective action is kept in a file with Human Resources. The Community Home Supervisor will continue to monitor and report her progress and performance to the Community Home Specialist. Should additional areas of concern or training needs emerge they will be addressed by the Community Home Supervisor and reported the Community Home Specialist for follow-up. 07/26/2015 Implemented
SIN-00215193 Renewal 11/01/2022 Compliant - Finalized
SIN-00051285 Renewal 09/05/2013 Compliant - Finalized