Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00219191 Renewal 02/13/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Chief Executive Officer/Program Specialist #1 had a physical examination on 07/18/19, and then again on 09/29/21. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. The agency has re- implemented the staff tracking schedule, in which the agency will collect all staff record dates and place them into Google Calendar. The renewal completion due date will be set for 30 days prior to the expiration date of the current documents. For example, if a staff¿s physical expires on 04/30/23, the renewal completion due date will be 03/30/23. The schedule will be placed into google calendar, which all admin staff are connected via email. The administrative coordinator and staff supervisors will be responsible for the review of all staff documents. 03/15/2023 Implemented
SIN-00185648 Renewal 03/31/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106A furnace inspection was completed on 1/15/2020 and then again on 2/12/2021.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. It is now ALC policy that all furnace inspections be scheduled 30 days prior to the expiration of the current furnace inspection date. An ¿ALC Agency Schedule Calendar¿ has been created and is connected to the emails of the CEO and administrative assistant. The administrative assistant will be responsible for scheduling the furnace inspections with ARS. ¿ALC Agency Schedule Calendar¿ includes a December 5th 2021 schedule reminder (including two days & one day before) for the administrative assistant to contact ARS to schedule the next inspection for January 5, 2022. The confirmed scheduled appointment will be placed into the ¿ALC Agency Schedule Calendar¿. 04/12/2021 Implemented
6400.110(e)On 4/01/2021 at 12:06pm the smoke detectors of the home, which has 4 floors, were not interconnected.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. Smoke Detector- The 2nd floor smoke detector has been replaced with an interconnected smoke detector. ¿ Please see invoice 04/12/2021 Implemented
SIN-00169855 Renewal 02/06/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill record for the fire drills conducted on 3/4/19 and 4/13/19 did not include the amount of times it took for evacuation. This section was 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. A fire drill policy has been developed to prevent re-occurrence of this violation. The policy states that after each monthly fire drill is conducted and fire drill log is completed, dated, & signed; a supervisory or administrative staff member will review the fire drill log and initial if there are no errors. If there are errors, the fire drill will be performed again, and a new fire drill log will be completed and signed, in which a supervisory or administrative staff member will review the log and initial.112c [Within 30 days of receipt of the plan of correction, the CEO shall educate all staff person responsible for conducting, documenting and auditing fire drills and fire drill records of their responsibilities to ensure fire drills are conducted and documented as required. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 3/3/20)] 02/17/2020 Implemented
SIN-00150777 Renewal 02/27/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The fire drill held on 4/15/18 at 12:00PM had and evacuation time of 3 minutes and 15 seconds. The fire drill held on 6/10/18 at 10:00PM had and evacuation time of 2 minutes and 33 seconds. The fire drill held on 10/18/18 at 10:00PM had and evacuation time of 3 minutes and 37 seconds. The home does not have extended evacuation in writing time by a fire safety expert. 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. Alternative Living Concepts contacted the Fire Marshal of Penn Hills. On 3/5/19, he conducted a fire drill with both residents. As a result with difficulties with an individual, he increased the allotted time for the individual to 5 minutes. We have an official letter from on file: Please see contents of letter below: Municipality of Penn Hills A HOME RULE COMMUNITY Fire Marshal¿s Office 102 Duff Road ¿ Penn Hills, Pa 15235-3494 March 5, 2019 Ms. Venetta Greenhowe, On Tuesday March 5, 2019 I conducted and observed a fire exit drill at Alternative Living Concepts located at 9311 Frankstown Road, Pittsburgh, Pa 15235. During the exit drill two residents and one staff member participated. The one resident required more time than the allotted 2 ½ minutes to exit the structure due to difficulty following staff instructions. After observations made of the means of egress and fire detections of the residence I have authorized additional time to allow 5 minutes for this resident to safely evacuate the structure. If you have any questions or concerns about this matter please feel free to contact me at my office 412-342-1095. Thank you for your time and consideration with this matter. Sincerely, Charles J. Miller Charles J. Miller Chief Fire Marshal/Chief Code Inspector [At least quarterly, the CEO or designee shall audit all fire drill records to ensure all individuals are able to evacuate the home within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. Immediately, the CEO or designee shall develop a tracking system to ensure the a fire safety expert specifies evacuation time in writing yearly and available upon request by the Department. (DPOC by AES,HSLS on 3/6/19)] 03/05/2019 Implemented
6400.141(c)(14)The physical examination for Individual #1 dated 4/13/18 did not include medical information pertinent to diagnosis in case of emergency. This section was blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Medical information pertinent to diagnosis and treatment in case of an emergency has been completed on the physical as of 2/28/19. Going forward, accompanying staff will ensure all spaces of all forms are completed BEFORE leaving the appointment. If it is found that a space is incomplete, staff will inform medical staff and have the form completed in entirety before leaving appointment. Staff are required to bring all completed forms to office, where the office manager will also review the form to ensure all spaces are completed. If it is found that the form is incomplete, office manager will take form to medical office immediately (in person) and have it completed. Office manager will ensure form is completed in entirety BEFORE leaving medical office. [Prior to assisting individuals on medical appointments, the CEO or designee shall train the staff persons on the aforementioned procedures and the requirements of physical examinations as per 6400.141(c)(1)(15). Documentation of the training shall be kept. (DPOC by AES,HSLS on 3/6/19)] 02/28/2019 Implemented
6400.164(a)Individual #1's February 2019 Medication Administration Record lists Oxcarbazepin Tab 600mg, give 1 tab by mouth twice a day. A blister pack of Carbazepin Tab 300mg, give 1 tablet by mouth every morning, had "bedtime" in handwriting and was dated as used for administration of 2 tablet at 8:00PM from 2/23/19 to 2/29/19.A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. Alternative Living Concept has developed the Medication Label Assurance Policy, which states: All med trainers are responsible for removing all discontinued/ old medications from the individuals' locked med boxes. Med trainers are responsible to complete appropriate documentation on MAR reflecting the discontinuance of the medication including date of discontinuance. In addition, all med trainers are responsible to place all new and delivered medications into the individual's med box of whom it was prescribed to. Med trainers are also responsible for completing appropriate documentation on MAR reflecting the new medication, if applicable, including dosage, time, date, and prescribing doctor. Med trainers will also be responsible for reviewing all MARs and locked medication boxes of all individuals. This will ensure that all individuals receive the current and correct medications, including medications prescribed, dosage, date, and prescribing doctor. All med trainers have received training on this policy and have signed and dated acknowledgement of training of this policy. 03/01/2019 Implemented
SIN-00131404 Renewal 03/19/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(c)Individual #1 had a psychiatric medication review completed 9/25/17 then again 2/28/18. Individual #1's psychiatric medication review completed 4/24/17 did not include the medications and the necessary dosages. (Repeated Violation-4/19/17, 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.the psychiatric medication review form was revised to include the medication and necessary dosage. Going forward, the revised PMR sheet will be used for all future PMRs. The PMRs for 7/17/17, 9/25/17, and 2/28/18, indicate that the revised sheet has been implemented, as these appointments were completed using the revised PMR sheet. Going forward, office manager will highlight all areas including medications and the necessary dosages.. A note will also be accompanied with the physical form for the doctor to complete ALL spaces of the PMR form. In addition, ALC staff attending appointment must ensure PMR sheet is complete in entirety. upon return of PMR form, office manager will also ensure PMR form is complete in its entirety. if not completed, office manager will contact psychiatrist to have form completed (documentation of all communications regarding the form in question will be kept in the individual's file.) [Immediately, the CEO shall develop and implement a tracking system to ensure timely completion of psychiatric medication reviews. Immediately, the CEO shall educated all staff persons responsible for ensuring timely completion of psychiatric medication reviews with all required information of their responsibilities to ensure timely completion with all required information as per 6400.163(c), aforementioned tracking system and the medical orders are followed and individuals are administered medications as prescribed. Documentation of the training shall be kept. Upon completion of psychiatric medication review, at least 2 staff persons trained as stated above shall audit the psychiatric medication review documentation to ensure all required information is included and orders are followed and medications are administered as prescribed. Documentation of audits shall be kept. (AS 4/12/18)] 07/17/2017 Implemented
SIN-00112505 Renewal 04/19/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101The door on the second floor leading to the attic was equipped with a padlock.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The padlock was removed, and a simple push lock handle was installed. Ongoing, to alleviate non compliance of this area, ALC will only install simple door handles and simple push locks to keep all doorways unobstructed. [On 6/23/17, the Department verified that the padlock was removed. Immediately and continuing at least monthly, the Program Specialist shall complete an onsite monitoring of all stairways, halls, doorways, passageways and exits from rooms and from the building to ensure all are unobstructed. Within 30 days of receipt of the plan of correction, all staff persons shall be trained to check to ensure stairways, halls, doorways, passageways and exits from rooms and from the building are unobstructed and to monitor throughout the course of their daily duties. (AS 7/5/17)] ] 05/05/2017 Implemented
6400.163(c)The psychiatric medication reviews completed for Individual #1 on 5/2/16, 9/7/16 and 11/18/16 did not include the necessary dosage. The psychiatric medication reviews completed for Individual #1 on 5/2/16 and 11/18/16 did not include the reason for prescribing the medication. The psychotropic medication reviews completed for Individual #2 on 6/27/16, 8/29/16, 11/14/16 and 2/6/17 did not include the reason for prescribing the medication. [Repeat violation 4/28/16 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.In order to correct this area of non- compliance, ALC will request the doctor of individual #1 to complete missing information for appointments dated for 5/2/16 and 11/18/16. ALC will request the doctor of individual #2 to complete missing information for appointments dated for 6/27/16, 8/29/16, 11/14/16 and 2/6/17. Ongoing, to alleviate recurrence of this area of non compliance, ALC will revise medication appt form to include the following changes: List of current Prescribed psychotropic medications, current dosage, reason for prescribing medication and the need to continue; the doctor will have the option to sign off with no changes, or if changes occur, the doctor will thoroughly document the change including the medication dosage, need to continue, and reason for prescription. completed with doctor's signature, date, and stamp. [Individual #1's psychiatric medication review completed 5/2/16, 9/7/16, 11/18/16 and 6/2/17 was update include missing required information. Individual #2's psychiatric medication review completed 4/24/17 did not include the dosages of the medications. On 6/27/17, the office manager sent Individual #2's psychiatric medication review to prescribing physician to have the documentation completed to include all required information. Immediately upon completion of the psychiatric medication review documentation by the physician, the program specialist or designee shall review to ensure all required information is included and will follow up and obtain missing information. At least quarterly for 1 year, the CEO or designee shall review the documentation to ensure all required information is included. Documentation of review shall be kept.(AS 7/6/17)] 05/05/2017 Implemented
6400.181(e)(1)Individual #1's assessment, completed 9/1/16, and Individual #2's assessment, completed 10/20/16, do not include functional strengths, needs and preferences. The assessment must include the following information: Functional strengths, needs and preferences of the individual. In order to correct this area of non- compliance, ALC has developed and additional page for current completed assessments to include the functional strengths, needs and preferences of the individuals. This page was added and completed to the current Assessments of individual #1 and #2. Ongoing, to alleviate the area of non compliance, ALC has revised the current Assessments used to include the functional strengths, needs and preferences of the individual. These new assessments will be used for all current and future individuals. [On 5/12/17, Individual #1's and Individual #2's assessments were updated to include functional strengths, needs and preferences. A new assessment form has been developed. For at least one year, upon completion by the program specialist, the CEO shall review all individuals' assessments to ensure all individuals' assessments are completed timely and include all required information. Documentation of reviews by the CEO shall be kept. (AS 7/5/17)] 05/05/2017 Implemented
6400.181(e)(2)Individual #1's assessment, completed 9/1/16, and Individual #2's assessment, completed 10/20/16, do not include likes, dislikes and interests.The assessment must include the following information: The likes, dislikes and interest of the individual. In order to correct this area of non- compliance, ALC has developed and additional page for current completed assessments to include the likes, dislikes and interest of the individuals. This page was added and completed to the current Assessments of individual #1 and #2. Ongoing, to alleviate the area of non compliance, ALC has revised the current Assessments used to include the likes, dislikes and interest of the individual. These new assessments will be used for all current and future individuals. [On 5/12/17, Individual #1's and Individual #2's assessments were updated to include likes, dislikes and interests. A new assessment form has been developed. For at least one year, upon completion by the program specialist, the CEO shall review all individuals' assessments to ensure all individuals' assessments are completed timely and include all required information. Documentation of reviews by the CEO shall be kept. (AS 7/5/17)] 05/05/2017 Implemented
6400.181(e)(9)Individual #1's assessment, completed 9/1/16, and Individual #2's assessment, completed 10/20/16, do not include functional and medical limitations.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. In order to correct this area of non- compliance, ALC has developed and additional page for current completed assessments to include Documentation of the individual's disability, including functional and medical limitations of the individual. This page was added and completed to the current Assessments of individual #1 and #2. Ongoing, to alleviate the area of non compliance, ALC has revised the current Assessments used to include Documentation of the individual's disability, including functional and medical limitations of the individual. These new assessments will be used for all current and future individuals. [On 5/12/17 Individual #1's and Individual #2's assessments were updated to include functional and medical limitations. A new assessment form has been developed. For at least one year, upon completion by the program specialist, the CEO shall review all individuals' assessments to ensure all individuals' assessments are completed timely and include all required information. Documentation of reviews by the CEO shall be kept. (AS 7/5/17)] 05/05/2017 Implemented
6400.181(e)(10)Individual #1's assessment, completed 9/1/16, and Individual #2's assessment, completed 10/20/16, do not include a lifetime medical history.The assessment must include the following information: A lifetime medical history. In order to correct this area of non- compliance, ALC has developed and additional page for current completed assessments to include A lifetime medical history. of the individual. This page was added and completed to the current Assessments of individual #1 and #2. Ongoing, to alleviate the area of non compliance, ALC has revised the current Assessments used to include A lifetime medical history of the individual. These new assessments will be used for all current and future individuals. [On 5/12/17 Individual #1's and Individual #2's assessments were updated to include a lifetime medical history. A new assessment form has been developed. For at least one year, upon completion by the program specialist, the CEO shall review all individuals' assessments to ensure all individuals' assessments are completed timely and include all required information. Documentation of reviews by the CEO shall be kept. (AS 7/5/17)] 05/12/2017 Implemented
6400.181(e)(12)Individual #1's assessment, completed 9/1/16, and Individual #2's assessment, completed 10/20/16, do not include recommendations for specific areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. In order to correct this area of non- compliance, ALC has developed and additional page for current completed assessments to include Recommendations for specific areas of training, programming and services. This page was added and completed to the current Assessments of individual #1 and #2. Ongoing, to alleviate the area of non compliance, ALC has revised the current Assessments used to include Recommendations for specific areas of training, programming and services. These new assessments will be used for all current and future individuals. [On 5/12/17 Individual #1's and Individual #2's assessments were updated to include recommendations for specific areas of training, programming and services. A new assessment form has been developed. For at least one year, upon completion by the program specialist, the CEO shall review all individuals' assessments to ensure all individuals' assessments are completed timely and include all required information. Documentation of reviews by the CEO shall be kept. (AS 7/5/17)] 05/12/2017 Implemented
6400.181(e)(13)(v)Individual #1's assessment, completed 9/1/16, and Individual #2's assessment, completed 10/20/16, do not include progress over the last 365 calendar days and current level in the area of socialization.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. In order to correct this area of non- compliance, ALC has developed and additional page for current completed assessments to include the individual's progress over the last 365 calendar days and current level in Socialization. This page was added and completed to the current Assessments of individual #1 and #2.Ongoing, to alleviate the area of non compliance, ALC has revised the current Assessments used to include the individual's progress over the last 365 calendar days and current level in Socialization. These new assessments will be used for all current and future individuals. [On 5/12/17 Individual #1's and Individual #2's assessments were updated to include progress over the last 365 calendar days and current level in the area of socialization. A new assessment form has been developed. For at least one year, upon completion by the program specialist, the CEO shall review all individuals' assessments to ensure all individuals' assessments are completed timely and include all required information. Documentation of reviews by the CEO shall be kept. (AS 7/5/17)] 05/12/2017 Implemented
6400.181(e)(13)(vi)Individual #1's assessment, completed 9/1/16, and Individual #2's assessment, completed 10/20/16, do not include progress over the last 365 calendar days and current level in the area of recreation.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. In order to correct this area of non- compliance, ALC has developed and additional page for current completed assessments to include the individual's progress over the last 365 calendar days and current level in recreation. This page was added and completed to the current Assessments of individual #1 and #2. Ongoing, to alleviate the area of non compliance, ALC has revised the current Assessments used to include the individual's progress over the last 365 calendar days and current level in recreation. These new assessments will be used for all current and future individuals. [On 5/12/17 Individual #1's and Individual #2's assessments were updated to include progress over the last 365 calendar days and current level in the area of recreation. A new assessment form has been developed. For at least one year, upon completion by the program specialist, the CEO shall review all individuals' assessments to ensure all individuals' assessments are completed timely and include all required information. Documentation of reviews by the CEO shall be kept. (AS 7/5/17)] 05/12/2017 Implemented
6400.181(f)The program specialist did not provide Individual #1's assessment, completed 9/1/16, and Individual #2's assessment, completed 10/20/16, to the SC and plan team members including Individual #1's behavior supports and Individual #2's day program.(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). Revised assessments of Individual #1 and # 2 will be sent to SC, and plan team members including behavior supports and day program upon completion. Ongoing, to alleviate the recurrence of this area of non- compliance, ALC has developed an " Assessment Checklist" which includes the process/ info of the completion of the assessment, including sending assessment to corresponding team, and 30 days prior to ISP meeting, Once ALC receives the ISP invite, program specialist will send completed Assessment s to SC, Plan team including Behavior supports and day program. [On June 30, 2017, the updated assessments for Individual #1 and Individual #2 were provide to the missed plan team members and documentation of the correspondence is kept in the individuals' record. At least quarterly for 1 year, the CEO shall review the correspondence documentation and aforementioned check list to ensure the program specialist provide all individuals' assessments to the plan team member, timely. Documentation of the reviews by the CEO shall be kept. (AS 7/5/17)] 05/05/2017 Implemented
6400.186(a)The program specilaist did not complete an ISP review for Individual #1 and Individual #2 for the review periods of 10/1/16 through 12/31/16 and 1/1/17 through 3/31/17.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. In order to address this area of non compliance, the Program Specialist, Venetta Greenhowe, will complete the ISP review for individual #1 , for the period of 1/1/17- 3/31/17 (since it just past). Ongoing, to avoid re-occurrence of non compliance of this area, ALC has developed a "3 Month ISP Review Schedule, effective current quarter: (2nd: 4/1/17- 6/30/17.) and so on, to ensure all Quarterly ISP Reviews are completed in a timely matter. All individuals enrolled at ALC will follow this schedule to ensure non- compliance never occurs again. [Individual #1 and Individual #2 for the review periods of 10/1/16 through 12/31/16 and 1/1/17 through 3/31/17 were completed. A "3 month ISP review schedule" had been developed for the program specialist to utilize. At least quarterly for 1 year, the CEO shall review the completed 3 month reviews and the aforementioned tracking system to ensure the program specialist has completed all individuals' ISP reviews, timely. Documentation of the reviews by the CEO shall be kept. (AS 7/5/17)] 05/05/2017 Implemented
SIN-00093785 Renewal 04/28/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed the self-assessment on 1/27/16. The agency's certificate of compliance expires on 4/10/16.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. To ensure ALC completes self- assessment with 3-6 months of the expiration of agency license, self- assessments will be completed 6 months prior to expiration of license. It will be completed no later than November 30, 2016. Ongoing, Self inspections will be completed exactly months prior to the expiration of the agency license. [CEO or designated staff person will complete the self-assessments within the required timeframes and CEO or designated staff person will review self-assessments to ensure timely completion. Documentation of reviews shall be kept. (AS 7/6/16)] 04/29/2016 Implemented
6400.21(a)Direct Service Worker #2, date of hire 8/25/15, did not have a Pennsylvania criminal history record check completed until 3/30/16.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. Forms were misplaced during transitions, new clearances were completed on 03/30/16. This indicated staff had no criminal record. Ongoing, CEO will ensure an application for a Pennsylvania criminal history record check will be submitted to the State Police for prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. [Immediately, CEO will develop and implement policies and procedures to ensure all staff person have all required information prior to hire including Pennsylvania criminal history check is submitted to State Police. CEO will review all required information to ensure completion prior to hire of staff persons. Documentation of reviews shall be kept. (AS 7/6/16)] 04/29/2016 Implemented
6400.31(b)The Individual "Rights" form signed by Individual #2, date of admission 9/2/15, was not dated; therefore, compliance is not able to be measured. The "Rights" forms for Individual #2, date of admission 9/2/15 and for Individual #1, dated 10/16/15, did not state the full rights per regulation 33(h) regarding access to a telephone and the opportunity to receive and make private calls, with assistance when necessary.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. Individual "Rights" for both individual #1 and individual #2 were revised to include the full right per regulation 33(h) regarding access to a telephone and the opportunity to receive and make private calls, with assistance when necessary.In addition, Individual rights were revised on 4/28/16. Upon this revision, individual #1 & #2 were given/ reviewed the rights, which were signed and dated upon completion if review, by both individual #1 and # 2. Ongoing, the revised individual rights will replace the old one. New admissions will be given the revised rights and ALL individuals will use the revise rights on an annual basis.[Individual #1 and Individual #2 signed complete "rights form" on 4/29/16. Immediately, CEO will develop and implement policy and procedure to ensure all individuals sign and date statements receipt of information on right within required timeframes. Staff will be trained on the aforementioned policy and procedure. (AS 7/6/16)] 04/29/2016 Implemented
6400.44(b)(1)The program specialist did not fully complete the initial assessment dated 10/28/15 for Individuals #1, date of admission 10/18/15. The program specialist did not fully complete the initial assessment dated 9/11/15 and 9/23/15 for Individual #2, date of admission 9/2/15.The program specialist shall be responsible for the following: Coordinating and completing assessments. Venetta Greenhowe reviewed and completed all assessment information for individual #1 and individual #2. Ongoing- Program Specialist will ensure completion if assessments for all individuals on an annual basis. to ensure completion, CEO will spot check all assessment documentation. [Acting Program Specialist updated the assessments for Individual #1 and Individual #2 on 5/26/16. Upon completion and at least quarterly of all individual's assessment by the program specialist the CEO will review to ensure accurate and timely completion of the assessment. Documentation of reviews of the assessments shall be kept. (AS 7/6/16)] 06/05/2016 Implemented
6400.44(c)Staff Person #3, hired for the program specialist position on 8/25/15, does not meet work experience required for the program specialist position. A program specialist shall have one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 1 year work experience working directly with persons with mental retardation. (2) A bachelor's degree from an accredited college or university and 2 years work experience working directly with persons with mental retardation. (3) An associate's degree or 60 credit hours from an accredited college or university and 4 years work experience working directly with persons with mental retardation.Program specialist qualifications were sent to Amy Scharf, who sent them to Harrisburg for review. Until a determination is made on the qualifications of C. J. Brundage, Venetta Greenhowe has assumed responsibility as program specialist, effective 4/28/16. Venetta Greenhowe meets the qualifications of program specialist. Venetta Greenhowe has reviewed, completed, and signed all program specialist documents. [Staff Person #3 submitted a copy of a diploma of a bachelor of arts degree and Employee Earning Record with a date of hire of 1/22/13 to 5/2/16 working in an after school program with an individual with diagnosed intellectual disability thus qualifying for group (2) of the qualifications for Program Specialist. Prior to hiring, CEO will review qualifications required for all positions including the program specialist position. Documentation of qualifications and reviews shall be kept. (AS 7/6/16)] 04/28/2016 Implemented
6400.46(c)Chief Executive Officer #4, dated of hire 8/25/14, had 19 hours of training relevant to human services or administration in training year January 1, 2015 to December 31, 2015. The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually.Medication Administration training was not counted in the 19 hours. According to Larry Mazza, staff may count 6 hours of training for medication administration training. See attached training verification from med trainer keesha sheffey, and email from Larry Mazza with supporting documents. Therefore, CEO has a total of 25 training hours after including the 6 hours of med training. [CEO will maintain documentation of annual training to ensure required annual training is completed. (AS 7/6/16)] 05/02/2016 Implemented
6400.68(b)At 2:48 PM, the hot water temperature measured at 123.2 degrees Fahrenheit at the bathtub in the second floor bathroom Hot water temperatures in bathtubs and showers may not exceed 120°F. on 4/28/16, Rooter Service Inc. sent a plumber to decrease the water temperature on the electric water heater to 114 degrees Fahrenheit. Ongoing, to ensure correct water temperature is in compliance ALC staff will complete a weekly water temp check, which will be recorded, signed and dated. [Immediately, CEO will develop and implement procedures to check temperatures and have adjustments made to ensure the hot water temperature in all bathtubs and showers does not exceed 120°F. All staff shall be trained in aforementioned procedures. Documentation of weekly water temperature checks shall be kept and reviewed at least monthly by the program specialist or CEO to ensure completion and the hot water temperatures do not exceed 120°F. Documentation of all reviews and trainings shall be kept. (AS 7/6/16)] 04/28/2016 Implemented
6400.74The outside steps leading from the front door to the driveway of the home did not have a nonskid surface.Interior stairs and outside steps shall have a nonskid surface. Non skid surface was applied to the outside steps leading from the front door to the driveway of the home. Ongoing, CEO will ensure ALL interior stairs and outside steps have a nonskid surface. [Pictures of outside steps were received by the department on 6/9/16. (AS 7/6/16)] 06/05/2016 Implemented
6400.77(b)The first aid kit did not contain a thermometer. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. A thermometer was obtained during the inspection, on 4/28/16, from the 1st floor 1st aid kit at 9311 frankstown road, and placed to the 2nd floor 1st aid kit at 9311 frankstown road. Ongoing, CEO will ensure thermometer is on the 1st aid kit checklist in addition to ensuring all 1st aid kits have a thermometer inside. Staff will conduct a 1st aide kit check every 3 months. [Immediately, CEO will train all staff working in the community homes of what is required to be in all first aid kits and the procedure for checking and obtaining missing or depleted items. At least monthly, the program specialist will check first aid kits to ensure all required items are present. Documentation of trainings and monthly checks shall be kept. (AS 7/6/16)] 04/28/2016 Implemented
6400.141(c)(3)The physical examination completed on 4/12/16 for Individual #2, date of birth 8/29/92, does not include immunizations.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. updated immunization record has been requested and obtained from PCP for individual #2. It has been attached to individual #2's 4/12/16 physical exam. Immunization records have been added and highlighted as a mandatory regulatory piece to the physical examination. in addition, staff have been trained to obtain immunization records at each doctor visit if applicable. [Prior to entering into the individual's record, the CEO or designated staff person who has been trained on the information required in the physical examinations will review the all physical examination to ensure all required information is present and will obtain missing information including immunizations. Documentation of trainings and reviews shall be kept. (AS 7/6/16)] 04/29/2016 Implemented
6400.141(c)(11)The physical examination for Individual #2, completed on 4/12/16 does not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. A "missing information" request form was sent to the PCP of individual #2 for appointment 4/12/16 to include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals... we are awaiting a response.Long term: Individual physical form has been revised to include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. as a mandatory regulatory piece. the revised physical form will be used for all future doctor appointments.[Prior to entering into the individual's record, the CEO or designated staff person who has been trained on the information required in the physical examinations will review the all physical examination to ensure all required information is present and will obtain missing information including assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Documentation of trainings and reviews shall be kept. (AS 7/6/16)] 04/29/2016 Implemented
6400.141(c)(13)The physical examination for Individual #2, completed on 4/12/16 does not include contraindicated medications.The physical examination shall include: Allergies or contraindicated medications.A "missing information" request form was sent to the PCP of individual #2 for appointment 4/12/16 to include allergies or contraindicated medications.. we are awaiting a response. Long term: Individual physical form has been revised to include allergies or contraindicated medications. as a mandatory regulatory piece. the revised physical form will be used for all future doctor appointments.[Prior to entering into the individual's record, the CEO or designated staff person who has been trained on the information required in the physical examinations will review the all physical examination to ensure all required information is present and will obtain missing information including contraindicated medications. Documentation of trainings and reviews shall be kept. (AS 7/6/16)] 04/29/2016 Implemented
6400.141(c)(14)The physical examination for Individual #1, completed on 11/9/15 does not include medical information pertinent to diagnosis and treatment in case of an emergency. The physical examination for Individual #2, completed on 4/12/16 does not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. short term: A "missing information" request form was sent to the PCP of individual #1 for appointment 11/9/15 to include medical information pertinent to diagnosis and treatment in case of an emergency. we are awaiting a response. A "missing information" request form was sent to the PCP of individual #2 for appointment 4/12/16 to include medical information pertinent to diagnosis and treatment in case of an emergency. we are awaiting a response.Long term: Individual physical form has been revised to include medical information pertinent to diagnosis and treatment in case of an emergency as a mandatory regulatory piece. The revised physical form will be used for all future doctor appointments.[Prior to entering into the individual's record, the CEO or designated staff person who has been trained on the information required in the physical examinations will review the all physical examination to ensure all required information is present and will obtain missing information including medical information pertinent to diagnosis and treatment in case of an emergency. . Documentation of trainings and reviews shall be kept. (AS 7/6/16)] 04/29/2016 Implemented
6400.151(a)The physical examination for Direct Service Worker #2, date of hire 8/25/15 was completed on 12/12/15. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Initial physical was misplaced. In the future, all physicals will be placed directly in employee file. in addition, CEO will ensure all staff have a physical examination within 12 months prior to employment and every 2 years thereafter. [Immediately, CEO will develop and implement a tracking system to ensure timely completion of staff physicals. CEO will review all staff physical examination to ensure completion within the required timeframes. Documentation in the tracking system and of the reviews shall be kept. (AS 7/6/16)] 04/29/2016 Implemented
6400.151(c)(3)The physical examinations for Direct Service Worker #1, completed 8/25/15; Direct Service Worker #2, completed 12/12/15 and Program Specialist #3, completed 3/24/16 do not include a signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. The physical examinations for Direct Service Worker #1, completed 8/25/15; Direct Service Worker #2, completed 12/12/15 and Program Specialist #3, completed 3/24/16, have all been revised. Employees 1,2 & 3 have revised staff physical form completed by PCP to include a signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken. Long term- ALC has revised the employee health assessment form to include: a signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken. The revised employee health assessment will be used for all future physical examinations for all employees. [CEO or designated staff person will review all staff persons physical examination to ensure all required information is present and will obtain missing information within the required timeframes. Documentation of reviews shall be kept. (AS 7/6/16)] 04/28/2016 Implemented
6400.163(c)The medication reviews dated 11/2/15, 1/11/16 and 4/4/16 for Individual#1, who is prescribed medication to treat symptoms of diagnoses including schizophrenic tendencies, anxiety and agitation did not include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. The medication reviews dated 11/10/15 and 2/8/16 for Individual #2 who is prescribed medications to treat symptoms of diagnoses including autism and obsessive compulsive disorder, did not include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. 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 "missing information" request form was sent to the doctor for individual #1 who is prescribed a medication to treat symptoms of a diagnosed psychiatric illness , regarding appointments 11/2/15, 1/11/16, and 4/4/16, to include the reason for prescribing the medication, the need to continue the medication and the necessary dosage.- we are still awaiting a response.a "missing information" request form was sent to the doctor for individual #2 who is prescribed a medication to treat symptoms of a diagnosed psychiatric illness , regarding appointments 11/10/15 and 2/8/16, to include the reason for prescribing the medication, the need to continue the medication and the necessary dosage.- the doctor has completed the requested information and it has been placed in individual #2's file. ongoing, the medical appointment form has been revised to include the following as mandatory regulatory information: 1. the reason for prescribing the medication 2. the need to continue the medication. 3. the necessary dosage. The revised medical appointment sheet will be used for all future appointments. [Prior to entering in the Individual's record, CEO or designated staff person will review documentation to ensure all required information is present and followed. Staff involved in ensuring individuals physician appointments shall be trained in the required information of psychiatric medication reviews. Documentation of trainings and reviews shall be kept. (AS 7/6/16)] 04/29/2016 Implemented
6400.183(5)Individual #1 who is prescribed Quetiapine and Olanzapine for schizophrenic tendencies, Lorazepam for anxiety and Clonazepam for agitation did not have a protocol to address the social, emotional and environmental needs of the individual. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. ALC has developed a protocol to address the social, emotional, and environmental needs of Individual #1, who is prescribed medication to treat symptoms of a diagnosed psychiatric illness. The SEE plan was reviewed with individual #1 dated and signed by both individual #1 and by ALC planning team members. The SEE Plan was submitted to individual #1's SC to be included in ISP. Ongoing, all individuals that are prescribed a medication to treat the symptoms of a diagnosed psychiatric illness, will have a protocol developed as part of the ISP, to address the social, emotional, and environmental needs of the individual. Upon completion of each SEE plan, program specialist will submit plan to SC to be input into the ISP [SEEPlan was implemented o 4/29/16. (AS 7/6/16)] 05/02/2016 Implemented
6400.186(b)The program specialist, Individual #1 and Individual #2 did not sign the 3 month ISP reviews dated January 2016. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Program Specialist, Individual #1, and Individual have re-reviewed, completed, sign, and dated the 3 month ISP review for January 2016. Ongoing, Upon completion of each 3 month ISP Review, the program specialist, and each individual will sign and date the 3 month ISP review. [Upon completion the CEO will review ISP reviews to ensure Individual and Program specialist sign and date the reviews as required. Documentation of reviews shall be kept. (AS 7/6/16)] 06/03/2016 Implemented
6400.186(e)The program specialist did not notify the plan team members for Individuals #1 and #2 of the option to decline the ISP review documentation. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. Program Specialist has sent ISP Review documentation to plan team members for both individual #1 and individual #2. In addition, the ISP review was sent with a "Declination of ISP Review documentation" form, in order to notify the plan team members, of individual #1 and individual #2, of the option to decline the ISP review documentation. ongoing, the program specialist will ensure upon each completion of ISP Reviews, for individual #1 and individual #2, Documentation will be sent to plan team members in addition to always attaching the "declination of ISP review documentation" form to ensure the all plan team members, of both individual #1 and individual #2, are notified of their option to decline the ISP review documentation. [The plan team members for Individual #1 and Individual #2 were informed of the option to decline ISP review documentation on 5/6/16. CEO will review the aforementioned process and ISP review documentation at least every 6 months to ensure all plan team members are notified of the option to decline ISP review documentation. (AS 7/6/16)] 06/03/2016 Implemented
SIN-00238722 Renewal 02/06/2024 Compliant - Finalized
SIN-00202478 Renewal 03/02/2022 Compliant - Finalized