Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00214317 Renewal 11/03/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace was inspected and cleaned on 2/17/2021 and then again on 3/7/2022.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. Allegheny Community Home Care has already scheduled a furnace inspection for 1/15/2023. That would be the first one for the 2023 year. 01/15/2023 Implemented
6400.181(a)Individual #1's annual assessment was completed on 9/2/2021 and then again on 9/26/2022. 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. Allegheny Community Home Care current program specialist was retrained on ISP documentation and annual reporting measures as it pertains to the annual assessment. 01/05/2023 Implemented
6400.181(f)The program specialist provided Individual #1's assessment, completed 9/26/2022, to the Individual #1's plan team members on 10/5/2022 for an Individual Plan meeting on 10/13/2022.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Allegheny Community Home Care current program specialist was retrained on ISP documentation and annual reporting measures as it pertains to the annual assessment. 01/05/2023 Implemented
SIN-00186726 Renewal 04/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.169(a)Direct Service Worker #1 was trained in medication administration on 4/24/2020 by Chief Executive Officer #2. Chief Executive Officer #2's medication trainer certificate expired 12/01/2019 and did not recertify certificate until 4/27/2020. Direct Service Worker #1 administered Clonazepam 1mg tab, with instructions to take 1 tablet by mouth at bedtime, to Individual #1 at 8:00pm on 4/01/2021, 4/04-4/08/2021, and 4/12-4/14/2021.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).(3) During the COVID pandemic, Governor Wolf shut down the state of PA on 3/17/20 and everyone was instructed to remain in the house unless it was life-threatening. There was no availability to safely secure a certified medication trainer to come into the home and do the observation on an already trained staff. The CEO safely completed the observation and documented the paperwork. The CEO had completed the renewal for the medication recertification, however due to the pandemic the final test was not finished until April 2020. (4) Allegheny Community Home Care CEO will ensure all staff are trained by a licensed professional prior to administering medication. On 4/15/21 the CEO had the staff in question retrained on medication administration by a licensed medication trainer. 04/14/2021 Implemented
SIN-00131408 Renewal 03/16/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.161(e)Selenium sulfide 1% shampoo, apply topically every Sunday and Thursday prescribed to Individual #1 was in Individual #1's medication box, but was not on Individual #1's March 2018 Medication Administration Record.Discontinued prescription medications shall be disposed of in a safe manner.Violation 55 PA Code Chapter 6400.161(e) Medications often are changed based on poor response to the medication or finishing medication like an antibiotic used to treat a temporary condition. In order to communicate that the medications is no longer being given, ACHC will document the discontinued of the medication. On the MAR ACHC will use single lines that clearly indicate the discontinuation without obliteration of the information. The medication trainer will put a single line through all of the times in the hour of administration column. In the date box following the last initialed dose of the mediation an ¿I¿ will be entered. In the box after that, draw a single line through all of the dates and time boxes to the end of the MAR row. On the line, write ¿discontinued initials and the date and then add a note about what occurred. The container with the discontinued medication will be removed from the storage area and disposed according to ACHC policy. ACHC will ensure all individual¿s medication will be disposed of in a safe manner. ACHC will use a medication destruction form to properly record disposal of all medications. ACHC will use the proper destruction methods outline in ACHC medication policy: 1. to flush medication down the toilet or 2. Return the discontinued medications back to the pharmacy. III. Destruction Method A. Medications will be destroyed by flushing down the toilet B. Medications will be destroyed by returning medication back to the pharmacy. Upon notification from the physician of a discontinued medication, the medication trainer will go the site and discontinue the medication on the MAR and use the medication destruction form to properly dispose the discontinued medication with the second witness as a staff member. The medication trainer will conduct all medication disposals with the second witness of a staff member. Quarterly retraining of medication destruction will be conducted by the medication trainer to the staff. The director of operations will monitor the medication trainer¿s duties of the proper disposal of medication. On March 16th, the medication trainer was notified that there was medication not properly destroyed/discontinued. The medication trainer immediately created a medication destruction form. This form was then approved by the director of operations. The medication trainer immediately filled out the medication destruction form and destroyed the medication at site #0001. The medication trainer then completed staff training at each site, and reviewed the medications at all other sites for accuracy. 03/16/2018 Implemented
SIN-00111815 Renewal 03/24/2017 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 within 3 to 6 months prior to the expiration date of the agency's certificate of compliance.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. ACHC will 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 VP, Blythe Smith will ensure that the self-assessments are completed accurately and timely moving forward. On March 27th, Blythe Smith submitted the self-assessment paperwork. The CEO, Tonja Smith reviewed the document for accuracy and placed the completed assessment in ACHC licensing folder. Immediately on site training was held to communicate the infraction and to ensure it doesn¿t happen again. In addition, the management team scheduled a meeting 6 months prior to the expiration date of the agency¿s licenses to ensure the procedure is not overlooked. 05/05/2017 Implemented
6400.21(a)Direct Service Worker #1, date of hire 9/18/16 had a Pennsylvania criminal background check completed 2/18/17.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. ACHC will review all files prior to the hire date. An application for a Pennsylvania criminal history record check shall 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. The CEO, Tonja Smith will ensure that the criminal clearance are completed promptly by pulling the clearance and placing the results in the employees file. 05/05/2017 Implemented
6400.141(c)(4)The physical examination dated 9/30/16 for Individual #2, did not include vision and hearing screening. This section was left blank. The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. ACHC will ensure all individuals served will have a completed physical by a license physician prior to admissions. If the physical is obtained during their residency at ACHC, the house supervisor will accompany all individuals to the doctor¿s office for their physical exam. The supervisor will ensure that all blanks on the physical are completed, or marked N/A. After the physical is completed, the house supervisor will submit the paperwork to the CEO within 48 hours for review. The CEO, Tonja Smith will ensure that the documentation is completed accurately. If the individual refuses to participate in a physical examination, the house supervisor will explain the benefits and complete proper documentation and place it in the individuals file. The house supervisor will be responsible for giving additional attempts every 30 days. On March 27th, the CEO conducted onsite training with each house supervisor to explain the current infraction, and how the agency has implemented checks and balances to assure accuracy according to the regulations. ACHC has scheduled a new physical for the individual that we had an infraction. [Individual #2's physical examination is scheduled for October 3, 2017 at 1:30PM. (AS 5/9/17)] 05/05/2017 Implemented
6400.141(c)(9)The physical examination dated 9/30/16 for Individual #2, date of birth 7/26/61, did not include a prostate examination. This section was left blank.The physical examination shall include: A prostate examination for men 40 years of age or older. ACHC will ensure all individuals served will have a completed physical by a license physician. The house supervisor will accompany all individuals to the doctor¿s office for their physical exam. If the individual refuses an examination, ACHC will consult with the individual explaining the benefits of the examination. If the individual still refuses, ACHC will provide documentation of refusal and will make continuous efforts for the examination. The CEO, Tonja Smith will ensure that the documentation is completed accurately moving forward. On March 27th, the CEO conducted onsite training with each house supervisor to explain the current infraction, and how the agency has implemented checks and balances to assure accuracy according to the regulations. ACHC has scheduled a new physical for the individual that we had an infraction.[Individual #2's physical examination is scheduled for October 3, 2017 at 1:30PM. (AS 5/9/17)] 05/05/2017 Implemented
6400.141(c)(11)The physical examination dated 9/30/16 for Individual #2 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section was left blank.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. ACHC will ensure all individuals served will have a completed physical by a license physician prior to admissions. If the physical is obtained during their residency at ACHC, the house supervisor will accompany all individuals to the doctor¿s office for their physical exam. The supervisor will ensure that all blanks on the physical are completed, or marked N/A. After the physical is completed, the house supervisor will submit the paperwork to the CEO within 48 hours for review. The CEO, Tonja Smith will ensure that the documentation is completed accurately. If the individual refuses to participate in a physical examination, the house supervisor will explain the benefits and complete proper documentation and place it in the individuals file. The house supervisor will be responsible for giving additional attempts every 30 days. On March 27th, the CEO conducted onsite training with each house supervisor to explain the current infraction, and how the agency has implemented checks and balances to assure accuracy according to the regulations. ACHC has scheduled a new physical for the individual that we had an infraction.[Individual #2's physical examination is scheduled for October 3, 2017 at 1:30PM. (AS 5/9/17)] 05/05/2017 Implemented
6400.141(c)(12)The physical examination dated 9/30/16 for Individual #2 did not include physical limitations of the individual. This section was left blank.The physical examination shall include: Physical limitations of the individual. ACHC will ensure all individuals served will have a completed physical by a license physician prior to admissions. If the physical is obtained during their residency at ACHC, the house supervisor will accompany all individuals to the doctor¿s office for their physical exam. The supervisor will ensure that all blanks on the physical are completed, or marked N/A. After the physical is completed, the house supervisor will submit the paperwork to the CEO within 48 hours for review. The CEO, Tonja Smith will ensure that the documentation is completed accurately. If the individual refuses to participate in a physical examination, the house supervisor will explain the benefits and complete proper documentation and place it in the individuals file. The house supervisor will be responsible for giving additional attempts every 30 days. On March 27th, the CEO conducted onsite training with each house supervisor to explain the current infraction, and how the agency has implemented checks and balances to assure accuracy according to the regulations. ACHC has scheduled a new physical for the individual that we had an infraction.[Individual #2's physical examination is scheduled for October 3, 2017 at 1:30PM. (AS 5/9/17)] 05/05/2017 Implemented
6400.141(c)(14)The physical examination dated 9/1/16 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 dated 9/30/16 for Individual #2 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. ACHC will ensure all individuals served will have a completed physical by a license physician prior to admissions. If the physical is obtained during their residency at ACHC, the house supervisor will accompany all individuals to the doctor¿s office for their physical exam. The supervisor will ensure that all blanks on the physical are completed, or marked N/A. After the physical is completed, the house supervisor will submit the paperwork to the CEO within 48 hours for review. The CEO, Tonja Smith will ensure that the documentation is completed accurately. If the individual refuses to participate in a physical examination, the house supervisor will explain the benefits and complete proper documentation and place it in the individuals file. The house supervisor will be responsible for giving additional attempts every 30 days. On March 27th, the CEO conducted onsite training with each house supervisor to explain the current infraction, and how the agency has implemented checks and balances to assure accuracy according to the regulations. ACHC has scheduled a new physical for the individual that we had an infraction.[Individual #1's physical examination dated 9/1/16 was updated 5/4/17 to address medical information pertinent to diagnosis and treatment in case of an emergency. Individual #2's physical examination is scheduled for October 3, 2017 at 1:30PM. (AS 5/9/17)] 05/05/2017 Implemented
6400.141(c)(15)The physical examination dated 9/30/16 for Individual #2 did not include special instructions for the individual's diet. This section was left blank.The physical examination shall include:Special instructions for the individual's diet. ACHC will ensure all individuals served will have a completed physical by a license physician prior to admissions. If the physical is obtained during their residency at ACHC, the house supervisor will accompany all individuals to the doctor¿s office for their physical exam. The supervisor will ensure that all blanks on the physical are completed, or marked N/A. After the physical is completed, the house supervisor will submit the paperwork to the CEO within 48 hours for review. The CEO, Tonja Smith will ensure that the documentation is completed accurately. If the individual refuses to participate in a physical examination, the house supervisor will explain the benefits and complete proper documentation and place it in the individuals file. The house supervisor will be responsible for giving additional attempts every 30 days. On March 27th, the CEO conducted onsite training with each house supervisor to explain the current infraction, and how the agency has implemented checks and balances to assure accuracy according to the regulations. ACHC has scheduled a new physical for the individual that we had an infraction.[Individual #2's physical examination is scheduled for October 3, 2017 at 1:30PM. (AS 5/9/17)] 05/05/2017 Implemented
6400.213(1)(i)The record for Individual #1 did not include color of hair, identifying marks and the religious affiliation. The record for Individual #2 did not include color of hair, identifying marks and the religious affiliation. 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.ACHC will ensure all individuals served will have a face sheet completed upon admission. The information it will contain is the following: 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. The CEO, Tonja Smith will ensure that the face sheet is completed moving forward within 5 days of admission. The house supervisor will complete the admission face sheet, and the CEO will review and make any appropriate corrections within 48 hours after submission. After approval, the face sheet will be placed in the individuals file by the CEO. On March 27th, the CEO conducted onsite training with each house supervisor to explain the current infraction, and how the agency has implemented checks and balances to assure accuracy according to the regulations. ACHC has completed a new face sheet for everyone we serve, and has submitted a copy to licensing for verification. [The records for Individual #1 and Individual 2#s' were update to include color of hair, identify marks and religious affiliation. (AS 5/9/17)] 05/05/2017 Implemented
SIN-00089592 Renewal 03/08/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone numbers of the nearest hospital and poison control center were not on or by the telephone in the living room.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. The poison control number and the nearest hospital number was added to the sticker on the phone on March 8, 2016. Moving forward, the stickers will have all numbers according to regulations 6400.71 on or by the phone. It will be my responsibility to monitor and provide training to all staff to ensure it doesn't happen again. Any further sites will have the appropriate contact number.[At least quarterly, CEO or designated staff person will complete physical site checks of the home to ensure all required telephone numbers are on or by each telephone in the home with an outside line. Documentation of the checks shall be kept. (AS 3/14/16)] 03/08/2016 Implemented
6400.105Two fabric tablecloths were across and hanging down the four sides of a table stored within one foot of the hot water tank and furnace in the basement of the home. Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. The blanket and the table in the basement was removed from near the hot water heater on March 8, 2016. Moving forward, flammable and combustible supplies or equipment will be safely stored away from heat sources. I will be responsible for monitoring and training all staff to ensure it doesn't happen again.[At least quarterly, CEO or designated staff person will complete physical site checks of the home to ensure flammable and combustible supplies and equipment are being utilized safely and stored away from heat sources. Documentation of the checks shall be kept. (AS 3/14/16)] 03/08/2016 Implemented
SIN-00171310 Renewal 02/24/2020 Compliant - Finalized
SIN-00111597 Unannounced Monitoring 12/21/2016 Compliant - Finalized