Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00234009 Renewal 10/17/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Individual #1 has been abused and neglected by the agency in the following manner: 1) Abandonment/ Supervision not consistent with Individual Plan. a) From February 27, 2023 to 10/7/23, there were 5 EIM incidents reported (Incidents 9175041, 9183773, 9199220, 9276514, and 9278221) that demonstrate a trend of agency staff abandoning Individual #1, leaving them unattended for periods of time and not consistent with the supervision needs defined by their 6/23/23 individual plan as follows: 1:1 staffing ration at home and 2:1 staffing ratio in community. 2) Failure to Provide Protection from Hazards due to Inadequate Supervision. a) Enterprise Incident Management Incident #927822 involved the failure of Individual #1 being protected from hazards, as they had been left alone in an agency vehicle without air conditioning on 9/11/23, when it was 90 degrees Fahrenheit outside for an unknown amount of time. b) Enterprise Incident Management Incident ##927822 also demonstrated the agency's failure of implementing their most recent individual plan, last updated 6/23/23, requiring a 2:1 staffing ratio in the community. According to Enterprise Incident Management Incident #927822, Individual #1 had been out in the agency vehicle at a community location with only one staff member on 9/11/23, before being left alone in the agency vehicle.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. 12/18/2023 Implemented
6400.43(b)(3)Chief Executive Officer (CEO) #3 has failed to provide for the safety and protection of Individual #1. From 2/27/23 to 10/7/23, there were 5 incidents reported through Enterprise Incident Management system (Incidents 9175041, 9183773, 9199220, 9276514, and 9278221) that demonstrate a problematic trend of Individual #1 being abandoned by agency staff, resulting in periods of non-supervision or supervision not being implemented as defined by their most current individual plan, last updated 6/23/23, requiring a 1:1 staffing ratio in the home and a 2:1 staffing ratio in the community. Enterprise Incident Management Incident #9278221 also involved the failure of Individual #1 being protected from hazards, as they had been left alone in an agency van on a 90-degree day without air conditioning.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. Allegheny Community Home Care discovered in January 2023 that the agency was not able to properly care for the client. The CEO notified the SC, county, and family members. After many attempts, the CEO and SC was able to locate a willing and able provider to accept the client. The client will be transitioning to another provider on 12/18/23. 12/31/2023 Implemented
6400.64(a)On 10/18/23, an empty Sheetz bag, a crumbled up white paper towel, and a white powdery substance sprinkled on the floor in approximately a 2-ft. line were observed directly underneath Individual #1's bed at 10:28 AM.Clean and sanitary conditions shall be maintained in the home. Allegheny Community Home Care immediately picked up the sheetz paper and disposed of it- while the inspector was there. 12/31/2023 Implemented
6400.151(a)Direct Services Worker #4, date-of-hire 5/8/23, had a physical examination completed on 5/10/23. 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 provider will change its onboarding process to allow new hires to complete their physical prior to orientation. 12/31/2023 Implemented
6400.214(b)On 10/18/23 at 11:13 AM, incident reports related to Individual #1 were not present in the home. [Repeat violation 11/3/22, et. al.] The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Allegheny Community Home Care will add in daily incident notes/logs into the clients home for daily communication. 12/31/2023 Implemented
6400.45(e)Enterprise Incident Management Incident #9293800 involving neglect for failure to provide supervision, reported that on 10/7/23 the direct services worker did not wait for relief staff to arrive and clocked out at 7:00 AM, leaving Individual #1 unsupervised from 7:00 AM to 9:30 AM. This was solely for the convenience of the direct service worker.An individual may not be left unsupervised solely for the convenience of the home or the direct service worker.Allegheny Community Home Care has immediately removed the client from harm and discharge the responsible staff member. 12/31/2023 Implemented
6400.182(c)Individual #1's current individual plan, last updated 6/23/23, defined their supervision requirements as follows: 1:1 staffing ratio of direct supervision in the home and 2:1 staffing ratio of direct supervision in the community. However, Individual #1's most recent assessment from 6/30/23 defined their level of care needed as follows: total supervision is required with a 1:1 staffing at both home and in the community; may have alone time in bedroom.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Allegheny Community Home Care will schedule a meeting with the clients supports team discuss appropriate staffing levels and make proper adjustments to ISP and/or assessment. 12/31/2023 Implemented
6400.186Enterprise Incident Management Incident #927822, involving neglect, documented that on 9/11/23 Individual #1 had been accompanied by one Direct Service Worker out in the community while being transported in the agency van. However, Individual #1's most current individual plan from 6/23/23, defined their community supervision requirements as follows: 2:1 staffing ratio of direct supervision.The home shall implement the individual plan, including revisions.Allegheny Community Home Care will schedule a meeting with the clients supports team discuss appropriate staffing levels and make proper adjustments to ISP and/or assessment. 12/31/2023 Implemented
SIN-00214320 Renewal 11/03/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)The electrical outlet on wall in Individual #1's bedroom does not have a cover. Floors, walls, ceilings and other surfaces shall be free of hazards.Allegheny Community Home Care has already fixed the wall outlet the same day as in home inspection (11/4/2022). 01/05/2023 Implemented
6400.72(b)The screen in Individual #1's bedroom window is dented and bowed outward at the top and bottom, causing it to not securely fit the window. [Repeat Violation, 6/3/2022] Screens, windows and doors shall be in good repair. Allegheny Community Home Care has corrected the bedroom window in the individual's bedroom. 01/05/2023 Implemented
6400.32(l)On 11/4/2022, there was a paper on the dining room wall entitled, "House Rules Expectations." This list of rules included, "visitation hours from 8AM-8PM," and "no visitors are allowed to sleep overnight."An individual has the right to receive scheduled and unscheduled visitors, and to communicate and meet privately with whom the individual chooses, at any time.Allegheny Community Home Care has removed the communication from the wall immediately and will ensure that no such correspondence is in any site. 01/05/2023 Implemented
SIN-00210484 Unannounced Monitoring 08/05/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.61(b)Since Individual #1's, date of admission 10/4/2021, the agency has been "sponge bathing" Individual #1 in her bed. The agency has not provided the adaptive equipment necessary to ensure Individual #1 is able to maintain hygiene.A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have adaptive equipment necessary for the individuals to move about and function at the home.The provider will ensure that all homes have the proper adaptive equipment necessary for the individuals with a physical disability. The provider will work closely with the property management, supports coordinator, and DME company to ensure all adaptive equipment is onsite. On 10/10/22, the provider is seeking additional disability accommodations for the client to have modifications done to the apartment. If they are not approved by the property manager, the provider will look into purchasing a home, rehabbing the home, and providing all necessary adaptive equipment necessary so the client may shower when requested. 06/01/2023 Implemented
6400.72(b)There is a hole approximately ten inches high by ten inches wide in the screen of the window facing the rear of home in Individual #1's bedroom. Screens, windows and doors shall be in good repair. The Provider will hire a full time maintenance man to ensure that all sites are in good repair and that all necessary maintenance requests can be completed in a timely fashion. The newly hired maintenance personnel replaced the screen. In addition, he purchased additional screens in the event another hole should appear, it can be fixed immediately. 10/31/2022 Implemented
6400.32(d)Since Individual #1's, date of admission 10/4/2021, the agency has been "sponge bathing" Individual #1 in her bed. Adaptive accommodations have not been made to ensure Individual #1's dignity to maintain hygiene.An individual shall be treated with dignity and respect.The provider will ensure that all homes have the proper adaptive equipment necessary for the individuals with a physical disability. The provider will work closely with the property management, supports coordinator, and DME company to ensure all adaptive equipment is onsite. On 10/10/22, the provider is seeking additional disability accommodations for the client to have modifications done to the apartment. If they are not approved by the property manager, the provider will look into purchasing a home, rehabbing the home, and providing all necessary adaptive equipment necessary so the client may shower when requested. 06/01/2023 Implemented
6400.166(a)(7)Individual #1 is prescribed Lorazepam 0.5 MG, take 1 tablet 3 times a day as needed for anxiety. Individual #1's August 2022 Medication Administration Record lists the dosage for this medication as 1.5 MG. [Repeat Violation, 3/25/2022]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.The agency will hire a medication trainer to ensure compliance. Lead Supervisors will verify that all medications have been administered by the prescriber¿s directions. Any incident of failure to administer medication by the prescriber¿s directions will be reported in the EIM system within 24 hours and corrective action will be developed and issued. The lead supervisor verified the correct dosage by calling the physician. The electronic MAR was corrected. The staff was training on the Plan of Correction and how not to cause a violation. 10/31/2022 Implemented
SIN-00207053 Unannounced Monitoring 06/03/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At 10:41AM, a skillet was on top of the stove with solid grease and food particles. At 10:43AM, the interior bottom of oven was covered in grease and burnt chards of food particles. At 10:47AM, the interior microwave plate had burnt food stuck to its surface. The dishwasher in the kitchen of the home had approximately an inch of stagnant water with food particles at the bottom and dishes inside. At 10:58AM, the bed linens were soiled, including a worn diaper which was laying on top of the bed sheets. At 11:00AM, an unmaintained bin of kitty litter with a multitude of visible cat feces was located in Individual #1's bedroom. At 11:09AM, numerous items were found under individual #1's bed, including a plate with food residue, a chicken nugget box with an open container of sauce, a lighter, an empty can of Mountain Dew, a plastic water bottle, a partially smoked cigars and a sticky substance on the hardwood floor. Clothes and blankets are strewn about the floor of Individual #1's bedroom closet and the spilling out onto the bedroom floor near the closet.Clean and sanitary conditions shall be maintained in the home. The lead supervisor was responsible for ensuring the homes were cleaned and sanitary. Unfortunately, this did not happen and the lead supervisor was terminated. The plan of correction was for the provider will hire a professional cleaning company to facilitate a deep cleaning. The CEO will be responsible for this project. The project was completed for all ACHC homes on 6/28/22. The provider will develop a daily chore list for all staff to understand their household duties. This was completed on 7/11/22. The provider will develop a weekly site audit sheet to ensure that lead supervisors complete a weekly checklist to ensure that all sites are clean and sanitary. This project was due on 7/15/22 and completed on 7/11/22. The lead supervisors will go into the sites and complete a weekly site audit for to ensure the home is cleaned and in sanitary conditions. 08/31/2022 Not Implemented
6400.64(f)At 11:23AM, a trash receptacle with a lid was overflowing with a full trash bag in the apartment's vestibule next to the exit door.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The lead supervisor was responsible for ensuring the homes were cleaned and sanitary. Unfortunately, this did not happen, and the lead supervisor was terminated. The provider will develop a daily chore list for all staff to understand their household duties. This will include taking out the trash. This was completed on 7/11/22. The provider will develop a weekly site audit sheet to ensure that lead supervisors complete a weekly checklist to ensure that all sites are clean and sanitary. This project was due on 7/15/22 and completed on 7/11/22. The lead supervisors will go into the sites and complete a weekly site audit for to ensure the home is cleaned and in sanitary conditions. 08/31/2022 Implemented
6400.67(b)The home has a detached baseboard on the face of the dividing wall between the bathroom and dining room exposing protruding nail heads and chipping plaster and paint. Floors, walls, ceilings and other surfaces shall be free of hazards.A maintenance repair order was placed to repair the detached baseboard immediately and ensure there are no nails heads or chipping plaster. The CEO hired a maintenance team to remove the detached baseboard and repaint the entire site. This was completed on 7/27/22. 08/31/2022 Not Implemented
6400.68(b)At 11:06AM, the hot water temperature measured 150.9°F at the bathroom sink. At 11:08AM, the hot water temperature measured 151.1°F at the kitchen sink. Hot water temperatures in bathtubs and showers may not exceed 120°F. The provider will ensure that the water temperatures are below 120 at all houses immediately. There was not an anti-scalding device in this site. The provider hired a plumbing contractor who installed the anti-scalding device on 7/13/22. 08/31/2022 Implemented
6400.76(a)The seat of a dining room chair was concaved and sagging in and the foam and padding was hanging out from the bottom. The seat of a second dining room chair in Individual #1's bedroom had no cushioning and was concave and sagging. Individual #1's bed frame was broken in several areas posing a collapsing and falling hazard. The side board of the frame was detached was leaning against wall in the corner of the bedroom, the foot board was separating from the bed and there were several support boards under boards that were either leaning or completely detached. Furniture and equipment shall be nonhazardous, clean and sturdy. The provider¿s lead supervisor did not report any problems with the sites furniture. The broken furniture was immediately removed, and replace with new chairs within 24 hours. 08/31/2022 Not Implemented
6400.77(b)The first aid kit in the home contained a disposable thermometer that could not provide an accurate temperature reading. 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. All First aid kits will 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. The lead supervisor removed the disposable thermometer and replaced it with a regular thermometer. This was done within 48 hours of discovery. 08/31/2022 Implemented
6400.80(b)At 11:29 AM, the concrete walkway pads coming off the porch from the side exit were randomly placed and unlevel rendering the exit not accessible for a wheelchair; as well as; a falling and tripping hazard. Individual #1 uses a wheelchair for mobility. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The provider will ensure that the unleveled walkway pads will be removed to ensure accessibility via wheelchair. On July 5th, the CEO contacted the property manager about the egress needing to be replaced. On July 8th, the CEO ordered a titan ramps ¿ portable aluminum wheelchair ramp for $500 to ensure the client ease of leaving the home through the patio door if necessary. 09/30/2022 Not Implemented
6400.105At 11:33 AM, the dryer lint screen had a thick layer of dust, lint, and fabric fibers.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. The supervisor failed to clean the lint after completing the laundry. Once the violation was discovered, the supervisor cleaned the lint out of the dryer immediately The Provider will ensure that all flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. 08/31/2022 Implemented
6400.114(b)At 10:55AM, numerous rolled cigars, ashes in a plastic ashtray and a lighter were observed on the dresser in Individual #1's bedroom. The provider's written smoking policy prohibits staff and individuals from smoking inside any agency home, building or vehicle.Written smoking safety procedures shall be followed.All assigned staff will review, sign and abide by the smoking policy. The HR Manager will develop a sign in sheet for staff to acknowledge they understand the smoking policies. The sign off sheet was completed on 7/26/22. On July 11th ¿ the Director spoke to house staff and client to inform them of the smoking area On July 14th ¿ the CEO purchased new smoking receptacles for the home. 08/31/2022 Accepted
6400.171At 10:45AM, the refrigerator in the kitchen of the home contained an uncovered bowl of mashed potatoes, an uncovered plastic cup of juice and a partially cut up watermelon inside of a plastic grocery bag. There were two uncovered bowls containing bite size pieces of watermelon on the counter next to the sink in the kitchen. There was a plastic lid containing bite size pieces of watermelon on Individual #1's bedroom floor.Food shall be protected from contamination while being stored, prepared, transported and served. The lead supervisor immediately wrapped all uncovered food in the refrigerator. On July 5th ¿ the Executive Assistant went and purchased an abundance of food containers for storage, and glad ziplock bags for the staff to use. The Lead supervisors will retrain all staff on safe food handling practices to ensure that food shall be protected from contamination while being stored, prepared, transported and served. This shall be documented on the site audit forms. 08/31/2022 Implemented
6400.166(d)Ferrous Sulfate Tab 325mg EC, take one tablet by mouth every other day for supplement prescribed to individual #1 was administered from 6/1/2022 through 6/3/2022.The directions of the prescriber shall be followed.The provider will ensure that the directions of the prescriber shall be followed immediately. All MAR¿s Will be reviewed immediately by the Lead Supervisors. 09/30/2022 Not Implemented
SIN-00202442 Renewal 03/24/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(a)On March 22, 2022, Individual #1's prescribed Baclofen 20 mg tab, take 1 tablet by mouth four times a day for spasms was increased to 30 mg, take 1 ½ tablets by mouth four times a day for two weeks. If not too sleepy then increase to 40 mg, two tablets four times per day. On March 25, 2022, upon inquiry from the Department regarding the medication change for Individual #1, Direct Service Worker #1 stated staff had been popping two tablets from the original blister pack, cutting one tablet in half, and then placing the half tablet in a plastic container. The Department observed the plastic container containing, half tablets of pills at 10:53AM.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.The provider is actively searching for an LPN/RN who will be responsible for monitoring of all medication and medical administration records. The hiring process is expected to be completed by 5/15/22. The LPN/RN will verify that all prescription and nonprescription medications include labels issued by a pharmacy. If a medication does not have a label issued by a pharmacy, the LPN/RN will contact the pharmacy to provide the label. Until the LPN/RN position if filled, the Lead Supervisors will be responsible for monitoring all medication and medical administration records. 05/30/2022 Not Implemented
6400.166(a)(13)The March 2022 Medication Administration Record for Individual #1 did not include the names and initials of the person administering the medication for the following prescribed medications and administration times: Baclofen 30 mg tab at 12:00PM, 4:00PM, and 12:00AM on 3/24/22; Gentle Laxat Sup. 10 mg at 8:00PM on 3/24/22; and Melatonin 3 mg at 8:00PM on 3/24/22.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.The provider is actively searching for an LPN/RN who will be responsible for weekly monitoring of all medication and medical administration records. The hiring process is expected to be completed by 5/15/22. The LPN/RN will verify that all medications have been administered and include the name and initials of the person administering the medication. Any incident of failure to include the name and initials of the person administering the medication will require corrective action to be developed and issued. Until the LPN/RN position if filled, the Lead Supervisors will be responsible for monitoring all medication and medical administration records. 05/30/2022 Not Implemented
6400.166(d)Gabapentin Cap 300mg prescribed to Individual #1 was not administered to Individual #1 at 4:00PM and 8:00PM on 3/24/22. Oxybutynin Tab 5 mg prescribed to Individual #1 was not administered to Individual #1 at 8:00PM am on 3/25/22. Omeprazole Cap 20 mg prescribed to Individual #1 was not administered to Individual #1 at 8:00AM on 3/25/22.The directions of the prescriber shall be followed.The provider is actively searching for an LPN/RN who will be responsible for weekly monitoring of all medication and medical administration records. The hiring process is expected to be completed by 5/15/22. The LPN/RN will verify that all medications have been administered by the prescriber¿s directions. Any incident of failure to administer medication by the prescriber¿s directions will be reported in the EIM system within 24 hours and corrective action will be developed and issued. Until the LPN/RN position if filled, the Lead Supervisors will be responsible for monitoring all medication and medical administration records. 05/30/2022 Not Implemented
SIN-00186734 Renewal 04/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)On 4/14/2021 at 10:47AM Chief Executive Officer #1 tested the smoke detector on the ceiling in the hallway adjacent to Individual #1's bedroom, and it was not operable. There were no other smoke detectors in the residence. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. (3) During the state inspection, while trying to initiate the smoke detector, it fell on the floor and broke. (4) Allegheny Community Home Care Program Manager will ensure all smoke detectors are working properly. (5) Program Manager will retrain each house supervisor on the proper way to check the smoke detectors. On 4/14/21 the CEO immediately replaced the shattered smoke detectors within 3 hours. The Program Manager reviewed all homes smoke detector for accuracy and compliance. 04/14/2021 Implemented
SIN-00131412 Renewal 03/16/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(f)On 3/16/18, the inspection date on the fire extinguisher in the dining area of the home was 2/2017. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. On March 16th, the program manager exchanged the expired fire extinguisher with an up to date fire extinguisher from the corporate office. The program manager then inspected every site¿s fire extinguisher for compliance. The director of operations retrained the program manager on how to properly read the fire tags to ensure compliance. The program manager called ABC Fire Company to schedule an appointment for an annual inspection of the fire extinguisher in violation, this was completed on March 23rd and a new 2018 fire tag was placed and the fire extinguisher was taken back to the site. ACHC will ensure all house fire extinguishers are inspected and approved annually by a fire safety expert. Program manager will conduct monthly checks of the fire extinguishers to ensure they are correctly dated for service by using a fire extinguisher tracking system during our monthly fire drills. All fire extinguishers will be placed on the same annual check of July 2018 to assure that all fire extinguishers are in compliance simultaneously and to ensure no repeats of the violation. Director of operations will conduct random quarterly audits of the fire extinguishers and the fire extinguisher tracking system to ensure that the fire extinguishers are properly inspected by the program manager according to the 6400 regulations. 03/16/2018 Implemented
SIN-00151856 Renewal 03/13/2019 Compliant - Finalized
SIN-00111818 Renewal 03/24/2017 Compliant - Finalized