Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00229437 Renewal 08/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106Documentation of the furnace being inspected and cleaned at least annually by a professional furnace cleaning company was not provided. Therefore, compliance could not be measured. [Repeat violation: 8/17/22 Et al.]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. A licensed HVAC company has been engaged to inspect and clean the furnace on September 6, 2023. 09/06/2023 Implemented
SIN-00210085 Renewal 08/17/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency's current Certificate of Compliance at the time of the renewal inspection expired 8/19/22. The agency did not complete a self-assessment of the home. The self-assessment provided indicates a start date of 8/4/22 and the end date indicates 8/6/22. The self-assessment provided has several regulations that are blank, to include the following: 6400.182(a) through and including 6400.209, 6400.188(a) through and including 188(d), 6400.189(a) through and including 6400.190(c), 6400.207(1) through and including 6400.207(2), 6400.211(a) through and including 6400.217, 6400.231 through and including 6400.245(d)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. CEO/Program Specialist/ Chief Operating Officer Conduct training with Nurse Coordinator, HR Specialist and Home Supervisors Begin self-assessment training in the following areas over a two-month period: ¿ Incident Reporting ¿ Criminal History Record Check ¿ Individual Funds and Property ¿ Grievance Procedures ¿ Individual Rights ¿ Staffing ¿ Physical Site ¿ Fire Safety ¿ Individual Health ¿ Staff Health ¿ Medications ¿ Nutrition ¿ Assessments ¿ Plan Development/Process/Content ¿ Home Services ¿ Day Services/Recreational and Social Activities ¿ Restrictive Procedures ¿ Prohibited Procedures ¿ Individual Records Training Staff and participants will be required to sign an acknowledgement form upon completion. The trainers will determine the dates and times for each training sessions. ¿ The Chief Executive Officer and Chief Operating Officer will begin the following virtue training sessions on 11/1/2022 through 11/30/22. 1. Incident Reporting, Individual Funds and Property, Grievance Procedures, Physical Site, Individual Health, Staff Health, Medications, Individual Health, and Nutrition ¿ The Program Specialist and Chief Operating Officer will begin the following virtue training sessions on 12/1/2022 through 12/31/22. 2. Assessments, Plan Development/Process/Content, Individual Records, Restrictive Procedures, Prohibited Procedures, Individual Rights, Fire Safety, Physical Site, and Home Services ["LRS Site Audit," dated 12/6/22, was received on 1/10/23 and reviewed 1/10/23. DPOC by HDKP, HSLS, on 1/24/2023]. 10/19/2022 Implemented
6400.112(c)The fire drill conducted on 4/1/22 does not indicate the time of day the drill was completed.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. Fire drill deficiencies were included as an agenda item on a mandatory virtual meeting in which all staff were required to attend. Staff were re-trained on how to properly fill out the form and to not leave any sections blank. The Program Specialist should be notified of any inoperative fire alarm/smoke detectors. [Training documentation, dated 10/7/22, for staff members related to fire drill documentation was received on 1/10/23 and reviewed 1/24/23. DPOC by HDKP, HSLS on 1/24/2023]. 10/11/2022 Implemented
SIN-00193224 Renewal 09/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(b)The agency used the Self-Inspection and Declaration Tool to measure and record compliance at the home instead of the Department's Licensing Inspection Instrument.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.15 (b) a Self-Inspection and Declaration Tool was used to measure and record compliance with the 6400 regulations in error. The required Self-Assessment Licensing Inspection Instrument will be used prior to the agency¿s annual inspection. 10/18/2021 Implemented
SIN-00191015 Add an Addendum 08/05/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.14(a)The home does not have a valid fire safety occupancy permit from the Department of Health or the Department of Public Safety of the city of Pittsburgh.If the home is located outside Philadelphia, Scranton or Pittsburgh and serves four or more individuals or if the home is located in a multiple family dwelling, the home shall have a valid fire safety occupancy permit listing the appropriate type of occupancy from the Department of Labor and Industry or the Department of Health. If the home is located in Philadelphia, Scranton or Pittsburgh, the home shall have a valid fire safety occupancy permit from the Department of Health or the Department of Public Safety of the city of Pittsburgh, the Department of Licensing and Inspection of the city of Philadelphia or the Department of Community Development of the city of Scranton, if required by State law or regulation or local codes. Source: RecordsTo correct the violation, the CFO contacted McKinney Properties (the property management company for Bryn Mawr Apartments) on several occasions to express our dismay in not having an occupancy permit upon the signing of the lease agreement. We were informed that due to COVID worker related shortages, the Borough of Wilkinsburg would not be able to issue an occupancy permit for 100 Bryn Mawr Court until July 27, 2021. Accordingly, we anticipated having the occupancy permit before the scheduled inspection on August 5, 2021. When we found out that the inspection had not been completed as promised, we contacted McKinney Properties again and was informed that the inspection would occur on August 17, 2021. The inspection was completed, and a copy of occupancy permit is being submitted to the Department on August 19, 2021. [Occupancy Permit submitted to department on 8/20/2021 and verified. DPOC by HDKP, HSLS, on 8/30/21]. 08/17/2021 Implemented
6400.77(b)The first aid kit located in the home did not contain scissors or 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. To correct the violation, the generally accepted type of first aid kit that was acquired July 28, 2021, replaced the noncompliant first aid kit. The first aid kit acquired includes scissors and a thermometer. A copy of the receipt along with a listing of the contents included in the first aid kit was provided to the Department on 8/19/21. [Receipt documenting purchase received on 8/20/2021 and verified. List of contents of purchased First Aid Kit received on 8/20/2021 and verified. DPOC by DHKP, HSLS, on 8/30/2021.] 08/09/2021 Implemented