Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00282037 Renewal 01/13/2026 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)There were no self-assessments for any of the homes.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. Always Reaching Kids Ministry completed a full self-assessment for each licensed residential home operated by the agency. The assessments measured compliance with all applicable provisions of 55 Pa. Code Chapter 6400 and were completed using DHS-approved self-assessment tools. Each assessment was reviewed by administrative leadership, signed, dated, and placed in the agency's compliance files. All required self-assessments were completed no later than January 15, 2026. 01/15/2026 Implemented
6400.21(b)There was no attestation of being a PA resident for past 2 years for staff members 2, 3, 4, 5, 6, and 7.If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire. Personnel files for all identified staff were reviewed. Written attestations verifying Pennsylvania residency were obtained where applicable. For staff unable to verify two years of Pennsylvania residency, FBI fingerprint-based criminal history checks were completed in accordance with DHS requirements. All documentation was placed in the personnel files by January 16, 2026. 01/13/2026 Not Accepted
6400.104The 03/01/25 notification did not mention the exact location of the bedrooms of the individuals who would need assistance evacuating in the event of an actual fire.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Person Responsible for Annual fire chief letters annually , Adrian Lindsay, Administrative Director .An updated written notification identifying the exact bedroom locations of individuals requiring evacuation assistance was submitted to the local fire department and retained on file by January 15, 2026. 01/15/2026 Implemented
6400.113(a)There was no fire safety training in file for individual 2. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. The individual received fire safety instruction in their preferred communication method. Documentation was completed and placed in the individual's record by January 15, 2026. 01/15/2026 Implemented
6400.142(a)There was no dental exam for individual 2 since 01/07/25.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. The root cause of this violation was failure to track routine medical appointment due dates. On 1/13/26 a dental exam was scheduled for individual #2. 01/13/2026 Implemented
6400.142(g)There was no dental hygiene plan in file for individual 2.A dental hygiene plan shall be rewritten at least annually. The root cause of this violation was incomplete health record maintenance. On 1/13/26 a dental hygiene exam was scheduled for individual #2. 01/13/2026 Implemented
6400.143(a)There was documentation of a refusal of dental treatment on 07/25/25 for individual 2, but there was no documentation of attempts to train the individual regarding the need for dental care.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. The root cause of this violation was insufficient documentation of education provided following treatment refusal. The record was updated to document ongoing education and attempts to train the individual #2 regarding the need for dental care on January 13, 2026. 01/13/2026 Implemented
6400.151(a)There was no physical examination in file for staff member 1, although there was TB testing done. There was no Physical examination in file for staff member 2.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 root cause of these violations was failure to verify physical exam completion prior to staff file finalization. Staff member #1physical examinations was scheduled on 1/13/26. Physicals and TB results for Staff 1 and Staff 2 have been uploaded. We are awaiting the communicable disease clearance statements; however, both staff have provided their test results. 01/13/2026 Implemented
6400.181(a)The 10/29/25 annual assessment for individual 2 is missing several required elements per the regulation. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The root cause of this violation was incomplete assessment review prior to finalization. A complete annual assessment was conducted, ensuring all required regulatory components were addressed. The updated assessment was finalized and placed in the individual's record by January 13, 2026. 01/13/2026 Not Accepted
6400.24Staff members 8 and 9 have criminal histories, but there was no policy or procedure provided regarding the hiring process for staff members with criminal histories that have direct contact with individuals.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.The root cause of this violation was the lack of a written policy governing hiring decisions for applicants with criminal histories. The agency developed and implemented a formal policy outlining evaluation criteria, administrative approval requirements, and documentation standards. The policy was approved and implemented by Janaury 13, 2026. 01/13/2026 Implemented
6400.24Per individual 2's 01/01/25 Room and Board agreement the individual's room and board was $892.08; however, 72% of the SSI maximum rate plus state supplemental was $712.15 for 2025. 55 Pa. Code 6100.686. Room and board rate.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.The root cause of this violation was the failure to adjust room and board rates following changes to SSI maximum allowances. The agreement was recalculated, corrected, and re-executed in compliance with current SSI limits by January 13, 2026. 01/13/2026 Not Accepted
6400.34(a)There were no individual rights signed off on for individual 2 in file before 01/26/25.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The root cause of this violation was incomplete admission documentation review. Individual rights were reviewed with the individual and designated persons, and a signed acknowledgment was obtained and filed by January 13, 2026. 01/13/2026 Not Accepted
6400.46(a)Fire safety training was done for staff member 2 on 11/25/25 and date of hire was 07/14/25.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.The root cause of this violation was inadequate confirmation of training completion prior to staff working independently. On 1/13/26, All staff training records were audited again for training compliance. Staff member was scheduled for fire safety training, including evacuation procedures, staff responsibilities, and fire response protocols. 01/13/2026 Implemented
6400.165(g)There was a psychiatric medication review on 12/11/25 for individual 2, and before that the previous one was done on 07/10/25.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The root cause of this violation was inadequate monitoring of medication review intervals. On 1/13/26, the individual was scheduled for and received an updated psychiatric medication review. The appointment was scheduled and confirmed on 1/13/26 (date of inspection) for March 10, 2026. The after-visit summary has been attached. 01/13/2026 Implemented
6400.166(a)(11)Individual 2's MAR does not have the diagnoses or purpose for the medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The root cause of this violation was insufficient supervisory review of MAR documentation. The MAR was reviewed and updated to include the diagnosis or purpose for each medication, including PRN medications. Corrected MARs were placed in the medication administration records by January 13, 2026. 01/13/2026 Implemented
6400.183(c)There was no ISP team sign in sheet in file for individual 2 listing the persons who participated in the meeting.The list of persons who participated in the individual plan meeting shall be kept.The root cause of this violation was incomplete ISP documentation retention. The house supervisor requested a copy of individual #2 ISP signature signature from their SC. A completed ISP team sign-in sheet was obtained for individual #2. and filed by January 14, 2026. 01/13/2026 Implemented
6400.213(1)(i)The content of individual 2 did not include the individual's admission date, identifying marks or the language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The root cause of this violation was incomplete review of individual records upon admission.The individual's record was updated to include all required personal information by January 13, 2026 01/13/2026 Implemented
SIN-00263445 Renewal 03/12/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The dresser in the front bedroom has broken handles. The tattered mini blinds for the window in the front bedroom is not functional and needs to be replaced.Floors, walls, ceilings and other surfaces shall be in good repair. The broken handles on the dresser in the front bedroom has been replaced to ensure safe and functional use. The damaged mini blinds will be removed and replaced with new, functional blinds 04/04/2025 Implemented
6400.68(b)The running water of the kitchen was tested and found to have a temperature of 134.0F and the bathroom was also tested with a temperature of 139.1F exceeding the threshold of 120F. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water temperature in all bathtubs and showers has been tested and adjusted to ensure it does not exceed 120°F. A licensed plumber will inspect and adjust the water heater if needed. 04/04/2025 Implemented
6400.72(b)The window in the living room is missing the handle needed to open/close it. The screen on the front door had tears in it. The left window in the front bedroom does not stay up without assistance. The middle window does not rise Screens, windows and doors shall be in good repair. The missing window handle in the living room has been replaced to ensure safe and functional use. Additionally, the torn screen on the front door will be repaired or replaced to maintain proper ventilation and pest control. 04/04/2025 Implemented
6400.181(a)Individual #4's annual assessments dated 1/8/23 and 1/9/25 are identical. Recommendations and progress areas were unchanged for both documents. 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. A revised and updated assessment for Individual #4 is currently being completed by the Program Specialist. It will incorporate observations, progress made, challenges encountered, and updated recommendations based on the individual's performance over the past year. Moving forward, additional measures have been implemented to ensure each annual assessment reflects current data and outcomes specific to the review period. 04/04/2025 Implemented
SIN-00240990 Renewal 03/14/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)Outside handrailing at the entrance to the front of the home is loose and needs to be secured to the foundation. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Conduct an immediate assessment of the loose hand railing at the entrance to the front of the home. Contacted maintenance within 24 hours. Secure the hand railing with cement to the foundation to ensure it is stable and safe for use. 06/05/2024 Implemented
6400.113(a)Ind. #2 was not reinstructed annually in general fire safety training. {REPEAT VIOLATION 3/17/23} An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. Individuals were trained on their fire safety, once it was realized that they had not received the training in the specified time, per regulation 6400.113(a). House Managers and Program Specialists were trained on this regulation. Outline and attendance record were added to the policy. 06/05/2024 Implemented
6400.142(a)Individual #2 does not have a dental examination performed by a licensed dentist annually current exam was completed 08/09/23. (Could not determine if exam is being completed annually). {REPEAT VIOLATION 3/17/23}An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Scheduled an a new dentist appoint and also went and picked up a copy of dental exam from 2022 to show that the individual has been going to the dentist annually 06/05/2024 Implemented
6400.181(d)The annual assessment dated 01/08/2023 for Ind. #2 was not signed by the program specialist.The program specialist shall sign and date the assessment. The Program Specialist signed the assessment she completed. 04/05/2024 Implemented
6400.166(a)(13)Staff members administering meds did not list signatures on the MAR.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.House manager immediately reviewed and updated the current Medication Administration Records (MAR) to ensure all administered medications have the corresponding staff signatures. Identify and rectify any missing signatures for medications already administered. 04/25/2024 Implemented
6400.213(1)(i)The individual's photo is not dated. Unable to determine if the photograph is current.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.Individual #2's face sheet was retaken and dated. All other face sheets were reviewed to ensure that all information required by 55 PA Code Chapter 6400.213 (1)(i) is present. 03/17/2024 Implemented
SIN-00220696 Renewal 03/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34This agency denied licensing representatives access to review individual #1's medication.The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.All staff was trained on the licensing process and ensuring that all access will be provided upon request. If staff is unable to determine who the licensing person is request identification 05/10/2023 Implemented
6400.15(a)Self-Assessments were not completed for any of this providers licensed homes.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. Self assessment was completed 05/11/2023 Implemented
6400.62(a)There was window cleaner, and bleach stored under the kitchen sink cabinet.Poisonous materials shall be kept locked or made inaccessible to individuals. Locked storage cabinet was purchased, and signs made to store all poisonous material and cleaners in 05/10/2023 Implemented
6400.66The light on the backyard wall was not operable at the time of the inspection.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Light bulbs purchased and changed 05/10/2023 Implemented
6400.67(a)There was a piece of missing tile in front of the refrigerator located in the kitchen.Floors, walls, ceilings and other surfaces shall be in good repair. tiles were replaced in front of the refrigerator. 05/10/2023 Implemented
6400.71The telephone emergency numbers of the nearest hospital, police department, fire department, and or any directions to call 911 were not posted near the phone 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. form was created to provide telephone number and direction to the nearest hospital, police department, fire department. 05/12/2023 Implemented
6400.76(a)The bottom dresser drawer in individual #1's bedroom did not have drawer pulls, which prevented access to the drawer contents and is in need of repair. Furniture and equipment shall be nonhazardous, clean and sturdy. new dresser was purchased 05/12/2023 Implemented
6400.77(b)There was no antiseptic in the first aid kit. Staff was able to provide the antiseptic during the review. 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 new first aide kits were purchased, and antiseptic placed in each kit 05/12/2023 Implemented
6400.82(f)There was no towel or paper towels in the bathroom.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. all staff was educated to ensure paper towels are present. 05/12/2023 Implemented
6400.104Notification to fire department letters were not completed for any of this providers licensed homes.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. notification letters provided. 05/11/2023 Implemented
6400.106Furnace inspections were not completed for any of the providers licensed homes.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. furnaces was cleaned 05/12/2023 Implemented
6400.112(a)Fire drills were not completed for any of this providers licensed homes. An unannounced fire drill shall be held at least once a month. fire drills were completed, and an unannounced fire drill was performed 05/12/2023 Implemented
6400.113(a)Individual #1 did not have fire safety training completed. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. fire safety training completed 05/10/2023 Implemented
6400.141(a)Individual #1 did not have a physical examination completed.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. physical exam was completed. 05/11/2023 Implemented
6400.151(c)(2)Staff #1, CEO did not have a tuberculosis screening completed in the past 2 years. The last annual physical completed on 11/30/21 did not address this. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. physical completed and chest xray was performed only required to perform every 5 years 05/12/2023 Implemented
6400.151(c)(2)Staff #2 did not have a tuberculosis screening completed in the past 2 years. The last completed physical on 8/15/21 did not address this. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. physical completed as well as tuberculin 05/11/2023 Implemented
6400.181(a)Individual #1 did not have an assessment completed. 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. assessment was completed 05/11/2023 Implemented
6400.32(r)(4)The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. Both individual #1 and #2 bedroom door locks had skeleton keys locks.The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency.doors were changed and replaced 05/11/2023 Implemented
6400.52(a)(2)Staff #2 did not complete the minimum amount of required annual training.The following shall complete 24 hours of training related to job skills and knowledge each year: Direct supervisors of direct service workers.all training completed and updated 05/12/2023 Implemented
6400.52(b)(1)Staff #1, CEO did not have the minimum annual training hours completed.The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons.training hours completed 05/11/2023 Implemented
SIN-00201900 Renewal 03/16/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency's self-assessment was completed 3/1/22 which is not within the 3 to 6 month required timeframe prior to the expiration of the agency's certificate of compliance, which is 3/28/22.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.The CEO has put into a place a reminder on November 1st of each year to complete ARKM's self-assessment which is 3-to-6-months prior to ARKM's licensing expiration date. 03/25/2022 Implemented
6400.21(a)The criminal history checks for staff person#3 was completed 3/14/22, date of hire 12/3/21. The criminal history check for staff person #4 was completed 3/14/22, date of hire 12/3/21.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 completed an audit of all personnel files to ensure that employee's criminal history record checks were completed within 5 working days after the person's date of hire. 03/25/2022 Implemented
6400.21(b)it could not be determined if staff persons #'s2,3,4,5,6, were residents prior to employment and no FBI checks were completed for these staff person's.If a prospective employee who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.The ARKM employment application has been revised to include a statement of the prospective employee's residency status in the state of Pennsylvania. 03/25/2022 Implemented
6400.22(d)(1)It could not be determined if there was an up to date financial record for individual#1, as the provided documents were illegible.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. ARKM will send legible financial statements for individual #1. 03/25/2022 Implemented
6400.62(d)In the cabinet beneath the sink there was comet bleach and dawn dish detergent being stored intermingled with along with canned food.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.The CEO has removed the stored poisonous materials from beneath the kitchen sink so that they are no longer intermingled with the house hold's canned food items. 03/28/2022 Implemented
6400.64(d)A large city-provided blue recycle bin with no lid was being used as a kitchen trash can.Trash in the bathroom, dining and kitchen areas shall be kept in cleanable receptacles that prevent the penetration of insects and rodents. A kitchen trash with a lid has been purchased to prevent penetration of insects and rodents. 03/28/2022 Implemented
6400.72(b)Two screens had holes in them, both several inches in size. Those screens were located in the rear first floor window and in the front unoccupied bedroom. Screens, windows and doors shall be in good repair. ARKM will repair the two screens located in the rear first floor window and in the front unoccupied bedroom window. 03/28/2022 Implemented
6400.73(a)The stairwell leading to the basement had a section of approximately 4 stairs which did not have a handrail. There were short handrails at the top and bottom of the stairwell which left roughly 4 stairs in the middle with no handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The hand rail leading to the basement has been ordered with an installation date of 3/29/22. 03/29/2022 Implemented
6400.110(a)There was no smoke detector present in the basement of the home. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. On 3/29/22 ARKM purchased an additional interconnected smoke detector for the basement of the home. 03/29/2022 Implemented
6400.110(e)The home contained 3 floors (2 floors and a basement) however none of the smoke alarms were interconnectedIf 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. ARKM interconnected smoke detectors have been purchased and installed at the home. 03/29/2022 Implemented
6400.113(c)There was no signed documentation showing a fire safety training was performed with individual#1. A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept.ARKM shall forward a copy of individual # 1 fire safety training as proof that the individual did receive fire safety training. 03/29/2022 Implemented
6400.141(b)The annual physical examination for individual#1 was incomplete.The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. A copy of Individual #1 physical examination has been completed with all pages included for review. 03/29/2022 Implemented
6400.142(a)There was no dental exam on file for individual#1.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Individual #1 completed dental form shall be forwarded as proof of a dental cleaning exam. 03/30/2022 Implemented
6400.151(a)Physical exam was requested but not provided for staff member#1 acting as program specialist. 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. ARKM will provide a copy of staff member #1 physical examination acting as program specialist. 03/29/2022 Implemented
6400.151(c)(3)The physical exam dated 2/19/22 for staff member#2 did not indicate if the staff person was free of communicable diseases. 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. ARKM will provide documentation that staff member #2 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. 03/29/2022 Implemented
6400.181(a)There was no assessment present in the record for individual #1. 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. ARKM will forward a copy of the initial self-assessment for individual #1. 03/30/2022 Implemented
6400.217There was no signed documentation showing that individual#1 consented to release of personal information.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. ARKM will forward a copy of individual #1signed consent of release of information. 03/30/2022 Implemented
6400.24Under the 1970 Controlled Substances Act, all class c medications must be double locked and counted at each administration of the medication. Individual#1 is prescribed Klonipin which is a controlled substance. This medication was not being counted prior to inspection.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.A controlled substance count sheet has been implemented for individual #1 prescribed Klonopin controlled medication. 03/30/2022 Implemented
6400.34(b)There was no signed documentation showing that individual rights were reviewed with individual#1.The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.ARKM will provide a copy of individual #1 signed individual rights statement. 03/30/2022 Implemented
6400.165(b)There are inconsistencies between the MAR and the prescription label for Individual#1's Hydroxyzine 50 MG. The bottle states 'Take one tablet by mouth every 8 hours as directed' however the MAR shows the administration times as 9am, 3pm and 6pm which does not line up with the 8 hours as written on the bottle.A prescription order shall be kept current.ARKM will correct the MAR for individual #1's Hydroxyzine 50 MG to align with pharmacy label. 03/30/2022 Implemented
6400.165(g)There were no psych med reviews on file for individual#1.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.ARKM will provide a copy of individual #1's psychotropic medication management reviews. 03/30/2022 Implemented
6400.213(1)(i)Photograph of individual #1 on face sheet is not datedEach individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The date of individual #1's photo has been labeled with the date the photo was taken of the individual. 03/30/2022 Implemented
SIN-00185909 Renewal 03/05/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34The basement door in the dining room was locked; provider did not have a key available at the time of inspectionThe facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.Basement door contains a sliding lock, no key or combination is required to access the basement. The basement door sliding lock has been push back to the unlock position to allow for access at anytime. A do not lock sign has been on the basement door. 03/05/2021 Implemented
6400.67(b)The kitchen counters were cluttered with food items and construction items The mudroom, located beyond the kitchen, was cluttered with garbage bins; the floor had dirt and debris on it. Floors, walls, ceilings and other surfaces shall be free of hazards.The kitchen counters have been cleared of food items and constructions items .The garbage bins have been placed outside of the home. The mudroom floor has been cleaned and free of any debris. 03/05/2021 Implemented
6400.68(b)Water temperature was not determined during the inspection; provider did not have a thermometer available despite being informed of the need for one. Hot water temperatures in bathtubs and showers may not exceed 120°F. A thermometer was purchased on 3/6/21 to check the hot water temperature. 03/06/2021 Implemented
6400.81(k)(2)Both resident bedrooms contained beds that were without frames that elevated them from the ground.In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. On 3/6/21 CEO had two new mattresses, two box springs, and two bedframes delivered by Raymour & Flanigan furniture company. 03/06/2021 Implemented
6400.82(e)The hall bathroom that has a bathtub that did not have a non-slip mat. Bathtubs and showers shall have a nonslip surface or mat. A non slip mat was placed in the bathtub on 3/6/21. 03/05/2021 Implemented