Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00246797 Unannounced Monitoring 06/18/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Poisons such as bleach and hand soap were found unlocked in the home.Poisonous materials shall be kept locked or made inaccessible to individuals. All poisons shall be locked away, the residential supervisor is responsible and ensure all poisonous materials shall be locked away. The poisonous materials were removed immediately after the visit. June 18th 2024. All homes were checked to ensure all poisonous materials were locked away. Completion was done on June 18th, 2024 07/09/2024 Implemented
6400.144For individual 1: Prescribed medication, Ketoconazole Shampoo 2%, could not be found in the home when medications were checked.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. All documentations shall be current and reflect prescription that is no longer prescribed. Residential Supervisor is responsible to check and report to management with any discrepancies. Documentation of discontinuation has been corrected on June 18th 2024. Discontinuation of medication from doctor was sent to licensing team. Agency wide check was conducted to ensure compliance. 07/09/2024 Implemented
6400.171There was a plate of food covered in foil sitting inside the microwave.Food shall be protected from contamination while being stored, prepared, transported and served. Residential Supervisor is responsible for correcting the problem. Food will not be left out for any period. Staff will check microwave and ovens every 3 hours to ensure proper storage of food. Agency wide check was conducted on June 20th, 2024, to ensure compliance. 07/09/2024 Implemented
6400.32(h)Two cameras were found in the living room of the home. Staff did not provide a signed copy of the individual's and/or guardian's agreement for cameras in the home.An individual has the right to privacy of person and possessions.Program Specialist is responsible for documentation of agreement of all camera's agency wide. Approval notice from all parties was sent to licensing team. Signed copies were provided. In the event that a camera is installed without approval of all parties it would be a violation. Cameras that were installed without approval must be removed. Agency wide check was conducted on June 20th, 2024. to ensure compliance. 07/09/2024 Implemented
6400.166(c)For individual 1: The medication record for the month of June 2024 is not properly indicating when the individual is refusing medication. According to the legend on the medication record, staff is supposed to initial their name and circle it. This did not occur on the following dates: 6/14/2024 6/15/2024 6/17/2024 There is no evidence medications are not being withheld or disposed incorrectly after reviewing the blister packs of medications during the review.If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual.Residential supervisor is responsible to ensure documentation is completed for refusals. Agency wide check was completed to ensure compliance. Prescribers were notified for all refusals. Documentation was completed on June 19th 2024th. 07/09/2024 Implemented
SIN-00234976 Renewal 10/17/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)73A The railing leading up to the second floor was loose and needing to be tightened. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The Residential Director is responsible for correcting the immediate problem of the loose railing leading to the second floor. This was corrected on 10/23/2023. An agency wide check was conducted to ensure all individuals are safe and secured from any perils of loose stairs or handrails for citation of 72A Residential Supervisor shall conduct a biweekly monitoring of all rails to ensure they are secure. An agency wide review of all sites rails was accomplished on 10/25/2023. 12/13/2023 Implemented
6400.76(a)76A The blinds in the dining room were broken. When asked staff stated that it has been that way since they came to the home. Furniture and equipment shall be nonhazardous, clean and sturdy. The Residential Director is responsible for correcting the immediate problem of broken blinds located in the dining room. This was corrected on 10/23/2023. An agency wide check was conducted to ensure all individuals furniture and equipment are sturdy, clean and nonhazardous. Residential Supervisor conducted agency wide check of all blinds which was accomplished on a target date of 10/25/23. 12/13/2023 Implemented
6400.82(e)82E The upstairs bathroom did not have a non-slip matt in the shower. Bathtubs and showers shall have a nonslip surface or mat. The Residential Director is responsible for correcting the immediate problem non-slip mat for the shower. This was corrected on 10/26/2023. An agency wide check was conducted to ensure all individuals are safe from any perils of not having a non-slip bathroom mat. Residential Supervisor conducted monitoring of all bathrooms for non-slip mats which was accomplished on a target date of 10/24/23 12/13/2023 Implemented
6400.112(c)112 (c ) No times on fire drill log noted.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. The Residential Director is responsible for correcting the immediate problem and ensure fire drills are conducted. The date, time, the amount of time for evacuation, exit route used, problems encountered alarm or smoke detectors work. This was corrected on 10/18/2023. An agency wide check was conducted to ensure all individuals are safe from any perils of not having a fire drill conducted. Noted fire drill was conducted. Documents are kept at the main office. Target date of completion 10/18/2023 Residential Supervisor conducted monitoring of all fire logs which was accomplished on a target date of 10/24/23. 12/13/2023 Implemented
6400.112(e)112(e)There was a asleep drill conducted on 12/27/22, the next sleep drill was due by 6/2023 however it was not conducted.A fire drill shall be held during sleeping hours at least every 6 months. The Residential Director is responsible for correcting the immediate problem and ensure fire drills are conducted. The date, time, the amount of time for evacuation, exit route used, problems encountered alarm or smoke detectors work and fire shall be held during sleeping hours every six months. This was corrected on 10/18/2023 as the fire drill record was located at the main office. An agency wide check was conducted on 10/25/2023 to ensure all individuals are safe from any perils of not having a fire drill conducted. Noted fire drill was conducted during sleeping hours. Documents are kept at the main office. Site is compliant for citation 112(e) Residential Supervisor conducted monitoring of all fire logs which was accomplished on a target date of 10/24/23. 12/13/2023 Implemented
SIN-00230123 Unannounced Monitoring 08/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(h)There were a number of out expired medications in the upstairs medication room that needed to be disposed.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.To dispose of prescription and over-the-counter drugs, ARCC Nursing/ Admin staff will destroy the blister packs ( to prevent HIPPA violations) and bag the individuals medication that has expired, or is no longer needed (explanations will be provided via MAR log, medication will be come from the individuals home) and will be discarded at an FDA Certified Controlled Division Center Collection of all discontinued medications or expired medication was collected on 08/18/2023 (CVS Pharmacy located at 6701 Ridge Avenue, Philadelphia PA 19128) for proper disposal. 08/18/2023 Implemented
SIN-00224744 Unannounced Monitoring 05/19/2023 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(e)The trash receptacles located in the rear of the home did not have lids.Trash receptacles over 18 inches high shall have lids. Lids for the trash can have been purchased and are on site. 05/25/2023 Requested
6400.71Emergency numbers is not posted on or near the telephone located in the kitchen.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. Emergency numbers has been posted on the kitchen wall next to the phone. 06/30/2023 Requested
6400.144Medication METFORMIN HYDRO TAB 500mg is not being administered as prescribed to Individual #1, the MAR instructs medication to be administered at 8am, 4pm and 8pm. Staff is signing the MAR for the 8pm dosage that is not being administered. Medication was not signed as administered on 05/07/2023 for the 8am and 4pm dosages. [REPEATED VIOLATION 8/30/22]Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Staff have been scheduled for Medication Admin training and will complete within the next thirty days... 06/30/2023 Requested
6400.32(c)Individual #1 provided a verbal statement that she was physically abused by staff. She provided the names of the staff that is striking her and verbally mistreating her. Staff in question is: Staff#1 and Staff #2 was mentioned as the staff hitting and yelling at the individual.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.EIM have been entered and investigations as well as corrective action leading to termination of any substantiated allegations of abuse. EIM 9215928 EIM 9215936 EIM 9205423 EIM922185 EIM 9215936 07/01/2023 Requested
6400.165(c)Prescription medication ERGOCALIFEROL CAP is not being administered as prescribed to Individual #1, this medication is to be given once a week as indicated on the MAR which is not being followed by administering staff. [REPEATED VIOLATION 8/30/22]A prescription medication shall be administered as prescribed.- All Staff are being scheduled for medication administration training and will have a practicum on file _ Staff have been scheduled to take Med Admin - Regulation Training 06/30/2023 Requested
6400.166(a)(13)Individual 1's Medication(s) FANAPT 12mg, DIVALPROEX 500mg and CEROVITE TAB 500mg was not logged as administered by staff on 05/07/2023 for the 8am dosages.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.-Staff has been counseled and will be retrained on medication administration - Regulation retraining 06/30/2023 Requested
6400.166(c)Medication BENZOYL PEROXIDE TOPICAL WASH 5%, is being signed as administered by staff daily however, individual #1 is refusing this prescribed medication and the refusal log is not consistent and not dated.If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual.Staff has been counseled on the correct way to document a refusal. Staff will also be enrolled in medication administration training within the next thirty days. 06/30/2023 Requested
SIN-00223825 Renewal 04/24/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment of each home operated, within 3 to 6 months prior to the expiration date of the agency's certificate date 08/03. The Self-Assessment provided was dated 04/24/2023 as the inspection date.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. Provider will complete quarterly self-assessments to ensure that all assessments are completed in a timely manner. ARCC ED/ CEO will submit self-assessments 3-6 months prior to the expiration date of the agency certificate of compliance. 06/06/2023 Not Implemented
6400.64(f)The outdoor trashcans did not have lids.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.Staff will complete a daily site checklist; residential manager will complete a site checklist. to ensure compliance of the residential homes. Staff were instructed/ trained on how to complete maintenance request on 5/5/2023 for all interior and exterior of the homes to ensure the residential homes remain in compliance. 06/06/2023 Not Implemented
6400.67(a)There was a broken doorknob on the closet of Individual 1 and the closet was no longer able to open as a result.Floors, walls, ceilings and other surfaces shall be in good repair. ARCC has hired Maintenance to complete any repairs to the exterior and interior of the homes to ensure compliance of regulations. The bedroom doorknob was replaced and repaired 5/24/2023. The Picture is attached in drop box 06/06/2023 Not Implemented
6400.110(e)The smoke detectors in the home were functional but not interconnected.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. Provider replaced the smoke detectors on 4/24/2023. Smoke detectors are now interconnected. Pictures were added to the drop box. 06/06/2023 Not Implemented
6400.111(a)The fire extinguisher on the second floor was not fully charged and the needle on the pressure gauge was in the red section.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Provider had fire extinguishers recharged. 06/06/2023 Not Implemented
6400.18(i)The agency failed to finalize incident reports through the Department's information management system by the Department within 30 days. The date of the incidents are, ID#9175721 - 03/01/23, ID#9174492 -- 02/27/23, ID#9172212 -- 02/22/23, ID#9171617 -- 02/21/23, ID#9171648 -- 02/21/23, ID#9170155 -- 02/17/23, ID#9169832 -- 02/17/23, ID#9169553 -- 02/16/23.The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension.The agency has hired a contractor to help with EIM completions to ensure all incidents are entered within twenty-four hours. 06/06/2023 Not Implemented
SIN-00210366 Renewal 08/30/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aid kit did not contain antiseptic and 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. ARCC/The Residential Director replenished the first aid kit at all sites to ensure all required items as per 6400.77 (b) are included. On 9/13/22 ARCC purchased a thermometer and antiseptics that wee placed into the first aid kit. Photo of the first aid kits are included. A staff meeting was held for the Provident site staff on 9/19/22 at 9:30am to address all citations and plans of corrections. 09/19/2022 Implemented
6400.144Prescription medication is not being administered as prescribed and not logged when administered for Ind. # 4..Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. ARCC met with the house supervisor to ensure they, as well as all staff are to following all medication administration procedures - thus ensuring all prescribed medications are administered. All employees at the home were retrained during the house meeting on Monday, September 19th at 9:30 am. (see attached attendance sheet) 09/19/2022 Not Implemented
SIN-00192323 Renewal 08/31/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71There were no Emergency telephone numbers on or near the telephone located 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. Emergency telephone contact information was placed near the telephone on 8/31/2021 per 6400.71 regulatory guidelines. see attachment #1 09/01/2021 Implemented
6400.77(b)The new First Aid kit did not contain a thermometer. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. The new (opened at time of inspection) first aid kit did not contain a thermometer, however a digital thermometer was on site (COVID-19 protocol) used daily for temperature checks for all who enter/exit site. (see attachment#5) 08/31/2021 Implemented
6400.77(c)The First Aid Kit did not contain a manual A first aid manual shall be kept with the first aid kit.The new (opened at time of inspection) first aid kit did not contain a manual. The residential supervisor placed a first aid manual on site per 6400.77(c) regulatory guidelines. (see attachment#2) 09/01/2021 Implemented
6400.151(c)(2)Program specialist/CEO Staff #1 TB test is out of date. Two physicals were observed in records submitted by the agency: one does not list a clear date for the physical but lists a TB test with a read date of 8/29/19. The other lists an appointment date of 9/11/20, but does not indicate a TB test was performed. 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. Upon discovery, the program specialist/CEO Staff#1 worked out of office until a negative TB screening was produced. (see attachment#4) 09/09/2021 Implemented
6400.46(b)It could not be determined that program specialist/CEO Staff #1 has received an annual fire safety training within the past year.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The program specialist/CEO Staff #1 successfully passed fire safety training conducted by Tri-State Training & Safety Consulting per 6400.46 (b) regulatory guidelines. (see attachment #3) 08/31/2021 Implemented
6400.46(d)It could not be determined that program specialist/CEO Staff #1 has received an annual CPR and first aid training within the past year.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.On 9/8/21 the program specialist/CEO Staff#1 successfully passed CPR/Fire Safety training conducted by Tri-State Training & Consulting per 6400.46 (d) regulatory guidelines. (see attachment #6) 09/08/2021 Implemented
6400.162(a)It cannot be determined that the agency has completed medication administration training with required annual or initial practicums and observations for any of their staff that administer medications. Three staff records were reviewed: CEO/program specialist Staff #1, and DSPs Staff #3 and Staff #2. The agency submitted internal certificates showing a medication training for each, but no ODP medication administration training documentation, nor observation or other practicum documentation. During the inspection, the agency's indicated that they did not have this documentation for any of their staff. As such, the agency is not permitted to administer medication and will be placed under remediation until their staff are adequately trained and observations are documented.A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication.On 8/31/21, the agency nurse provided medication administration for Individual #1 until ARCC staff members Staff #2 and Staff #3 were adequately trained using ODP observations and practicum documentation per 6400.162 (a) regulatory guidelines. This training was implemented by ARCC medication administrator The program specialist CEO Staff #1 will not administer any medication at ARCC. (see attachments 16,17,18) 09/10/2021 Implemented
6400.162(a)It cannot be determined that CEO/program specialist Staff #1 has completed an annual medication administration training and practicum. The agency submitted an internal certificate that indicates the staff member completed a training but the staff that signed that document signed two different dates: 1/14/20, and 1/14/21. No ODP medication administration training documentation nor observation or other practicum records were available at time of inspection.A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication.The program specialist/CEO Staff#1 is prohibited to administer medications at ARCC per 6400.162 (a) regulatory guidelines. 08/31/2021 Implemented
SIN-00263961 Renewal 03/18/2025 Compliant - Finalized
SIN-00251749 Unannounced Monitoring 09/17/2024 Compliant - Finalized