Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00243856 Renewal 05/20/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)At the time of the inspection, the bathroom with the shower did not have paper towels or individual hand towels available.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 residential supervisors and program specialists were retrained to ensure all programs have paper towels and or hand towels accessible at each sink and bathroom for all individuals and staff to utilize. 05/24/2024 Implemented
SIN-00193101 Renewal 09/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)Individual #1's 12/1/2020 physical examination record did not include documentation that they received an annual Gynecological examination including a breast examination and a Pap test since their admission to the facility in 2019. The individual's physician only they stated on the physical examination record, "I do not recommend an internal pelvic exam and Pap smear unless there is an issue. I recommend yearly external examinations." The individual's 12/1/2020 physical examination did not include record of an external examination being completed.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. The Program Supervisor will ensure this is adequately documented what the recommendation is for these gynecological exams and ensure they are completed in the timeframe suggested. If there is required paperwork the Supervisor will ensure proper physician letters are collected and kept updated. If the individual refuses a desensitization plan will be implemented by the Program Specialist. All staff will be trained on it. The Program Specialist will ensure monthly that this is requirement is being met by the monthly tracking sheet completed by the Program Specialist. This should also be reviewed every 6 months the team assigned for the LII process. If there is a legal guardian that is making medical decisions that paperwork will be also on hand. 09/23/2021 Implemented
6400.141(c)(8)Individual #1's 12/1/2020 physical examination record did not include documentation that they received a mammogram or that their physician deferred this examination and the reason for deferment.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. The Program Supervisor will ensure this is adequately documented what the recommendation is for Mammogram exams and ensure they are completed in the timeframe suggested. If there is required paperwork the Supervisor will ensure proper physician letters are collected and kept updated. If the individual refuses a desensitization plan will be implemented by the Program Specialist. All staff will be trained on it. The Program Specialist will ensure monthly that this is requirement is being met by the monthly tracking sheet completed by the Program Specialist. This should also be reviewed every 6 months the team assigned for the LII process. If there is a legal guardian that is making medical decisions that paperwork will be also on hand. 09/22/2021 Implemented
6400.144Individual #1's 12/1/2020 physical examination record stated a referral was placed for the individual to receive a Gynecological examination and mammogram. On 2/11/21 the individual's physician again recommended that the individual receive a mammogram. At the time of the 9/13/2021 inspection, there are no records maintained that the individual received a mammogram. Staff documented on 12/2/2020 that the individual's physician ordered bloodwork to recheck vitamin D and triglyceride levels. There are no records of the results of this bloodwork.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. The Program Supervisor will ensure this is adequately documented what the recommendation is for mammograms and ensure they are completed in the timeframe suggested. If there is required paperwork the Supervisor will ensure proper physician letters are collected and kept updated. If the individual refuses a destination plan will be implemented by the Program Specialist. All staff will be trained on it. 09/22/2021 Implemented
6400.145(1)The Emergency Medical Plan developed for The Arc of Centre County is the same for all households. There is only one emergency medical plan developed. The Emergency Medical Plan is to be individual specific and is to identify the individual's hospital of preference.The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. This policy was updated to reflect preference of hospital for each individual resigning in a 6400 licensed residential home and how they will be transferred, as well as reflect emergency situations. 09/22/2021 Implemented
6400.181(e)(7)Individual #1's current, 10/2/2020 assessment does not include their ability to move away quickly from heat sources.The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. The Program Specialist updated the assessments to reflect the individual's abilities to recognize, move away and or use of heat sources this wild be done annually or if the persons ability to recognize or move away has changed in anyway the ISP and Assessment will have a critical revision upon recognizing such change in ability. 09/22/2021 Implemented
6400.181(e)(9)Individual #1's current, 10/2/2020 assessment does not include their severe reaction to bee stings and bug bites. Per the individual's record, they experience severe swelling with bug bites and bee stings and requires immediate medical attention. The individual assessment only states the individual is very sensitive to bug bites and irritations.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. The Program Specialist updated the assessment and ensured it was clear and concise of what adverse allergies and reactions occur if a bee sting occurs. This assessment should also reflect the actions needed if stung by a bee. 09/22/2021 Implemented
6400.181(e)(12)Individual #1's current, 10/2/2020 assessment does not include recommendations for services and training. The assessment only included recommendations for programming.The assessment must include the following information: Recommendations for specific areas of training, programming and services. The assessment was immediately updated and staff retrained on the individuals trainings, recommendations and services that should occur in the annual year. 09/22/2021 Implemented
6400.32(e)Individual #1's record contains a note on 12/3/2020 stating that the agency, The ARC of Centre County, contacted the individual's mother to ask the mother's permission to approved of a medication regimen to lessing Individual #1's COVID-19 symptoms. The note concluded that the mother declined the medical intervention. The agency reported that Individual #1 does not have a legal guardian or any other legal representatives assigned by courts to make decisions on the individual's behalf. There are no records maintained that Individual #1 was asked, informed of, and provided their right to make choices and accept risks associated with a suggested medical regimen to lesson their COVID-19 symptoms. Additionally, staff have documented that the individual's mother requested a mammogram not be completed. However, there are no records this was discussed with the individual or that that individual's mother is Individual #1's legal representative to make such decisions that negate the individual's rights to make such decisions.An individual has the right to make choices and accept risks.The mother did obtain legal representation as the POA. Documents will be attached for review. All supervisors and Program Specialist were retrained on the importance that the parent does not mean they are the legal guardian and that appropriate paperwork. Prior to the POA being obtained the individual was reviewed her rights and resigned the document. All staff have been retrained to ensure that An individual has the right to make choices and accept risks. If the parent is not the legal guardian or POA then it is the individuals right to take on that risk. If there is a legal guardian there must be adequate documentation to support this. The Supervisor and Program Specialist are responsible to monitor this at all times. 09/22/2021 Implemented
6400.34(a)At the time of the 9/13/2021 inspection, there are no records maintained that Individual #1 had their regulatory right, 6400.32(v), reviewed with them in 2020 or 2021.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 program Specialist did have the rights updated and signed immediately. 10/01/2021 Implemented
6400.166(a)(2)Individual #1 September 2021 Medication Administration Record does not include the prescribing physicians' names.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.Supervisors and Program Specialists will ensure that the MARS have all required information. All MARs were immediately updated with the prescribing physician. 10/01/2021 Implemented
6400.166(a)(11)Individual #1 September 2021 Medication Administration Record (MAR) does not include the diagnosis or purpose for each medication listed on the MAR.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.Supervisors and Program Specialists will ensure that the MARS have all required information. All MARs were immediately updated with the diagnosis of the medications. 10/02/2021 Implemented
6400.166(a)(13)The name and initials of the persons administering all of Individual #1's medications over the previous year, is illegible on most of the individual's monthly medication administration records.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.Trained staff that can pass medications names and initials of the person administering the medication were updated on the MAR to ensure they are legible. All staff were retrained immediately to ensure expectation is met going forward. 10/01/2021 Implemented
6400.186Individual #1's Individual Support Plan (ISP) states that staff are to help the individual brush and floss their teeth daily, they require staff to remind them to brush their own teeth with crest gel toothpaste after meals and snacks with a 3-sided toothbrush, Chapstick brand lip balm during the day is a must, and that Individual #1 is not capable of total self-care of oral hygiene. There are no records maintained that staff are physically or verbally assisting Individual #1 to complete all oral hygiene care as described in the individual's ISP.The home shall implement the individual plan, including revisions.The Program Specialist updated the ISP to reflect the individual's abilities to complete dental hygiene. The Progress notes attached to the POC also review the abilities and what they individual is able to assist with. 09/22/2021 Implemented
6400.213(1)(i)Individual #1's record did not include identifying marks. The record indicated this regulation was not applicable however, this regulation is applicable to all individuals within the licensed setting and must be documented for measuring compliance.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.All record were updated to reflect if there are include identifying marks. If they do not have identifying marks they will write none and not N/A. 09/22/2021 Implemented
SIN-00178078 Renewal 10/14/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individual #1 received training in the fire safety requirements specified in 6400.113(a) on 12/19/18 and not again until 9/3/20, outside the annual time frame requirement. 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 Chief Programming Officer will now be in charge of monitoring annual fire safety training instead of the training department. Every August the CPO will administer the training materials to the Program Specialist and Residential Supervisors to train the individuals in their assigned location. They will then hand them into the CPO and this part of the LII will be monitored by the CPO and signed off of the LII going forward. In the past the training department completed this with staff annual training and then reported to the Program Specialist that it was completed and in compliance. The CPO will oversee the program fire books; this will include individual trainings. Completed: 10/26/2020 10/26/2020 Implemented
SIN-00160877 Renewal 09/17/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Backsplash behind the kitchen sink is damaged and water logged.Floors, walls, ceilings and other surfaces shall be in good repair. The counter top and back splash will be replaced 10/18/2019 by T & A Maintenance. The back splash is connected to the countertop, so both will be replaced at the same time. Countertop and new back splash was ordered and will be replaced by 10/18/2019 per contractor. The monthly structural survey was updated to ensure Supervisor will complete a thorough walk through to inspect all avenues of the home, Program Specialist will conduct a second check. This form will then be sent to Safety Committee and the Chief Programming Officer for review monthly. Also during the LII internal audit twice a year a team conducting the audit should also be monitoring this and documenting such on the LII. All Program Specialists and Supervisors were retrained on this procedure and monitoring on 9/25/2019. 10/18/2019 Implemented
6400.72(b)Front door has rust on both bottom corners on the outside and the lower outside trim is damaged and splintered. Screens, windows and doors shall be in good repair. Doors and trim will be replaced 10/18/2019 by T & A Maintenance. The supervisor immeditaly contacted the maintenance company and received quote on 9/25/2019. The door and trim will be replaced by 10/18/2019 per contractor. The monthly structural survey was updated to ensure Supervisor will complete a thorough walk through to inspect all avenues of the home, Program Specialist will conduct a second check. This form will then be sent to Safety Committee and the Chief Programming Officer for review monthly. Also during the LII internal audit twice a year a team conducting the audit should also be monitoring this and documenting such on the LII. All Program Specialists and Supervisors were retrained on this procedure and monitoring on 9/25/2019. 10/18/2019 Implemented
SIN-00119263 Renewal 10/03/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment for this home was not completed 3 to 6 months prior to the expiration date of the agency's certificate of compliance. The certificate of compliance expiration date was 6/15/17 and the self-assessment was completed on 4/5/17.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. All Program Specialist were retrained on this regulation, 15a. All self-assessments will be completed bi-annually. The Self -assessment will be done every September and every February-March 15 of every year going forward. Program Specialists are responsible for being the lead of the self-assessment and for the team assigned to the program. The Program Specialist is responsible that the dates are met. The Program Specialist will then be turn the self-assessemenr into Amy Bennett, Chief Programming Officer, for a final check and to ensure remediation of any citations are completed in a timely manner. 10/11/2017 Implemented
SIN-00099953 Renewal 08/22/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The 2/10/16 fire drill log did not indicate if all smoke detectors were operable.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. All Program Specialists and Supervisors were retrained to ensure that all smoke detectors are working. This should be done monthly during fire drills and the monthly structural survey. These documents are then second checked by the program specialists to ensure compliance. 10/04/2016 Implemented
6400.112(f)According to the fire drill logs, twelve of the fourteen fire drills used the front door as the evcuation route. Alternate exit routes shall be used during fire drills. All Program Specialists and Supervisors were retrained to ensure that different routes are being used to evacuate during fire drills. This should be done monthly during fire drills and supervisor should follow the monthly fire drill schedule that reflects the different doors to be used. These documents are then second checked by the program specialists to ensure compliance. 10/04/2016 Implemented
6400.112(h)The 11/26/15 fire drill log did not indicate if all individuals met at the meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.All Program Specialists and Supervisors were retrained to ensure that individual are evacuating to the proper designated meeting place. This should be done monthly during fire drills and the monthly checklist These documents are then second checked by the program specialists to ensure compliance. 10/04/2016 Implemented
6400.163(c)REPEATED VIOLATION-05/04/15 Individual #1 did not have psychiatric medications reviews prior to 02/01/16. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.All Program Specialists and supervisors were retrained on ensuring that quarterly medication reviews are completed. A monthly tracking sheet is t be completed by the supervisor and then the program specialist will second check it to ensure that this is completed and tracked monthly. 10/04/2016 Implemented
6400.164(a)Individual #1's August 2016 medication administration log indicated metamucil powder should be administered two times per day with food. The pharmaceutical label indicated metamucil powder shoudl be administered three times per day. A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. Individual #1's August 2016 MAR was updated to reflect the physician order, prescribed June 17, 2016. A copy also is included of the prescription label. 09/30/2016 Implemented
6400.181(e)(13)(iii)REPEATED VIOLATION-05/04/15 Individual #1's 07/15/16 assessment did not include progress over the past year in residential living. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. The individual's assessment was updated to include progress in residential living. All program Specialists were retrained to ensure this is updated annually to reflect all individuals progress in this area. 10/04/2016 Implemented
6400.181(e)(13)(iv)REPEATED VIOLATION-05/04/15 Individual #1's 07/15/16 assessment did not include progress over the past year in personal adjustment. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. the individual's assessment was updated to include progress in personal adjustment. All program Specialists were retrained to ensure this is updated annually to reflect all individuals progress in this area. 10/04/2016 Implemented
6400.181(e)(13)(v)REPEATED VIOLATION-05/04/15 Individual #1's 07/15/16 assessment did not include progress over the past year in socialization. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. The individual's assessment was updated to include progress in socialization. All program Specialists were retrained to ensure this is updated annually to reflect all individuals progress in this area. 10/04/2016 Implemented
6400.181(e)(13)(viii)REPEATED VIOLATION-05/04/15 Individual #1's 07/15/16 assessment did not include progress over the past year in managing personal property. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. The individual's assessment was updated to include progress in Managing Personal property. All program Specialists were retrained to ensure this is updated annually to reflect all individuals progress in this area. 10/04/2016 Implemented
6400.181(e)(13)(ix)Individual #1's 07/15/16 assessment did not include progress over the past year in community integration. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.The individual's assessment was updated to include progress in community intergration. All program Specialists were retrained to ensure this is updated annually to reflect all individuals progress in this area. 10/04/2016 Implemented
6400.183(5)Individual #1's Individual Support Plan (ISP) did not include the social, emotional, environmental needs plan. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. All program specialists were retrained to ensure that the ISP reflects the SEEN plan. A updated ISP for the individual is included in the POC to reflect this. 10/04/2016 Implemented
6400.183(7)(iii)Individual #1's Individual Support Plan (ISP) did not include his/her potential to advance in vocational programming. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. The ISP was updated to reflect that individual is not able to participate in Vocational programming. All Program Specialist were retrained to ensure that this is documented for all those on their caseloads. 10/04/2016 Implemented
6400.183(7)(iv)Individual #1's Individual Support Plan (ISP) did not include his/her potential to advance in competitive employment. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Competitive community-integrated employment. The ISP was updated to reflect that individual is not able to participate in community-integrated employment. All Program Specialist were retrained to ensure that this is documented for all those on their caseloads. 10/04/2016 Implemented
6400.185(b)Individual #1's Individual Support Plan (ISP) included an outcome of structured activity five times per week. Individual #1's 11/23/15, 05/11/16 and 08/11/16 ISP reviews included Individual #1's participation on the structured activity outcome two times per week. The ISP shall be implemented as written.The outcomes were updated to reflect on the proper amount of activities the individual should be participating weekly. All program specialists were retrained on ensuring that all outcomes and ISP's are matching and reflecting what the staff and individuals should be working on for the outcomes. 10/04/2016 Implemented
6400.186(a)The program specialist did not complete the Individual Support Plan (ISP) reviews; the house manager completed the document. The 11/23/15 ISP review was completed late. The review should have been completed by 11/14/15. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. A quarterly review was completed by program specialist for an individual.. This individual will not have one until November 2016. All program specialists were retrained that they will be the ones competing and signing all quarterly reviews. Any quarterly review that is prepared after October 1, 2016 will be completed per the regulation. 10/04/2016 Implemented
6400.186(c)(2)REPEATED VIOLATION-05/04/15 Individual #1's 11/23/15, 02/11/16, 05/11/16, and 08/11/16 Individual Support Plan (ISP) reviews did not review his/her intensive supervision needs. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. A review was completed by program specialist that reflected the intensive needs for supervision. All program specialists were retrained on ensuring this is completed monthly and on quarterly reviews. 10/04/2016 Implemented
6400.186(c)(4)(iii)Individual #1's Individual Support Plan (ISP) included a structured activity outcome. The outcome was achieved and the program specialist did not send notificaiton to the supports coordinator to modify the outcome. The program specialist shall make a recommendation regarding the following, if applicable: The modification of an outcome or service to support the achievement of an outcome in which no progress has been made. . All program Specialists were retrained to ensure all communication on changes or modifications on outcomes or the ISP are made to the Supports Coordinator are saved for documentation. Updated outcome was completed and included in the POC documentation. 10/04/2016 Implemented
6400.186(d)There was no documentation to show Individual #1's Individual Support Plan (ISP) reviews were sent to plan team members. The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. A new formatted letter was created and will be used starting October 1, 2016 for all Program Specialists to use and ensure a copy is made and included with the quarterly review that they were sent the reviews. We will still complete the tracking sheet at the office to ensure this is being done in a timely manner. 10/01/2016 Implemented
6400.213(11)Individual #1's 07/15/16 assessment indicated a high fiber diet. The 06/15/16 physical exam and Individual Support Plan (ISP) indicated a pureed diet with thickened liquids, 20-30 mg of fiber daily, and 2 TBSP of bran cereal daily. Individual #1's ISP indicated he/she required two staff members except during car rides with no stops and transporation to and from day program. The 07/15/16 assessment indicated individual #1 required 2:1 staffing except when outside on the property and walks in the neighborhood at which time 1:1 staffing was required. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. The Assessment and Dr. order were updated to reflect the proper diet information and to ensure they are consistent In what specifics are documented. 09/16/2016 Implemented
SIN-00282978 Renewal 02/17/2026 Compliant - Finalized
SIN-00207855 Renewal 07/19/2022 Compliant - Finalized
SIN-00141571 Renewal 10/04/2018 Compliant - Finalized
SIN-00079653 Renewal 05/04/2015 Compliant - Finalized
SIN-00048046 Renewal 04/09/2013 Compliant - Finalized