Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00243863 Renewal 05/20/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1 has purchased numerous gift cards over the last year. There are not individual gift card logs for each gift card purchased.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. All gift cards were separately placed on ledgers for tracking. These will be audited weekly at the program and quarterly by PS. 05/24/2024 Implemented
6400.211(b)(3)Individual #1's demographic information did not include who to contact for medical consent.Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. The medical consent form was updated to see the correct person assigned at The Arc that will be the emergency contact for the individual. 05/24/2024 Implemented
6400.32(c)Individual #1 was scheduled with ENT on 9/12/23. The appointment was canceled due to the provider not having staff to take Individual #1 to the appointment. The appointment was rescheduled for 11/10/23. The 11/10/23 appointment was canceled due to a "scheduling conflict." The next available appointment was not until 12/1/23.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.All supervisors and PS/s were retrained on the importance of ensuring all dr appointments are met in a timely manner. attached is the last appointment to show that the appointment was completed. 05/24/2024 Implemented
6400.166(a)(4)Individual #1's OTC/PRN medications are not on the MAR.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.All MARS were updated and will have OTCs listed on them monthly, even if they are not used. The order will be placed with the MAR each month. The supervisor is responsible for completing the MAR. They will also complete weekly MAR reviews and ensure MARS are correctly completed. PSs should be checking bi-weekly, and the HR training department does MAR quarterly reviews. 05/24/2024 Implemented
6400.166(b)On 9/3/23, a PC was made to Individual #1's doctor that they may have received a double dose of Donepezil. This was not logged on the MAR.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The medication error was immediately filed and retraining was issued to the staff that missed these medications. It was reviewed that medications must be reported with in 72 hours or as soon as they are founded. The nurse stated they felt that this was not a medication error but due to not enough information it was still recorded as such, re-training was completed to state documentation must be more thorough in the future. 05/24/2024 Implemented
SIN-00207861 Renewal 07/19/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water tested at the kitchen sink and at the bathtub were both 123.7 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. A new thermometer was purchased on 7/28/22. Contractor, Riders Contracting, came in to fix water temperature on 7/21/22. 07/28/2022 Implemented
SIN-00193107 Renewal 09/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
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
SIN-00178085 Renewal 10/14/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The written evacuation plan for the home does not include the location of where Individual #3 is to be transported for emergency relocation. The current, written plan states she is to be taken to The Arc of Center County agency office located on North Atherton St. However, Staff person#1 reported during the 10/14/2020 onsite inspection, that their old office location on North Atherton Street is no longer owned/leased by the agency effective 10/1/2020. The written evacuation plan also doesn't include the means of transportation to be used in the event of an emergency or the emergency relocation for the other individuals residing in the home. The plan states that the home and individuals in the home could relocate to a list of 8 other residential group home facilities, "if capacity allows" but does not state which relocation site capacity allows for additional individuals.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The relocation points were updated with the new office address on 10/27/2020. We had not had the new letter head for the new office at the time if inspection. The relocation policy was updated to reflect the program will use their designated program car and that if more vehicles are needed they will contact other programs to being more agency vehicles. The policy also reflects the individuals if they cannot go with their families will go to other programs if capacity allows at that time. If not we will take them to a hotel, with staffing, until they can return to their program. 10/27/2020 Implemented
6400.113(a)Individual#1 received training in the fire safety requirements specified in 6400.113(a) on 1/8/19 and not again until 8/28/20, outside the annual time frame requirement. Individual #2 received said training on 1/11/19 and not again until 9/28/20. Individual #3 received training in fire safety on 1/14/19 and not again until 8/17/2020. 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 an din compliance. The CPO will oversee the program fire books, this will include individual trainings. 10/26/2020 Implemented
SIN-00119270 Renewal 10/03/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)Repeat 8/22/16: Fire drill conducted on 10/19/16 did not indicate that the 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 Supervisors are responsible for completing fire drills monthly. They then turn the fire drill form into the Program Specialist for approval. A new check off form was completed to ensure that all sections of the fire drill form are completed. The Fire drill and the check list will then be turned into the Chief Programming Officer for final approval. All Program Specialists will start using this form November 1, 2017. The Arc is currently looking into software that that fire drill form will be on a form that the supervisor can not go to the next section with out other sections being completed to prevent further sections being missed in the future. 10/11/2017 Implemented
SIN-00099960 Renewal 08/22/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)Individual #1 had a $25 gift card that was not recorded on the cash ledger. (2) Disbursements made to or for the individual. All staff were retrained on ensuring that gift cards are immediately placed on a ledger and properly stored in the individuals money bags for their small account. These will be monitored weekly by the supervisor during weekly audits. 09/30/2016 Implemented
6400.67(a)The sink in the half bathroom did not drain. Floors, walls, ceilings and other surfaces shall be in good repair. The sink was fixed to drain properly. This will be monitored monthly by the structural survey completed by the Supervisor. A second check will be placed by the program specialist monthly to ensure all structures, windows, etc. are in good repair and/ being fixed or repaired in a timely manner. 10/04/2016 Implemented
6400.72(b)The back screen door had four holes approximately one inch in diameter. Screens, windows and doors shall be in good repair. The screen door had it's screen replaced. This will be monitored monthly by the structural survey completed by the Supervisor. A second check will be placed by the program specialist monthly to ensure all structures, windows, etc. are in good repair and/ being fixed or repaired in a timely manner. 10/04/2016 Implemented
6400.164(a)The 04/29/16 and 05/15/16 medication administration record did not include the time of administration for Ammonium Lactate cream. 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. At the time of this documentation error it, should be noted that individual was the one responsible for administering the medications. The nurse saw it was not documented and placed her initials because she knew it was competed. All nurses were retrained that if an individual is self medicating that they are not to initial the individuals medication logs, that it is the individuals responsibly. A current MAR is included on the POC. 09/30/2016 Implemented
6400.167(b)Individual #1 was prescribed Sertraline 10 mg to be administered once daily. The medication was not administered on 05/26/16. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.The individual was taken by the family to the appointment and the family did not give the prescription to fill and administer. The Nurses at the program were retrained on agency policy on filling a medication and ensuring if the family takes an individual on a appointment that all scripts and documentation are completed accurately. 09/30/2016 Implemented
6400.181(e)(4)Individual #1's 04/22/16 assessment did not include unsupervised time in the community. The assessment must include the following information: The individual's need for supervision. The assessment summary was updated to reflect the amount of time the individual is able to beat the home and in the community independently. 10/01/2016 Implemented
6400.181(e)(5)Individual #1's 04/22/16 assessment indicated he/she was self medicating with staff assistance. The assessment must include the following information:  The individual's ability to self-administer medications.The individuals assessment was updated to reflect that individual is self-medicating. the outcome that this was met and discontinued is also included in the POC. 08/24/2016 Implemented
6400.183(4)Individual #1's Individual Support Plan (ISP) did not include unsupervised time in the community or in the home. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. A updated outcome is in place for individual to be in the community and a specific amount of time independently. This is also included in the assessment summary. 10/01/2016 Implemented
6400.186(a)The program specialist did not complete the Individual Support Plan reviews. 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 the individual . 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. 10/01/2016 Implemented
6400.186(e)The option to decline the Individual Support Plan review documentation was not provided to Individual #1's father. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. A letter was completed by the individual that they do want their father to be included in team meetings. All Program Specialists were retrained to ensure all team members are invited to meetings. If they decline proper documentation will be provided as such. 10/03/2016 Implemented
6400.213(11)Individual #1's 03/20/16 physical exam indicated seasonal allergies and Eurythromyacin. The April 2016 medication administration log indicated no known allergies. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. The physical exam, MAR and ISP were updated to reflect proper allergy diagnosis. All nurses that would be updating this information were retrained to complete and ensure consistant documentation. The Supervisor will also second check this monthly on the monthly appointment tracking sheet. This will then be rechecked by the RN/program specialist. 10/03/2016 Implemented
SIN-00160884 Renewal 09/17/2019 Compliant - Finalized
SIN-00141578 Renewal 10/04/2018 Compliant - Finalized