Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
SIN-00239402
|
Renewal
|
02/27/2024
|
Compliant - Finalized
|
|
|
Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.66 | At the time of inspection, neither of the home's two rear exterior lights could be made to function via their corresponding light switches. The rear yard of the home, including the home's attached deck, lacked adequate lighting for nighttime conditions. | 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 were changed to be functioning. Supporting documents submitted. |
02/29/2024
| Implemented |
6400.106 | Documentation shows that the two most recent furnace inspections for this location occurred on 11/07/2023 and 09/28/2022---more than 365 days apart. The furnace at this location was not inspected and cleaned by a professional furnace cleaning company annually as required. | 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.
| Furnace inspections will be done yearly. Any delay's by inspection vendor to be recorded and kept on file. |
02/29/2024
| Implemented |
6400.112(c) | The fire drill record for the drill conducted on 9/26/2023 did not have a recorded evacuation time. | 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. | Program Specialist to ensure all areas of the fire drill are completed. |
02/29/2024
| Implemented |
6400.165(g) | Individual #1 takes psychotropic medications to treat the symptoms of a psychiatric illness and sees a psychiatrist quarterly. The physician encounter forms for the 02/05/2024 and 11/06/2023 psychiatry visits were missing documentation of the reason for prescribing the medications, documentation of the need to continue the medications, and documentation of the necessary dosage of the medications. | 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. | Paperwork from appointments were faxed to The Arc of NEPA office. Proper paperwork now on file at the residence. |
02/29/2024
| Implemented |
|
|
SIN-00202556
|
Renewal
|
03/28/2022
|
Compliant - Finalized
|
|
|
Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.141(c)(8) | Individual #1 had an annual mammogram completed on 9/21/20. Individual #1 is over 50 years of age and requires annual mammograms. Annual mammogram for 2021 was completed on 10/15/21. This exceeds the annual requirement and grace period. | 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. | All required annual appointments shall be completed within the timeframe specified as per regulation 6400.141 c 8. Assigned program specialist is responsible for oversight of completion. Next appointment will occur on 10/15/2022. |
03/30/2022
| Implemented |
6400.181(e)(3)(iv) | Individual #1 had an annual assessment completed on 9/1/21. The annual assessment did not include documentation of Individual #1's current level of performance and progress in personal needs with or without assistance from others. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. | Skills assessment part of the Annual Assessment updated to include level of performance and progress in personal needs. Form was updated on 3/30/2022 and attached with POC> |
03/30/2022
| Implemented |
|
|
SIN-00069744
|
Unannounced Monitoring
|
09/05/2014
|
Compliant - Finalized
|
|
|
Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.80(b) | According to the original ARC Smoking Policy smoking was allowed " outside of the facility ". The area near the garage and mulch was designated as the smoking location by the placement of a cigarette butt container resulting in unsafe conditions. The Scranton Fire Department stated ( via phone call ) that the fire on September 4, 2014 was accidental in nature and was probably the result of a cigarette in the mulch. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Patrick Quinn, Director of Residential Services, developed and circulated an addendum to The Arc of NEPA's Smoking Policy, as well as an updated Locked Poisons/ Fire Safety/ Cigarette Container Cleaning Checklist. The Standard procedure for the poison policy checklist now includes a fire safety check and a cigarette disposal until cleaning checkelist. Policy revisions also instituted designated smoking areas and standardized smoke extinguishing kits.
Policy clarifies that all designated smoking areas must be clear of landscapping materials, shrubbery or otherwise combustible materials. The designated smoking area must be posted and made known to all staff, consumers and visitors.
Smoking kits have been placed at all homes. Cigarettes willl extinguished in the repository of the container. Containers are fill with sand. |
09/15/2014
| Implemented |
|
|
SIN-00066869
|
Unannounced Monitoring
|
07/23/2014
|
Compliant - Finalized
|
|
|
Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.33(a) | On 06/12/2014 staff #1 verbally and physically abused Individual #1 while practicing physical therapy techniques. Staff #1 grabbed Individual #1 's head to guide her to a standing position even when Individual #1 complained staff #1 said " that doesn't hurt does it ". When Individual #1 tried to sit back down staff #1 said " go ahead fall I'm not catching you ". | An individual may not be neglected, abused, mistreated or subjected to corporal punishment. | Staff that failed to report incident on 6/12/2014 must attend the Provider Monitoring Training on Abuse, Incident Management, Investigation, and Individual Rights.
HCQU to provide staff training on positioning, transfers, and individual's mobility needs.
Target must attend Provider Monitoring Training on Abuse, Incident Management, and Individual Rights.
Staff meeting held for the purposes of discussing individual's changing physical needs and identifying tools to accommodate changes, and to encourage individuals to participate in prescribed therapies.
Target to be trained on Arc policies related to Incident Management, Is This Abuse?, Individuals Rights, and Positive Practices. Target will then be transferred to another residential home.
Physical Therapy is no longer prescribed by treating physician in consideration of individual's lack of interest. |
08/22/2014
| Implemented |
|
|
SIN-00055917
|
Renewal
|
11/19/2013
|
Compliant - Finalized
|
|
|
Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.44(c) | There wasn't any record i.e. diploma or transcript to verify the qualifications for staff #1. | (c) A program specialist shall have one of the following groups of qualifications:
(1) A master's degree or above from an accredited college or university and 1 year work experience working directly with persons with mental retardation. (2) A bachelor's degree from an accredited college or university and 2 years work experience working directly with persons with mental retardation. (3) An associate's degree or 60 credit hours from an accredited college or university and 4 years work experience working directly with persons with mental retardation.
| Staff #1's transcripts were obtained on 11/19/2013 as record of qualification. Qualifications will be obtained prior to hire. |
11/19/2013
| Implemented |
|
|
SIN-00147563
|
Renewal
|
01/23/2019
|
Compliant - Finalized
|
|
SIN-00129468
|
Renewal
|
02/20/2018
|
Compliant - Finalized
|
|
SIN-00089416
|
Renewal
|
02/02/2016
|
Compliant - Finalized
|
|