Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00220402 Renewal 02/08/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(g)Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness. Individual #1 had a 3-month psychotropic medication review on 10/3/2022 and then again on 1/23/2023. This exceeds the every 3 month requirement.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.Individual #1 was scheduled to be seen for a psychotropic medication review on 1/23/2023 as noted in the violation summary, however, he was hospitalized at the Butler Memorial Hospital on 1/15/2023 - 1/20/23 and then was directly transferred to the Chicora Medical Center for rehabilitation on 1/20/23-2/3/2023. He was then readmitted to the hospital on 2/5/2023 - 2/22/2023 and then was directly transferred to the Chicora Medical Center for rehabilitation on 2/22/23-3/3/2023. He was rescheduled for this appointment upon his release back to the group home for 4/17/2023 which was the soonest available appointment his provider had available. Proof of the appointment completion will be emailed to the licensing supervisor upon completion. 04/13/2023 Implemented
SIN-00170823 Renewal 02/12/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(f)The program specialist provided Individual #1's assessment, dated 8/6/19, to the plan team members on 8/6/19 for the annual ISP meeting held on 8/19/19.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The current Residential Program Specialists will be trained in the area of 55 PA Code Chapter 6400.181(f) with a focus on providing the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting by February 26, 2020 by the Residential Program Director. The Residential Program Director will monitor and log all completed initial and annual individual assessments to ensure that all assessments are completed in accordance with the regulations. [Documentation of a half hour of training for 5 staff persons on 2/25/2020 provided to the Department. Documentation of aforementioned monitoring will occur on a spread sheet that will be updated at least monthly by the Director of Residential Services. (AES,HSLS on 2/27/20)] 02/26/2020 Implemented
SIN-00130806 Renewal 03/08/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)On March 9, 2018 at 10:16 AM, the hot water temperature measured 123.6 degrees Fahrenheit in the bathtub of the bathroom to the left in the main hallway of the home. Hot water temperatures in bathtubs and showers may not exceed 120°F. House Managers were reinstructed on the 6400.68 regulation and have began to test water temperatures on a weekly basis. Water Temperatures will be reflected on the house weekly visit/inspection sheet. Effective July 1, 2018 the house direct care staff will check water temperatures on a daily basis. A water temperature log will be kept at each house. The house manager will review the log weekly. Additionally, the agency compliance officer will check houses randomly, on a monthly basis. The Compliance Officer will select one house from each House manager monthly. Any deficiencies noted by the Compliance Officer will be identified and a retraining of the House Managers will occur. Effective Date: June 1, 2018 Responsible Party: House Managers, Program Director and Compliance Officer [Within 30 days of the receipt of the plan of correction, the CEO shall train the aforementioned staff persons in the aforementioned procedures and their responsibilities to ensure hot water temperatures in bathtubs and showers do not exceed 120°F. Documentation of the training shall be kept. (AS 6/20/18) 06/01/2018 Implemented
6400.113(a)Individual #1, date of admission 10/14/15, was instructed in general fire safety on 6/12/17. The prior record of fire safety training was not dated; therefore, compliance could not be measured. [Repeated Violation-3/8/17, et al] 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 Clinical Director will ensure that all new admissions receive all required trainings. The admissions checklist will be reviewed by the Clinical Director and the Program Director before anyone is admitted into the group home. Both the Clinical Director and the Program Director will sign the admission checklist and the form will be filed in the client file. The Program Secretary will maintain a file of all fire safety trainings and will provide a list to the clinical director of individual that need annual fire safety training. The House Managers will ensure all individuals are trained on fire safety. Effective Date: June 1, 2018 Responsible Party: Program Director, Clinical Director/RN and House Managers [Within 30 days of the receipt of the plan of correction, the CEO shall train the aforementioned staff persons in the aforementioned procedures and their responsibilities to ensure all individuals, including an individual 17 years of age or younger, are 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. Documentation of the training shall be kept. (AS 6/21/18)] 06/01/2018 Implemented
SIN-00111233 Unannounced Monitoring 01/25/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)On 1/2/17, at approximately 4:30 PM, Individual #1 became upset and angry when a bagel was not available to have for dinner. Individual #1 began eating something else at the table when Direct Service Worker #1 asked Individual #1 to take his/her medication. Individual #1 continued yelling and proceeded down the hallway and into the staff office to get the telephone. Direct Service Worker #1 told individual #1 that s/he was not allowed in the staff office and had to be around staff when on the telephone. Individual #1 and Direct Service Worker #1 became involved in a physical altercation in the hallway and in Individual #1's bedroom resulting in bruising to Individual #1 left inner thigh and right forearm. An individual may not be neglected, abused, mistreated or subjected to corporal punishment. Direct service worker was terminated for abuse. All residential staff received Abuse training through the local HCQU on February 27, 2017. Abuse training for all staff will be scheduled with the HCQU every 6 months starting with September 2017 [Prior to working with individuals, all staff person shall be trained in the types and definitions of abuse and neglect, abuse prevention and required reporting of abuse and neglect. Documentation of trainings shall be kept. (AS 6/13/17)] 05/28/2017 Implemented
Article X.1007An administrator or employee who has reasonable cause to suspect that a recipient between the ages of 18-59 with a disability is a victim of abuse, neglect, exploitation or abandonment shall immediately make a report in accordance with Adult Protective Services (APS) Law (Act 70). On 1/2/17 at approximately 4:30PM, Direct Service Worker #1 and Individual #1 were engaged in a physical and verbal altercation. Direct Service Worker #2 was also working in the home at the time of the incident. On 1/4/17 at 3:30 PM, DDTT informed House Supervisor #3 of the allegation of abuse. On 1/4/17 at 1:30PM, House Supervisor #3 reported the allegation of abuse to Adult Protective Services. On 1/4/17 at 3:30PM, an incident of abuse was entered into the Enterprise Incident Management System.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.House supervisor #3 is no longer with The Arc. Program Supervisors will be trained in Act 70, Mandatory Abuse/Neglect Reporting by June 9, 2017. Program Supervisors have received training in Abuse on February 27, 2017. New Supervisors have been trained in Abuse prior to working with individuals. [Immediately, the CEO or designated management staff person shall develop and implement policies and procedures to ensure all staff person working in community homes are trained prior to working with individuals in the agencies procedures to ensure immediate reporting by an administrator or employee who has reasonable cause to suspect an individual is a victim of abuse, neglect, exploitation or abandonment in accordance with Adult Protective Services Law. Within 60 days of receipt of the plan of correction and continuing upon hire and at least annually thereafter, all staff persons shall be trained in a face to face training by an outside source or a designated management staff person in the aforementioned policies and procedures to ensure immediate reporting in accordance with (APS) Law. Documentation of trainings shall be kept. (AS 6/13/17)] 05/28/2017 Implemented
SIN-00090660 Renewal 02/29/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(1)Individual #1's assessment, dated 5/14/15, was completed by a Program Coordinator and reviewed by a Program Specialist.The program specialist shall be responsible for the following: Coordinating and completing assessments. Effective March 1, 2016, Program Specialists are required to complete the assessment in whole. They will meet with the individual's staff plus the individual to complete each section of the assessment. After completing the assessment, the Clinical Director will review it to make sure that the assessment is completed correctly and that it was done by the Program Specialist [A meeting was conducted with all program specialist on March 2, Residential Director and Clinical Director reviewed the assessments with program specialist and reviewed that program specialist must complete the assessments and the procedures to do so. Documentation of aforementioned reviews by the clinical director shall be kept. (AS 4/1/16)] 03/12/2016 Implemented
6400.186(c)(1)There was no monthly documentation for August, September, and October 2015 of the Individual #1's participation and progress toward ISP outcomes supported by services provided by the residential home.The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. monthly progress reports are to be completed by staff and submitted to their Program Manager at the end of every month. File audits each month are to be done by the 10th of the month and this audit will identify if any monthly's are late or were not completed. [Aforementioned monthly file audits will be completed by the Program Coordinator to ensure a review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter is completed. Documentation of aforementioned monthly file audits shall be kept and reviewed at least quarterly by the Clinical Director or designated management staff to ensure completion and that a review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter is completed. (AS 4/1/16)] 03/12/2016 Implemented