Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00219204 Renewal 02/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)Individual #1's bedroom lacked a mirror.In bedrooms, each individual shall have the following: A mirror. Provider purchased and installed a new bedroom mirror on the wall in Individual #1's bedroom. 02/23/2023 Implemented
6400.141(c)(13)Individual #2's Annual Physical Examination, dated 07/21/2022, does not list the individual's allergies or contraindicated medications, if any. The lines next to the items reading "Allergies/Sensitivities" and "Contraindicated Medications" on the physical form were left blank by the person(s) completing the form. If an individual does not have any known allergies or contraindicated medications, the form must state so. A complete lack of information in these areas does not meet regulatory requirements.The physical examination shall include: Allergies or contraindicated medications.Areas of The Arc of NEPA's physical examination forms that are frequently missed by provider and Physician were highlighted and font was made bigger. Physical form was also updated to include area for Arc staff to initial and Program specialist to initial following the physical to ensure all areas are completed. 03/13/2023 Implemented
SIN-00202549 Renewal 03/28/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(g)Individual #1 had psychiatric medication reviews on 4/06/2021 and 2/10/2022 via telehealth and there was no documentation completed by the physician or prescriber recording the reason for prescribing the medications, the name and dosage of the medication and the need to continue 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.Medication form has been revised as of 3/30/2022. Form contains information to cover the reason, name, dosage, and need to continue medication. 03/30/2022 Implemented
SIN-00147556 Renewal 01/23/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water in the home measured at 124.1 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. The importance of water temperature under 120 degrees Fahrenheit was reviewed with staff. Staff were informed that if the water temperature exceed 120 degrees, the individuals in the home could suffer burns. The Arc's maintenance staff were contacted immediately upon being told the water temperature had risen to 124.1 degrees on 1/24/19. Maintenance staff came to the home immediately and adjusted the water temperature. The Program Specialist of the home also stayed at the home until the water was registering under 120 degrees. The Program Specialist will begin conducting weekly checks of the water temperature to ensure the water remains at 120 degrees or lower. The Program Specialist will keep a weekly documentation log of water temperatures and immediately report to maintenance staff if water temperature goes above 120 degrees Fahrenheit. 02/21/2019 Implemented
6400.73(a)The individuals come down to the basement for snacks. There are several concrete stairs that lead up to Bilco doors and ground level that the individuals would use in case of an emergency to evacuate. There are no railings. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The importance of having a handrail leading from the basement to the outside was reviewed with staff, including maintenance staff. Individuals in the home use the basement and in case of an emergency, a handrail will assist individuals with limited mobility safely evacuate the home. A railing was installed from the bottom of the basement stairs leading up to the bilco door on 1/25/2019 by the Arc's maintenance staff. 01/25/2019 Implemented
SIN-00108228 Renewal 03/21/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)Individual #2 did not evacuate during the 08/23/16 drill or the 10/29/16 drill. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Program Specialist and Supervisor developed a fire safety evacuation plan for all staff and the individual's home. Individual #2 and all staff reviewed the plan on April 20, 2017. Individual has been compliant with plan to date. 03/30/2017 Implemented
SIN-00069105 Renewal 01/06/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There is a long crack ( approx. 8 ft. )in the living room ceiling.Floors, walls, ceilings and other surfaces shall be in good repair. The cracked living room ceiling was repaired on February 21 and 22, 2015. Pat Quinn had oversight on the completion of the work. The repair entailed the removal of all loose material, spackling, and painting of the ceiling. The crack was caused by the fact that the upstairs bedroom above the living room was added as an addition by the original owners prior to the Arc purchasing the home in the 1980¿s. Pat Quinn met with the owner of Northeast Home Improvements, Inc. The contractor plan is to open up sections of the ceiling, install additional lateral support beams in the ceiling to support the bedroom floor, and then fully restore the ceiling via sheet rocking, spackling, and painting. No date has been set yet for this work (it will be subsequent to Theodore Street bathroom work), however the ceiling is safe. Pat Quinn will maintain oversight of this project. 03/01/2015 Implemented
6400.76(a)The dining room chairs and table are badly stained. Furniture and equipment shall be nonhazardous, clean and sturdy. New sturdy Table and chairs ordered and in the process of being delivered 3/8/2015. In the meantime, chairs were replaced on 2/23/2015. EFO is in the process of completing the order. Maryclaire Kretsch is responsible for ordering the new table and chairs. Sheila Nealon, Manager, and Shelby Smith, Supervisor, are responsible for ensuring condition and safety of furniture. 02/27/2015 Implemented
6400.163(c)Psychotropic medication reviews were not completed at least every three months regarding Individual #1 . A review was completed in March of 2014 and not again until July of 2014 which exceeds the three month review limit. 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.Reviewed regulation with all supervisory staff and program specialists regulation 6400.163(c). Established calendar of upcoming psychiatric due dates for all consumers at all residential homes. Sheila Nealon, Manager, and Program Specialist(s), are responsible for ensuring compliance. Reviewing regulation re: medication reviews and the importance of ensuring consumers are receiving regulated and unregulated medical care again on 3/5/2015 at a supervisor¿s meeting. 01/09/2015 Implemented
SIN-00184402 Renewal 03/16/2021 Compliant - Finalized
SIN-00089409 Renewal 02/02/2016 Compliant - Finalized