Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00184549 Unannounced Monitoring 02/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(4)ARC assessment dated 2/8/20 indicates that "Individual #1 requires full 24-hour supervision both at the home and in the community due to limited safety practices and skills." The Individual Service Plan (ISP) notes her required supervision to be "Supervision Care Needs: "Individual #1 continues to need 24 hour supervision at home because of limited safety practices and awareness. There are no plans to start alone time because of Individual #1's limited safety skills." and is further detailed as "Individual #1 eats independently, but needs to be supervised and have staff at the table with her." Assessments are to be person specific plans that address the specific needs of the person. An individualized assessment is required to satisfy the regulation. The Individual Service Plan (ISP) states in the "Meals and Eating" section that "Individual #1 eats independently, but needs to be supervised and have staff at the table with her. She needs to have her food cut into small presentation sized pieces for her by staff. She needs to take small bites when eating and needs." The assessment dated 2/8/20 does not note that additional supervision is required while eating. The assessment must include the following information: The individual's need for supervision. It is the responsibility of the Program Specialist to ensure that information contained in the ISP and assessment is accurate and consistent with one another. Program Specialists will review all individual files on their case loads and verify all is true and accurate. This process will be ongoing and ISP's will be updated when there is revisions to assessments. DSP's that work with individuals will be trained on the supervisory needs for both health and safety prior to working with individuals and after yearly reviews of ISP's. CLA supervisors are responsible for this training and a new ISP training has been developed. Also during the time of orientation, a you tube video will be showed pertaining to food consistencies. ISP training form attached. 03/18/2021 Implemented
6400.181(e)(10)The assessment dated 2/8/20 did not contain a Lifetime Medical History. A Lifetime medical history is required.The assessment must include the following information: A lifetime medical history. As per regulation 6400.181 e (10), all individuals residing in Arc CLA's shall have a Lifetime Medical History attached to the assessment and it will be updated yearly or as necessary. Program Specialists will review their case loads and ensure that individuals Lifetime Medical histories are attached and updated. The Program Manager of Residential Services will review with the Program Specialists information to be included individual files and documentation of such training will be kept on file. 03/18/2021 Implemented
6400.181(e)(13)(i)The ARC assessment dated 2/8/20 included a section titled "Progress Toward: A. Health:" This section of the assessment notes three hospitalizations for low sodium levels and a fluid restriction that occurred in 2019 but contains no reference to the choking incident that occurred on 3/16/19. The "Health" section is an incomplete assessment on the current progress and current level in health over the last 365 calendar days.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. Information listed in the assessments are to accurate and true in accordance to regulation 6400.181 e (13) i. It is the responsibility of the Program Specialist to ensure that medical events that happen throughout the calendar year, are documented in the health area section of the assessment. The information with be reviewed by both the Program Specialist and CLA supervisor. Such information will be updated no later than 24 hours post discharge from a hospitalization. 03/18/2021 Implemented
6400.46(d)Staff #2 received initial training on CPR/First Aid on 8/13/19. The Arc description of this training is documented as "First Aid(video) also includes CPR (non-test). No additional training followed. Annual training by a certified instructor is required.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.All Direct Support Professionals and well as Program Specialists, shall receive training within 6 months of hire and annually thereafter, by a certified instructor in the areas of CPR, first-aid, and Heimlich techniques. Staff #2 received First-aid, CPR, and AED training on 3/10/2021 and will receive it annually thereafter. The CLA supervisor and Program Specialist are to ensure compliance of this regulation. Supporting documents attached. 03/18/2021 Implemented
6400.52(c)(6)The Arc training records provided: "ISP Review Acknowledgment Form" dated 8/10/19 was the only documentation of annual training on the ISP for Individual #1 conducted for Staff #1. There is no record of annual training being completed in 2020 as is required.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.All DSP's that work will individuals must complete an initial training and then yearly thereafter on individuals ISP's. Staff #1 has been trained on all residents ISP's and documentation is noted. It is the responsibility of both of the CLA supervisor and Program Specialist the ensure compliance to this regulation. A new ISP training form has been created to further assist in making sure all areas of the ISP is reviewed. Form attached. 03/18/2021 Implemented
SIN-00169139 Renewal 01/21/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Individual #1 was psychologically and physically abused by Staff #1 and Staff #2 between January 2019 and March 2019. Staff #1 took videos of Staff #2 throwing chicken into various areas inside and outside of the home and having Individual #1 eat the chicken while staff laughed. Chicken was thrown into the front yard, into snow, onto the bathroom floor in front of the toilet, into the basement and into the shower. A video also shows Individual #1 being coerced by Staff #1 to sing songs containing racial slurs. Another video shows Staff #1 and Staff #2 physically abusing Individual #1 by throwing a washcloth into her face repeatedly. Staff would throw the washcloth at Individual #1, ask her to hand the washcloth back to staff and staff would then throw the washcloth into the face of Individual #1 again.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.The Arc of Northeastern Pennsylvania Recovery Plan Response to APS Investigation 137 Chesterfield Lane Scranton, PA, 18504 The following represent actions taken and planned steps in response to the APS abuse investigation at the Chesterfield Lane Community Home, beginning on December 27, 2019 ¿ Initial wellness checks on victim conducted by her Guardianship office and Arc staff immediately subsequent to allegation- no overt signs of trauma ¿ Maryclaire Kretsch authored two statements in response to the incident for potential press release; statements approved by Phil Condron and Atty. Joe O¿Brien ¿ Meetings with Arc staff held to discuss the events and recovery; reinforce the good work staff perform day in and out ¿ Maryclaire authored a letter to all employees for distribution regarding the value of their care and moving past this incident ¿ Administrative forum held on ¿Protection from Abuse & Obstacles to Reporting Abuse¿ with several action steps identified going forward surrounding reporting culture ¿ Four Supervisory/Program Specialist/Administrative level trainings on Incident Management scheduled with L/S Quality Management Coordinator in February and March ¿ Agency-wide survey developed which includes reporting -themed questions; several survey options available and anonymous comment boxes to be installed in various locations. The survey is also available online. ¿ Administrative personnel will now attend all Incident Management trainings during new hire orientations to emphasize reporting protocols and mandated reporter obligations. This practice has occurred with last new -hire orientation class. ¿ Daily meetings planned via ¿Zoom¿ conference line with Senior Manager of Licensed Services and/or Director of program Operations to discuss ¿24 -hour report¿- (staffing, incidents, appointments, medical, etc). ¿ Quarterly meetings of the Incident Management Committee will dedicate an agenda item at each meeting to ongoing dialogue on reporting culture. ¿ A poster campaign regarding culture of zero-tolerance and reporting abuse will be launched at all sites ¿ A ¿tip Line¿ link for anonymous reporting will be available on The Arc website ¿ Tip/Suggestion boxes to be placed at several locations at Meadow Avenue for same purposes ¿ Collaboration with McGuire Memorial Homes (Western PA) underway to discuss their recovery plan from a similar incident, as recommended by ODP. Phone conference held on 1/30/20. ¿ The Arc will be installing cameras in line with ODP guidance in Residential homes. ¿ The Arc is in contact with the Lackawanna County District Attorney¿s Office for agency wide training on laws surrounding mandated reporting, and Abuse/Neglect of Care Dependent Persons. ¿ The Arc will be instituting enhanced unannounced visits to Residential homes by CLA Supervisors and Program Specialists; no fewer than twice per month and up to four times per month with a stipend reimbursement 01/31/2020 Implemented
6400.73(a)There are approximately 7 steps leading up through the Bilco doors in the basement. There is no handrail at this exit. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Handrails were installed and secured and rechecked for safety. Prevention/Correction: All supervisory staff and program specialist discussed and reviewed regulation 6400.73(a). Maintenance Department also informed of the need for handrails when installing ramps that exceed two steps. Program Specialists will check handrails during weekly visits and whenever new ramps and interior stairways are constructed and maintain records of the findings of their checks. 02/03/2020 Implemented
6400.141(c)(7)Individual #1 (DOB: 1/12/1988) had a Gynecologist appointment on 8/3/2018. She didn't have another appointment until 8/23/2019, which exceeds the annual requirement.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. Corrections/Prevention: Individual Appointment forms are in place in front of the individuals¿ book/record. All necessary medical appointments/procedures/vaccinations will be tracked on the form and monitored by supervisory staff and program specialists. Forms will be reviewed and implemented at supervisory meeting on 2/18/2020. 02/18/2020 Implemented
SIN-00129467 Renewal 02/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(a)Individual #1 was informed of her rights on 4/6/2016. She wasn't informed of them until 4/30/2017, which exceeds the annual requirement.Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter. Individuals will be informed of their rights annually. ((Program Specialist will be retrained in the requirements 6400.31-CH 5/8/2018)) 03/07/2018 Implemented
6400.181(f)Individual #1's ISP meeting was held on 7/17/2017. Her assessment was provided to her team until 7/15/2017.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Assessments will be completed four months prior to the individual's annual Individual Support Plan review date. ((Program Specialist will be retrained on on requirements of 6400.181 -CH 5/8/18)) 02/23/2018 Implemented
SIN-00108234 Renewal 03/21/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(1)The section pertaining to Individual #1's medical history was left blank on her physical form.The physical examination shall include: A review of previous medical history. Medical history was added to individual #1's physical form. All individual physical forms will be reviewed by Program Specialists upon completion and revised as necessary. 03/28/2017 Implemented
6400.141(c)(6)Individual #1's last TB test was on 12/09/14. It was due by 12/09/16 and has yet to be completed.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Individual #1 received the TB testing on March 28, 2017. Test was read on March 30, 2017. To insure that required testing is completed within the appropriate time frame, Program Specialists will review medical appointments monthly. Home supervisors will maintain calendars for individual appointments. 03/28/2017 Implemented
6400.213(1)(i)There was no current dated photo in Individual #1's file.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.Photo has been added to individual #1 file. Training was conducted with all Program Specialists and Supervisory staff on regulation 6400.213 (1) (I) on March 30, 2017. Program Specialist will review personal information sheet monthly and photos will be reviewed monthly. 03/22/2017 Implemented
SIN-00219210 Renewal 02/23/2023 Compliant - Finalized
SIN-00202555 Renewal 03/28/2022 Compliant - Finalized
SIN-00089415 Renewal 02/02/2016 Compliant - Finalized
SIN-00055916 Renewal 11/19/2013 Compliant - Finalized