| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.20(a) | Staff person #3 was hired on 10/19/2022. An application for a Pennsylvania (PA) criminal history background check wasn't submitted to the State Police until 7/26/2023. At the time of the 8/7/2023 inspection, the results of Staff person #3's 7/26/2023 PA criminal background check were pending, and the results were still unknown. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the facility who will have direct contact with individuals, and for part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. | An application for a criminal history check will be submitted to the PA State Police for all employees having direct contact with the individuals. A record check will be completed for part-time employees and temporary employees who have direct contact with individuals. These checks will be completed within 5 days of the date of hire. |
08/09/2023
| Implemented |
| 2380.88(c) | During the 8/7/2023 inspection, the fire extinguisher in the kitchen did not include documentation from the Underwriters Laboratories of the specific rating of the fire extinguisher. The agency corrected this onsite by installing a fire extinguisher with a minimum 2A-10BC rating in the kitchen. | A fire extinguisher with a minimum 10-B rating shall be located in each kitchen. This extinguisher is required in addition to the extinguishers with a minimum 2-A rating required for each floor in subsections (a) and (b). | The fire extinguisher in the kitchen area requires a UL sticker displaying a minimum of a 10-B rating. Therefore, a fire extinguisher that displays the correct UL sticker from the opposite side of the program area was switched with the fire extinguisher that was in kitchen area. |
08/09/2023
| Implemented |
| 2380.111(c)(1) | Individual #1's 4/19/23 physical examination record did not include a review of their medical history. The examination record stated a summary of the individual's medical history is, "good health" and the only diagnosis listed was severe autism with intellectual disability. Two medications were listed, clonidine and miralax, but the reason for prescribing the medications was not included on the record. The individual has a history of seizures at birth, but this information was not included on the physical examination record.
According to the individual's individual support plan (isp), they are diagnosed with Pervasive Developmental Disorder and has a bowel disorder. The isp states they also take melatonin to assist with sleeping. | The physical examination shall include: A review of previous medical history. | In the ISP for Individual #1, the medical history includes the entries of "Good Health" and incidents that occurred at birth, but that information is not included in the physical examination record. Also, the diagnoses need to match up with the prescribed medication. At the next appointment, Individual #1's family physician will be asked to add the missing information to the physical examination record. |
08/09/2023
| Implemented |
| 2380.111(c)(4) | REPEAT from 8/9/2022 annual inspection: Individual #1's 4/19/23 physical examination record did not include a hearing screening. The examination record stated, hearing examination was unable to be performed. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | In the Hearing component of the physical examination record for Individual #1, the physician stated the hearing test was unable to be performed. Upon speaking with the guardian of Individual #1, the guardian informed me that Individual #1 does not permit anything on their ears. The traditional hearing test requires the use of headphones; therefore, the test was unable to be performed. The PCP will be contacted by end of this week to request clarifying documentation of the hearing screening. This documentation will include a signed statement by the physician that he/she does not recommend a hearing screening. |
08/09/2023
| Implemented |
| 2380.181(e)(9) | Individual #1's current, 6/22/23 assessment does not include documentation of all their diagnosis or reason for taking all their prescribed medications. Their assessment lists their only diagnosis as, severe autism with intellectual disability. The assessment records there are taking clonidine twice a day, miralax as needed, and vitamin D3 once daily, but does not include the reason for prescribing the medications.
According to the individual's individual support plan, they are also taking melatonin nightly to assist with sleep, but the individual's mediation and sleep limitations are not included in the assessment.
Individual #2's current, 9/23/22 assessment does not include their diagnosis of anxiety, depression, and chronic headaches.
Individual #2's assessment states in 2022 the individual had an issue with their hypertension (high blood pressure) and it was purported they were not to take ibuprofen but instead Tylenol due to this. The individual's current, 9/23/22 physical examination record did not include ibuprofen as a contraindication. The agency was unsure if it was. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | As in Citation #3, the diagnoses need to match up with the prescribed medica/tion. Antipsychotic medication is prescribed for the diagnosis of Severe Autism with IDD, but an explicit explanation of why the antipsychotic medication is prescribed will be added by the physician at Individual #1's next appointment. |
08/09/2023
| Implemented |
| 2380.21(u) | Individual #1 has two legal co-guardians. The agency did not review the individual's rights defined in 2380.21 with the individual's legal co-guardians upon the individual's 4/24/2023 date of admission. | The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter. | Individual #1's record will reflect a signed guardians review of Individual Rights. The record currently reflects a signed Individuals review of Individual Rights. |
08/09/2023
| Implemented |
| 2380.36(a) | Staff person #3 was hired on 10/19/22 and started working with individuals. They didn't receive training in general fire safety and requirement specified in 2380.36(a) until 5/26/23, after working with individuals. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered. | Staff #3's record reflects fire safety training on 5/26/23, which is after their hire date. Staff #3 is in compliance at this time. |
08/09/2023
| Implemented |
| 2380.37(a) | The training sign-in sheet that staff persons signed for reviewing Individuals #1 and #2's individual support plan (isp) did not include the date the training occurred, the length of training, which isp the training is referencing, or if there was an in-person component to the training. | Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept. | The ISP Training record of Individuals #1 and #2 now include the itemized list of what was included in the ISP training, including a date of training. |
08/09/2023
| Implemented |
| 2380.38(b)(5) | Staff person #3 did not receive orientation prior to working with individuals on their individual-specific plans, protocols, and health needs related to their diagnoses, physical limitations, medical limitations, communication needs, dietary needs, behavior supports, etc. | The orientation must encompass the following areas: Job-related knowledge and skills. | Similar to Citation #8, prior to working with individuals, Staff #3 did not have a signed record of ISP training of the individuals. All employees receive ISP training before working with the individuals. Until the state inspection, this training did not have a signed record of having received and completed the ISP training. That said, Staff #3, who has been employed at The Arc as a program specialist for the past 38 years, now has Individual-specific, signed records of having received and completed the ISP training for each individual. |
08/11/2023
| Implemented |
| 2380.39(c)(5) | Staff person #2 did not receive annual training on individuals' individual-specific plans, protocols, and health needs related to their diagnoses, behavior supports, the safe and appropriate use of behavior supports. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Similar to Citation #10, Staff #2 did not have record of having completed Individual-specific ISP training before working with the individuals. All employees receive ISP training before working with the individuals. Until the state inspection, this training did not have a signed record of having received and completed the ISP training. |
08/11/2023
| Implemented |
| 2380.39(c)(6) | Staff person #2 did not receive annual training on individuals' individual-specific plans, protocols, and health needs related to their diagnoses, physical limitations, medical limitations, communication needs, dietary needs, behavior supports, etc. | 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. | Similar to Citation #10, Staff #2 did not have record of having completed Individual-specific ISP training before working with the individuals. All employees receive ISP training before working with the individuals. Until the state inspection, this training did not have a signed record of having received and completed the ISP training. Specific hours of training and the completed training are included on the ISP Training record. |
08/11/2023
| Implemented |
| 2380.125(f) | Individual #1 is prescribed clonidine .1mg twice daily. Individual #1's individual support plan (isp) states they are taking the medication for behaviors, since taking the medication their behaviors have decreased, and they are diagnosed with Pervasive Developmental Disorder (PDD). Individual #2 is prescribed medication for depression and diagnosed with anxiety. The agency does not have a plan to address the individuals' social, emotional, and environmental needs related to the symptoms of the psychiatric illness. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | Individual #1's record will include the diagnosis and prescribed medication for that diagnosis. For Individual #2, a SEEN plan will be developed to address the individuals' needs related to her psychiatric illness. |
08/11/2023
| Implemented |