Inspection ID

Reason for Inspection

Inspection Date

Inspection Status

SIN-00234979

Renewal

10/17/2023

Non Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
2380.20(b)	2380.20(b) There was no affidavit or documentation for all new hirers since last year that notes that the staff have not lived outside of PA in the past 2 years.	If a prospective employe who will have direct contact with individuals resides outside of this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.	The Director of Programs is responsible for correcting the immediate problem of get all new hires respond to the question if they lived outside of the PA in the last two years. This was corrected on 11/15/2023. An agency wide check was conducted to ensure all staff records reflect whether the lived outside of PA in the past two years. Supervisor conducted audit of all staff files which accomplished on a target date of 10/25/23	12/13/2023	Implemented
2380.111(c)(3)	113 (c)(3) There was no indication on the physical if there was no communicable disease for staff number one.	The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.	The Director of Programs is responsible for correcting the immediate problem ensuring all staff has a documented no communicable disease before start working with any individual. This was corrected on 11/15/2023. An agency wide check was conducted to ensure all staff records reflect a status of free of communicable disease. Supervisor conducted audit of all staff files which accomplished on a target date of 10/25/23.	12/14/2023	Implemented
2380.113(c)(1)	113( c)(1) There was no general exam noted on the current physical for staff number one.	The physical examination shall include: A general physical examination.	The Director of Programs is responsible for correcting the immediate problem ensuring all staff has a documented general exam before start working with any individual. This was corrected on 10/25/2023. An agency wide check was conducted to ensure all staff records reflect a completion by a Dr. Supervisor conducted audit of all staff files which accomplished on a target date of 11/15/2023.	12/14/2023	Implemented
2380.113(c)(3)	113 (c)(3) There was no indication on the physical if there was no communicable disease for staff number one and number three.	The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in § 27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.	The Director of Programs is responsible for correcting the immediate problem ensuring all staff has a documented no communicable disease before start working with any individual. This was corrected on 10/25/2023. An agency wide check was conducted to ensure all staff records reflect a status of free of communicable disease. Supervisor conducted audit of all staff files which accomplished on a target date of 11/15/23.	12/14/2023	Implemented
2380.113(c)(4)	113 (c) (4) There was no indication on the physical if there were no medical problems that may interfere with their work for staff number one.	The physical examination shall include: Information of medical problems which might interfere with the safety or health of the individuals.	The Director of Programs is responsible for correcting the immediate problem ensuring all staff has a documented indication that the staff has no medical problems that may impede them from working with any individual. This was corrected on 10/25/2023. An agency wide check was conducted to ensure all staff records indicates they have no medical problem that would hinder them from working with any individual. Supervisor conducted audit of all staff files which accomplished on a target date of 11/15/2025	12/14/2023	Implemented
2380.181(a)	181a An annual assessment has not been completed for Individual number two and three.	Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.	Program Specialist will be in charge to ensure all assessments are completed within 60 days of admission and yearly after the initial assessment. A review of all individual assessments was completed on 10/28/2023. A target date of 11/25/2023 was achieved.	12/15/2023	Implemented
2380.181(e)(1)	181e1 Individual Number one 9/28/23 assessment does not contain a record of their strengths, needs, and preferences.	The assessment for individual number one must include the following information: Functional strengths, needs and preferences of the individual.	Program Specialist will be in charge to ensure all assessments contains a record of strengths, needs, and preferences. A review of all individual assessments record was completed on 11/15/2023. A target date of 12/04/2023 was achieved.	12/15/2023	Implemented
2380.181(e)(2)	181e2 Individual Number one 9/28/23 assessment does not contain a record of their dislikes.	The assessment must include the following information: The likes, dislikes and interests of the individual, including vocational and employment interests.	Program Specialist will be in charge to ensure all assessments contains a record of dislikes. A review of all individual assessments record was completed on 11/15/2023. A target date of 12/04/2023 was achieved.	12/15/2023	Implemented
2380.181(e)(5)	181e5 Individual Number one 9/28/23 assessment does not accurately reflect their self-medication status. It indicates they take medication with supervision in the program; agency staff, however, indicated during the inspection that he does not take medications in the program, and never has.	The assessment must include the following information: The individual¿s ability to self-administer medications.	Program Specialist will be in charge to ensure all assessments are correct. A review of all individual assessments record was completed on 10/25/2023. A target date of 12/04/2023 was achieved. Individual 1did not take medications at facility which was corrected in his assessment.	12/15/2023	Implemented
2380.181(e)(6)	181e6 Individual number one 9/28/23 assessment does not address their ability to safely use or avoid poisonous materials.	The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.	Program Specialist will be in charge to ensure all assessments reflects the ability of an individual has the ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. A review of all individual assessments record was completed on 11/15/2023. A target date of 12/04/2023 was achieved.	12/15/2023	Implemented
2380.181(e)(10)	181e10 Individual number one file does not contain a lifetime medical history document.	The assessment must include the following information: A lifetime medical history.	Program Specialist will be in charge to ensure individual record will include a Lifetime medical history. A review of all individual assessments record was completed on 11/15/2023. A target date of 12/04/2023 was achieved.	12/15/2023	Implemented
2380.181(e)(13)(i)	Individual number one 9/28/23 assessment does not contain a record of a year's worth of progress in the following areas: health, motor and communication skills, personal adjustment, socialization, recreation, and community integration.	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.	Program Specialist will be in charge to ensure all assessments contains a record of years' worth of progress in the areas of health, motor, A review of all individual assessments record was completed o and communication skills, personal adjustments, socialization, recreation and community integration. A review of all individuals record was completed on 11/15/2023. A target date of 12/04/2023 was achieved.	12/15/2023	Implemented
2380.36(a)	The record did not include a fire safety training was conducted prior to working with the individuals for staff number one and staff two.	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.	Program Specialist will be in charge to ensure staff complete fire safety training by a fire expert. A review of all staff file was completed on 11/15/2023. A target date of 12/04/2023 was achieved.	12/15/2023	Not Implemented
2380.38(a)(1)	Staff number one and two had no record that the new hire orientation took place 30 days prior to working with individuals.	Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons.	Program Specialist will be in charge to ensure staff complete orientation within 30 days prior to working with any individuals. A review of all staff file was completed on 11/15/2023. A target date of 12/04/2023 was achieved.	12/15/2023	Implemented
2380.38(b)(5)	2380.38(5): There was no job-related knowledge and skills training noted in the record for staff number two.	The orientation must encompass the following areas: Job-related knowledge and skills.	Program Specialist will be in charge to ensure staff complete orientation which includes job related knowledge and skills. A review of all staff file was completed on 11/15/2023. A target date of 12/04/2023 was achieved.	12/15/2023	Implemented
2380.181(f)	181f Individual number one record does not indicate they have shared assessments with the plan team within 30 days of their ISP meetings.	The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.	Program Specialist will be in charge to ensure all assessments are shared with plan team 30 days before their ISP meeting. A review of all individual assessments record was completed on 10/25/2023. A target date of 12/21/2023 was set as measure.	12/15/2023	Implemented

SIN-00230048

Unannounced Monitoring

08/18/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
2380.53(a)	Poisons were found unlocked in several spots around the facility. Lysol spray was found in an unlocked cabinet under the kitchen sink. A supply closet containing cleaning chemicals was found unlocked in the first aid room. In the day program kitchen area, also known as the eye washing room, there were unlocked cleaning supplies under the sink.	Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.	All poisonous materials were locked away on 08/18/2023. Staff was trained to lock away poisonous material after each use. All cabinets have electronic locks.	08/18/2023	Implemented
2380.55(a)	Unsanitary conditions were observed throughout the program. Throughout the facility, many carpets had large dark stains, some several feet in diameter, and trash and other detritus was found on the ground in many rooms. The men's bathroom floor had several large dark stains, including a large brown dried/accumulated urine stain under the urinal. In the kitchen, there were two microwave ovens that had food spillage stuck to their dishes and needed cleaning. The toaster oven had food debris on the food tray that needed to be cleaned. The refrigerator had unknown liquid spilled in the freezer area that need to be clean.	Clean and sanitary conditions shall be maintained in the facility.	The entire building was cleaned and satanize on 08/18/2023. Food debris was removed from refrigerator and microwave. All spillage was removed, and area cleaned and sanitized.	08/19/2023	Implemented
2380.67(a)	The woman's bathroom near the kitchen had a missing light cover and a hanging piece of metal. The adjacent room next to the day program activity area had trash and open tools on the floor, where participants had access.	Furniture and equipment shall be nonhazardous, clean and sturdy.	Bathroom light fixture was completed on 08/21/2023. Tools was removed and secured on 08/18/2023. Building was cleaned on 08/18/2023, and hazardous equipment removed to a lock area.	08/21/2023	Implemented
2380.70(d)	In the first aid room, the first aid kit was missing antiseptic, and tweezers.	First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors.	First Aid Kit was replenished of antiseptic and tweezers on 08/18/2023	08/18/2023	Implemented
2380.86	A space heater was found behind the desk in the All-Program Director's office.	Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including offices.	Space Heater was removed from Director's office. ARCC did not purchase a space heater to be used in any off our office settings. Compliance was achieved on 08/18/2023	08/18/2023	Implemented
2380.132(10)	In the freezer there were 3 unlabeled containers of frozen liquids, which staff could not identify.	If the facility provides or arranges for meals for individuals, the following requirements apply: Food shall be protected from contamination while being stored, prepared, served and transported. Food shall be stored in sealed containers.	In the event that food is stored for individuals' labels will be applied with the date, time, and identification of item stored and how long the item can be stored for. Compliance was met on 08/18/2023	08/18/2023	Implemented
2380.176(a)	Individual records were unlocked in several areas. The allergy information for all individuals was found posted openly in the kitchen. The program specialist's office was unlocked, and individual files were found in accessible boxes on the desk and floor.	Individual records shall be kept locked when they are unattended.	All records were locked and secured on 08/18/2023. Allergy posting in kitchen has been removed on 08/18/2023.	08/18/2023	Implemented

SIN-00223828

Renewal

04/24/2023

Non Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
2380.20(a)	Staff Members 1 and 2's background checks were completed greater than 5 days after hire. Staff Member 3 has no criminal background on file.	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.	ARCC has developed a new hire checklist in accordance with regulations to support human resources manager. This employee file checklist has been created to ensure all criminal background checks are completed upon hire.	06/01/2023	Implemented
2380.89(c)	The evacuation time for the months of August 2022 through April of 2023 were listed as a time of day rather than amount of time it took to evacuate.	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 was operative.	Fire Drill was conducted on 4/26/2023 with the correct documented time of evacuation instead of the time of day. Staff was trained by Program Specialist to do the timed evacuation with a stop clock.	05/31/2023	Implemented
2380.89(d)	On 1/16/23 the fire drill took five minutes as recorded on the fire drill record.	Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.	ARCC has trained and reviewed fire drills in accordance to regulations. ARCC has contacted a national fire safety instructor level 2 a deputy fire marshal who will work with ARCC to review fire safety regulations and conduct training with all staff every six months and with new staff within the first thirty days of hire.	06/09/2023	Implemented
2380.91(a)	Individual 1 had fire safety training on 3/13/23 which was 6 months after admission in October of 2022.	An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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 facility.	Individual must me trained by a Fires safety Expert upon admission to program. A tracking log is implemented to ensure all trainings are completed.	05/26/2026	Implemented
2380.111(c)(1)	Individual 1 physical dated 5/10/22 did not indicate medical history. The section on the form was left blank.	The physical examination shall include: A review of previous medical history.	Physical Form was updated to reflect medical history. Physical form was downloaded to dropbox	05/15/2023	Not Implemented
2380.111(c)(6)	Individual 2's annual physical dated 10/3/22 did not indicate whether or not the person was free of communicable disease.	The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals.	Physical form was updated that individual is free of communicable diseases.	05/16/2023	Not Implemented
2380.111(c)(7)	Individual 1's physical dated 5/10/22 did not indicate health maintenance. The section on the form was left blank.	The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.	ED, and Residential Supervisor have scheduled quarterly audits with file check list to review residential files to ensure accuracy. ARCC also has highlighted sections of the physical form to ensure accuracy when the PCP is completing the annual form.	06/06/2023	Not Implemented
2380.111(c)(10)	Individual 1's physical dated 5/10/22 did not indicate information pertinent to diagnosis. The section on the form was left blank.	The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.	Physical Form was updated to reflect pertinent diagnosis. Form was uploaded to Dropbox	05/26/2023	Not Implemented
2380.111(c)(11)	Individual 1's physical dated 5/10/22 did not indicate dietary needs. The section on the form was left blank.	The physical examination shall include: Special instructions for an individual's diet.	Physical form was updated to include dietary needs. All components of the Physical form must be completed. Form was uploaded to Dropbox	05/16/2023	Not Implemented
2380.181(e)(5)	Individual 1's assessment dated 11/19/22 indicates that Individual 1 does not take medication while at the day program. He currently takes 3 medications at 12 noon while at the day program. Individual 2's annual assessment dated 9/5/22 lists someone else's name, Victor as the assessed individual. There is no other information regarding Individual 2's self-medication abilities.	The assessment must include the following information: The individual¿s ability to self-administer medications.	Assessment was updated to reflect individual takes medication at day program. Asssement was uploaded to Dropbox	05/15/2023	Not Implemented
2380.181(e)(13)(i)	Individual 2's annual assessment dated 9/5/22 did not indicate progress and growth clearly in each area of concern.	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.	Assessment was updated to indicate progress and growth in each area. Assessment was uploaded to Dropbox.	05/17/2023	Not Implemented
2380.181(e)(13)(ii)	Individual 2's annual assessment dated 9/5/22 did not indicate progress and growth clearly in each area of concern.	The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Motor and communication skills.	Assessment was updated to reflect progress and growth over 356 days. Form was uploaded to dropbox	05/17/2023	Not Implemented
2380.181(e)(13)(iii)	Individual 2's annual assessment dated 9/5/22 did not indicate progress and growth clearly in each area of concern.	The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment.	Assessments was updated to reflect progress made over the past 365 days. Uploaded to dropbox	05/17/2023	Not Implemented
2380.181(e)(13)(iv)	Individual 2's annual assessment dated 9/5/22 did not indicate progress and growth clearly in each area of concern.	The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.	Assessments was completed and updated to reflect area of socialization over the period of 365 days. Assessments was uploaded to dropbox	05/26/2023	Not Implemented
2380.181(e)(13)(v)	Individual 2's annual assessment dated 9/5/22 did not indicate progress and growth clearly in each area of concern.	The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.	Assessment was updated to reflect to show growth in recreation over 365 days. Assessment was downloaded to dropbox	05/16/2023	Not Implemented
2380.181(e)(13)(vi)	Individual 2's annual assessment dated 9/5/22 did not indicate progress and growth clearly in each area of concern.	The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.	Assessments was updated to reflect community Intergration and progress that was made over the past 365 days. See Dropbox for uploaded documents.	05/26/2023	Not Implemented
2380.181(e)(14)	Individual 2's annual assessment dated 9/5/22 does not indicate whether or not the individual can swim or not.	The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.	Assessment has indicated if the individual can swim or cannot swim. Assessment was updated and downloaded into the Dropbox.	05/26/2023	Not Implemented
2380.38(b)(5)	Staff Member 5's record does not clearly demonstrate they received training on job-related skills within 30 days of their hire on 2/15/23. Their record does not contain a ledger showing orientation trainings, just certificates, none of which are for topics specifically related to job skills / on the job knowledge.	The orientation must encompass the following areas: Job-related knowledge and skills.	A review of the staff file was conducted, training was completed to reflect job-related skills.	05/26/0203	Implemented
2380.122(a)	Staff Member 4 does not have a current medication administration training practicum on file. A current training record was requested but not provided.	A facility whose staff persons are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication.	Practicum was completed and uploaded to dropbox	04/25/2023	Not Implemented
2380.155(a)	There is a restrictive behavioral support plan in place according to Individual 1's annual assessment and the behavioral support plan, however it is not being implemented and/or procedures for this plan have not been enacted since admission to the day program on 9/19/22. Individual 1's record contained a behavioral support plan which is restrictive but has not been implemented according to the director of the 2380 program. Some of the restrictive components include; Do not allow Individual 1 to escape demands, Do not allow access to electronic devices, Under NO CIRCUMSTANCES is Individual 1 to sleep during waking hours (7:30 am to 9:00 pm).	For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 2380.154 (relating to human rights team), prior to use of a restrictive procedure.	ED contacted the director of Operation at Biaton it has been clarified there are no restrictive measures, and this individual does not have a behavioral plan. The residential provider stated in writing there are no behavioral supports. Please see the uploaded email.	06/01/2023	Not Implemented
2380.186	Individual 1's ISP dated 1/5/2023 indicates that they do not have a behavioral support plan while there is a BSP in their file at their 2380 program which was signed off on by staff at the program. In addition, the annual assessment for Individual 1 dated 11/19/2022 indicates that there is a BSP that includes restrictive procedures.	The facility shall implement the individual plan, including revisions.	ARCC ED has created a self-auditing tool to check employee files monthly/ ARCC has created a checklist that corresponds with table of contents to ensure all documents that correspond with each section are in the file. ARCC contacted the residential provider on 5/17/2023 who confirmed this individual no longer has behavioral supports. This email has been uploaded to the drive.	06/01/2023	Not Implemented

SIN-00210369

Renewal

08/30/2022

Non Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
2380.70(a)	There is no designated first aid area in the facility ,	The facility shall have a first aid area that is separated by partition or privacy screen from program areas.	On September 6, 2022 ARCC Program Specialist created and labeled a designated first aid area in the facility (see attached photos).	09/06/2022	Implemented
2380.91(a)	Documentation stating Individual #2 was trained upon admission or annually in general fire safety was not provided	An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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 facility.	Individual #2 completed fire safety on 1/25/22. ARCC failed to submit all required documents to the inspector in a timely manner. ARCC Program Specialist reviewed all individual files to ensure all participants have successfully completed the general fire safety training. ARCC Program Specialist will ensure all individual files have the required training and signed documents as it relates to 2380.91 upon admission or annually thereafter.	09/22/2022	Implemented
2380.111(c)(1)	The physical exam dated 5/9/2022 individual #2 did not discuss if individuals medical was reviewed, the field was left blank	The physical examination shall include: A review of previous medical history.	The Program Specialist met with all direct care staff at the site staff meeting (9/19/22) to discuss the protocol for attending appointments; including completion of forms, the correct forms to take, and any supplemental documents including the LTMH, current medications, and emergency red packets. During the meeting the Program Specialist and Director reviewed the annual physical form and all of its components. (See meeting agenda)	09/19/2022	Implemented
2380.111(c)(3)	The physical exam of Ind. #1 dated 5/16/2022 did not contain the individual's Immunization record	The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.	The Program Specialist met with all direct care staff at the site staff meeting (9/19/22) to discuss the protocol for attending appointments; including completion of forms, the correct forms to take, and any supplemental documents including the LTMH, current medications, and emergency red packets. The Program Specialist requested the immunization record from Individual #1 PCP on 9/23/22. During the meeting the Program Specialist and Director reviewed the annual physical form and all of its components. (See meeting agenda)	09/19/2022	Implemented
2380.111(c)(10)	The physical exam dated 5/16/2022 for Ind. #1 did not contain information pertinent to diagnosis in case of emergency. There was no field or area to notate it was reviewed.	The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.	The Program Specialist met with all direct care staff at the site staff meeting (9/19/22) to discuss the protocol for attending appointments; including completion of forms, the correct forms to take, and any supplemental documents including the LTMH, current medications, and emergency red packets. During the meeting the Program Specialist and Director reviewed the annual physical form and all of its components. (See meeting agenda)	09/19/2022	Implemented
2380.113(c)(3)	The physical for Staff #1 does not indicate whether or not the staff is free of communicable diseases. The physical for Staff #2 does not indicate whether or not he is free of communicable diseases.	The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in § 27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.	Staff #1 scheduled a medical appointment for 9/23/22 to have the physical appointment form completed in its entirety. Staff #2 medical appointment is scheduled for 10/3/22. (see attached confirmed appointment - we will prove the updated medial appointment once ARCC obtains the updated form). Staff meetings occurred 9/19-9/22 for all staff to review areas of non compliance and actions needed to correct the citations.	09/22/2022	Not Implemented
2380.173(1)(ii)	Individuals #1 record did not contain information about the individual's Identifying marks or characteristics Individuals #2 record did not contain information about the individual's Identifying marks or characteristics	Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.	ARCC Program Specialist has created a 1 page face sheet on 9/8/22 that includes the following information: Race, Height, Weight, color of hair, color of eyes and identifying marks. (see attached 1 page document).	09/13/2022	Implemented
2380.177	There was no documentation that individual #2 signed consent for information release upon admission	Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.	ARCC Program Specialist has obtained individual #2 signed consent for information release upon admission on September 23, 2022 . (see attached document).	09/23/2022	Implemented
2380.181(d)	The program specialist did not sign and date the assessment	The program specialist shall sign and date the assessment.	On September 22, 2022 ARCC/The Director has updated the annual assessment for individual #1. The assessment was signed and dated by the program specialist (see attached assessment for individual #1).	09/22/2022	Implemented
2380.181(e)(6)	The assessment dated 5/13/2022 for individual #1 did not discuss the individual's ability to use or avoid poisons, the field was left blank.	The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.	On 9/22/22 the Program Specialist updated the annual assessment for Individual #1 to include the individuals ability to use or avoid poisons.	09/22/2022	Implemented
2380.181(e)(7)	The assessment dated 5/13/2022 for individual #1 did not discuss the individual's knowledge of heat sources, the field was left blank	The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.	On 9/22/22 the Program Specialist updated the annual assessment for Individual #1 to include the individual's knowledge of heat sources. (see attached annual assessment)	09/22/2022	Implemented
2380.181(e)(10)	A lifetime medical history was not located in individuals #1 record.	The assessment must include the following information: A lifetime medical history.	On September 15, 2022 ARCC/The Director has developed Lifetime medical Assessments from PCHC ensuring it meets the Chapter 6400 regulations. The Director created a Lifetime Medical History form for Individual #1 on September 19, 2022. LTMH is attached via email.	09/15/2022	Implemented
2380.181(e)(12)	Recommendations for specific areas of training was not discussed in the assessment dated 8/20/22 for Ind. #2	The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.	On 9/22/22 the Program Specialist updated the annual assessment for Individual #2 to include the recommendations for specific areas of training. See attached assessment.	09/22/2022	Implemented
2380.181(e)(13)(iv)	The individuals #1 progress and current levels of Socialization and recreation were not discussed in the assessment dated 5/13/2022 The individuals #2 progress and current levels of Socialization and recreation were not discuss in the assessment dated 8/20/22	The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.	On 9/22/22 the Program Specialist updated the annual assessment for Individual #1 and #2 to include the process and current levels of socialization and recreation. (see attached annual assessments)	09/22/2022	Implemented
2380.21(v)	Documentation that individual #2 reviewed or signed individual rights was not provided.	The facility shall keep a copy of the statement signed by the individual or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.	Individual Rights for Individual #2 were signed on 1/25/22. See attached signed individual rights. The Program Specialist will ensure all signed acknowledgements, authorization of release and other pertinent documents are placed in all individual files.	09/13/2022	Implemented
2380.36(a)	There is no fire safety training for Staff #1 provided at time of inspection. There is no fire safety training for Staff #2 provided at time of inspection for the training year.	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.	Fire Safety for staff #1 was completed on 6/29/22 and Fire Safety for staff #2 was completed on 6/30/22. See attached certificates from Tri State.	09/13/2022	Implemented

SIN-00154229

Renewal

04/25/2019

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
2380.20(a)	Staff person #3's date of hire was on 10/30/18 and their criminal history check was not completed until 11/29/18.	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.	The Staff member had a prior criminal background check which was inadvertently discarded when 1 year had passed since It was run. We ran a new background check and documented that check in the staff member's file. The Director will be responsible for ensuring that background checks are completed within 5 working days after their hire.	06/21/2019	Implemented
2380.20(a)	Staff person #4's date of hire was on 11/5/18 and their criminal history check was not completed until 3/12/19.	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.	The Staff member had a prior criminal background check which was inadvertently discarded when 1 year had passed since It was run. We ran a new background check and documented that check in his file. The Director will be responsible for ensuring that background checks are completed within 5 working days after their hire. All of the above changes will be completed by 6/21/19	06/21/2019	Implemented
2380.20(b)	All the new hired staff for the agency did not have a signed affidavit that they lived in Pennsylvania for the past 2 consecutive years.	If a prospective employee who will have direct contact with individuals resides outside of this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.	We have added signed affidavit that potential employees have lived in Pennsylvania for the past 2 consecutive years to our employment application. The Director will be responsible for ensuring that Staff have lived in Pennsylvania for the past 2 consecutive years, or, if they will have direct contact with individuals and they reside outside of this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire. All Changes listed above will be completed by 6/21/19	06/21/2019	Implemented
2380.33(c)(1)	Staff person #2 did not have the qualifications of a program specialist, documentation of degree was not found in the record.	A program specialist shall have one of the following groups of qualifications: A master's degree or above from an accredited college or university and 1 year of work experience working directly with persons with disabilities.	We were unable to obtain a copy of the Program Specialist's degree because she was unable to access it. We have since hired a new Program Specialist whose degree and resume we will send for proof of her education and experience. The Director will be responsible for ensuring that the Staff qualifications are complete and are included in their employment file. All of the above changes will be made by 6/21/19	06/21/2019	Implemented
2380.36(c)	Staff person #5 did not have any documentation of training.	Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually.	We will ensure that Staff person #5 will have training and that training will be documented. The Director will be responsible for ensuring that Staff will have at least 24 hours of training relevant to human services annually. All Changes listed above will be completed by 6/20/19	06/20/2019	Implemented
2380.36(f)	The fire safety trainings conducted for all the staff did not have documentation that it was conducted by a fire safety expert.	Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f).	ARCC assures and will provide documentation that that the Fire Safety trainings that were conducted for all staff was conducted by a fire safety expert. ARCC Director will be responsible for ensuring that the Fire Safety trainings will be conducted by a Fire Safety Professional, and that the Fires Safety Professional will be be included with the training certificates	07/20/2019	Implemented
2380.36(g)	All staff's CPR and First Aid training had been completed through Tri-State Training & Safety Consulting LLC, which is not a recognized health care organization.	There shall be at least one staff person for every 18 individuals, with a minimum of two staff persons present at the facility at all times who have been trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation within the past year. If a staff person has formal certification from a hospital or other recognized health care organization that is valid for more than 1 year, the training is acceptable for the length of time on the certification.	All staff's CPR and First Aid training will been completed through a recognized health care organization. The Director will be responsible for ensuring that Staff's CPR and First Aid training will been completed through a recognized health care organization. All Changes listed above will be completed by 6/29/19	06/29/2019	Implemented
2380.91(a)	Individual #1 did not have documentation of Fire Safety training.	An individual 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 facility.	We will ensure that Individual #1 has documentation of Fire Safety training. The Program Specialist will be responsible for ensuring that all individual's records will have documentation of Fire Safety training. All Changes listed above will be completed by 6/20/19	06/20/2019	Implemented
2380.111(c)(5)	Individual #2 physical exam did not include a Tuberculin test.	The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted.	ARCC will confirm that individual #2 physical exam includes a Tuberculin test. ARCC Program Specialist will be responsible for ensuring that all individual's records will have a physical exam that includes a current Tuberculin test.	07/20/2019	Implemented
2380.111(c)(10)	Individual #1's physical examination dated 2/7/19 did not include information pertinent to diagnosis. it was left blank.	The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.	We will check Individual #1's Physical examination form dated 2/7/19 and to ask that it be updated to include information pertinent to diagnosis. The Program Specialist will be responsible for ensuring that all individual's records will include information pertinent to diagnosis. All Changes listed above will be completed by 6/21/19.	06/21/2019	Implemented
2380.113(c)(2)	Physical exam dated 3/28/19 for staff #1 did not include if Tuberculin skin test was completed.	The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.	We will check the Physical exam dated 3/28/19 for staff #1 and ask that it be updated to include if Tuberculin skin test was completed. The Director will be responsible for ensuring that Staff Physical Exam Forms include if Tuberculin skin test was completed. All Changes listed above will be completed by 6/20/19	06/20/2019	Implemented
2380.113(c)(3)	Physical exam dated 3/28/19 did not include if Staff #1 was free from communicable disease.	The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in § 27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.	We will have the Physical exam form dated 3/28/19 updated to include if Staff #1 had a serious communicable disease. The Director will be responsible for ensuring that all Staff's records will have the Physical exam form updated to include if Staff has a serious communicable disease. All Changes listed above will be completed by 6/21/19	06/21/2019	Implemented
2380.113(c)(4)	Physical exam dated 3/28/19 did not include if Staff #1 had any medical problems.	The physical examination shall include: Information of medical problems which might interfere with the safety or health of the individuals.	We will attempt to have Physical exam form updated (3/28/19) to include if Staff #1 had any medical problems. The Director will be responsible for ensuring that Staff Physical forms include if they have any medical problems. All Changes listed above will be completed by 6/20/19	06/20/2019	Implemented
2380.114(a)	Physical exam dated 3/28/19 did not include if Staff #1 had a serious communicable disease.	If a staff person or volunteer has a serious communicable disease as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or a medical problem which might interfere with the health, safety or well-being of the individuals, written authorization from a licensed physician is required for the person to be present at the facility.	We will have the Physical exam form dated 3/28/19 updated to include if Staff #1 had a serious communicable disease. The Director will be responsible for ensuring that all Staff's records will have the Physical exam form updated to include if Staff has a serious communicable disease. All Changes listed above will be completed by 6/20/19	06/20/2019	Implemented
2380.173(1)(i)	Individual #1 and Individual #2's records did not document their social security numbers.	Each individual's record must include the following information: Personal information including: The name, sex, admission date, birthdate and social security number.	We will confirm that Individual #1 and Individual #2's will document their social security numbers. The Program Specialist will be responsible for ensuring that all individual's records will document their social security numbers. All Changes listed above will be completed by 6/19/19	06/19/2019	Implemented
2380.173(1)(ii)	Individual #2's record did not document any identifying marks.	Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.	We will confirm that Individual #2's record will document any identifying marks. The Program Specialist will be responsible for ensuring that all individual's records will document any identifying marks. All Changes listed above will be completed by 6/19/19	06/19/2019	Implemented
2380.173(1)(iv)	Individual #1 and individual #2's records did not document ant religious affiliation.	Each individual's record must include the following information: Personal information including: Religious affiliation.	We will confirm that Individual #1 and individual #2's records will document any religious affiliation. The Program Specialist will confirm that all individual's records will document any religious affiliation. All Changes listed above will be completed by 6/19/19	06/19/2019	Implemented
2380.173(1)(v)	Individual #1 and individual #2's record did not include a current dated photograph.	Each individual's record must include the following information: Personal information including: A current, dated photograph.	ARCC assures that a current dated photograph of Individual #1 and #2 will be added to each individual file. ARCC Program Specialist is responsible for ensuring that all individual's records will include a current dared photograph	07/19/2019	Implemented
2380.177	Individual #2's record did not have a written consent for the release of information.	Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.	ARCC will confirm and assures that all individual's records will have a written consent for the release of information. ARCC Program Specialist will be responsible for ensuring that all individual's records will have a written consent for the release of information.	07/19/2019	Implemented
2380.181(c)	Individual #1's annual assessment dated 8/8/18 did not include what the assessment was based on. Individual #2's annual assessment dated 2/26/19 did not include what the assessment was based on.	The assessment shall be based on assessment instruments, interviews, progress notes and observations.	We will update the assessments to reflect what the assessments were based on. The Program Specialist will ensure that the assessments are noted to reflect what the assessments were based on. All of the above updates will be completed by 6/21/19	06/21/2019	Implemented
2380.181(d)	Individual #1 and individual #2's annual assessments were not signed and dated by the program specialist.	The program specialist shall sign and date the assessment.	ARCC will review all individual's assessment forms and sores that all assessments have been dated and signed by the Program Specialist. ARCC DIRECTOR will be responsible for ensuring that the Program Specialist signs and does all assessments forms.	07/19/2019	Implemented
2380.181(e)(5)	Individual #1's assessment did not include their ability to self-administer medications.	The assessment must include the following information: The individual's ability to self-administer medications.	ARCC have added the ability to self-administer medications to our standard assessments. ARCC Program Specialist will be responsible for ensuring that all current and future individual's assessments includes the ability to self-administer medication.	07/19/2019	Implemented
2380.181(e)(6)	Individual #1's assessment did not include their ability to safely use or avoid poisons.	The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.	ARCC have included then ability to safely use or avoid poisons in our standard assessment. ARCC Program Specialist will review all individual's ability to safely use or avoid poisons is in each individual's standard assessment .	07/19/2019	Implemented
2380.181(e)(9)	Individual #1 and individual #2's assessment did not include their disabilities , and functional medical limitations.	The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations.	The assessment of each individual's disability including functional and medical limitations has been included in our standard assessment form. ARCC Program Specialist will be responsible for assuring that the assessment of individual's disability including functional and medical limitations has been included in our standard assessment form. All of the above was completed 06/19/2019	07/19/2019	Implemented
2380.181(e)(10)	Individual #1 and individual #2's assessment did not include their lifetime medical history.	The assessment must include the following information: A lifetime medical history.	ARCC have included a lifetime medical history in our standard assessment form. ARCC Program Specialist will be responsible for assuring that the lifetime medical history will be included in each individual's assessment . All of the above will be completed bye 06/19/2019	07/19/2019	Implemented
2380.181(e)(12)	Individual #1 and individual #2's assessment did not include recommendations of training, programming, and competitive employment.	The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.	ARCC have included recommendations for specific areas of training, vocational, programming and competitive community-integrated employment in our standard assessment forms. ARCC Program Specialist will be responsible for reviewing all current and future individuals forms for recommendations for specific areas of training, vocational programming and competitive community-integrated employment. All the above will be completed by 6/19/19	07/19/2019	Implemented
2380.181(e)(14)	Individual #1 and individual #2's assessment did not include their knowledge of water safety and ability to swim.	The assessment must include the following information: The individual's knowledge of water safety and ability to swim.	ARCC have added the knowledge of water safety and ability to swim in the assessment form. ARCC will check quarterly and assures that all assessment forms include knowledge of water and ability to swim. All of the above was completed by 6/19/19	07/19/2019	Implemented
2380.181(f)	Individual #1 and individual #2's assessment was not sent to the Supports Coordinator and team 30 days prior to the Individual Support Plan(ISP) meeting.	The program specialist shall provide the assessment to the SC or plan lead, 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).	The assessment of the individual will be sent to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to the next ISP, ISP Annual Update Meeting or ISP Plan Revision Review. We will review all upcoming ISP meetings quarterly, complete assessments and send them out to SC or plan lead as applicable. All of the above will be completed by 6/21/19.	06/21/2019	Implemented
2380.184(c)	Individual #2's record had no documentation of the sign in sheet.	A plan team member who attends a meeting under subsection (b) shall sign and date the signature sheet.	Program Specialist will review records and sign and date and have attendees sign and date the ISP review signature sheets. The Program Specialist will be responsible for ensuring that the Program Specialist and all attendees sign and date the ISP Signature form at the time of the ISP, ISP Annual Update, and ISP Revision Meeting. The Program Specialist will review all of the files and ensure that all of the signatures and dates are in place for Program Specialist and all attendees going forward. All of the above will be completed by 6/21/19	06/21/2019	Implemented
2380.186(b)	Individual #1 and individual #2's records did not have signature sheet with the Program Specialist and individual signing and dating.	The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.	Program Specialist will review records and sign and date and have individual sign and date the ISP review signature sheets. The Program Specialist will be responsible for ensuring that the Program Specialist and the Individual sign and date the review at the time of the ISP Review Meeting. The Program Specialist will review all of the files and ensure that all of the signatures and dates are in place for Program Specialist and Individuals going forward. All of the above will be completed by 6/21/19	06/21/2019	Implemented

SIN-00129909

Renewal

01/25/2018

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
2380.32(b)(3)	CEO shall be responsible for the safety and protection of individuals. Staff administering medications who are not med trained. No documentation as to which staff administered medication to Individual #1. Medication documentation missing dosages of medications administered. Staff # 3 does not have current physical in record.	The chief executive officer shall be responsible for the administration and general management of the facility, including the following: Safety and protection of individuals.	Certified Med Administrator comes in daily to administer. CEO will maintain all records for administering medication and ensure all staff is in compliance with training. Compliance was made immediately 01/29/2018	01/29/2018	Implemented
2380.32(b)(4)	The CEO has not ensured compliance with this chapter. Many documents missing from the records. Staff administering medications who are not med trained. No documentation as to which staff administered medication to Individual #1. Medication documentation missing dosages of medications administered.	The chief executive officer shall be responsible for the administration and general management of the facility, including the following: Compliance with this chapter.	Certified Med Administrator comes in daily to administer. CEO will maintain all records for administering medication and ensure all staff is in compliance with training. Compliance was made immediately 01/29/2018.	01/29/2018	Implemented
2380.33(b)(10)	Program specialist did not complete monthly reviews for Individual # 1. Individual # 1 has been attending program since 11/29/17.	The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual's participation and progress toward outcomes.	Program specialist has completed monthly review for Individual #1 from 11/29/2017 to Present. Program Specialist will complete a weekly checklist for individuals to ensure all documentations are completed in a timely manner.	01/26/2018	Implemented
2380.36(a)	No documentation that Staff # 1 or Staff # 3 were oriented to include daily operation of facility, staff responsibilities, policies and procedures occurred prior to working with individuals. Department policies and procedures training held on 07/27/17. Staff # 1 began working with individuals on 07/25/17. Staff # 3's records do not document that orientation occurred prior to working with individuals.	The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions.	The Ridge assures orientation that includes daily operation of facility as well as policy and procedures occurs prior to working with any individuals. The CEO is responsible for training. Documents will be provided that new staff was trained before hand.	01/27/2018	Implemented
2380.36(h)	Staff # 2 and Staff # 3's training records do not include the source, content or length of training.	Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.	All records are up to date including training sources, content, dates and length of training. Certificates are current. Staff #2 and #3 are no longer employed will provide documentation for new staff training and compliance. CEO will conduct quarterly checks for all staff training.	01/29/2018	Implemented
2380.57	Bulb broken in the back rear exit outside the door	Rooms, hallways, interior stairways, outside steps, interior and outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.	Bulb was replaced by maintenance and Lead Direct Care will check outside for any future bulb outage. This was replaced immediately on 01/25/2018.	01/25/2018	Implemented
2380.62	No Emergency phone numbers on phone in activity area (Social studies),	Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.	Lead Direct Care has placed emergency numbers on the back of all phones. It was placed 01/25/2018. Will conduct checks every week to ensure numbers are attached.	01/25/2018	Implemented
2380.69(e)	Trash receptacle in bathroom with single toilet does not have a lid/cover.	Each bathroom shall have a wall mirror, soap, toilet paper, covered trash receptacle and individual clean paper towels or air hand dryer.	CEO immediately replaced all trash receptacles with lids. Weekly checks will be made by the CEO of the physical site to ensure compliance.	01/25/2018	Implemented
2380.83(a)	Emergency evacuation plan did not identify Individual Responsibilities	There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation, an emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency.	Emergency evacuation plan was updated immediately to show responsibilities of staff and individuals. CEO revised plan on 01/29/2018	01/29/2018	Implemented
2380.84	The facility did not have an onsite fire safety inspection completed by a fire safety expert. There was an annual certification for fire alarm system completed by Herbert Speech.	The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.	City of Philadelphia came out and did inspections will provide documentation.	03/13/2018	Implemented
2380.89(a)	Individuals were attending the program as of 07/25/17 however no fire drill was conducted July, August, September, October and November of 2017.	An unannounced fire drill shall be held at least once a month.	CEO will conduct monthly unannounced fire drills. The Ridge will assure that all future fire drills will be conducted in a timely manner. CEO will do weekly checks that any reoccurrence will not take place.	01/26/2018	Implemented
2380.89(g)	Fire drill conducted on 12/19/17 did not indicate that individuals evacuated to the designated meeting place	Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.	Form was updated immediately by CEO to reflect designated meeting place.	01/25/2018	Implemented
2380.91(a)	Individual # 1 did not have fire safety training since being admitted to the program on 11/18/17. Individual # 2's record does not indicate fire safety training occurred. DOA 09/25/17.	An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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 facility.	Individuals were trained on 01/29/2018 with fire safety video. Program specialist will train and check on quarterly basis to ensure all individuals are current.	01/29/2018	Implemented
2380.111(a)	Individual # 2 had a physical exam 11/17/16 and not again until 12/05/17.	Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.	CEO will ensure all individuals will have a current physical within 12 months prior to admission at The Ridge Human Services.	01/26/2018	Implemented
2380.111(c)(1)	Individual # 2's 12/05/17 physical does not indicate that medical history was reviewed.	The physical examination shall include: A review of previous medical history.	CEO required that all information be updated on physical immediately. The Ridge ensures all individuals and future individuals will have all required information of physical exam.	01/29/2018	Implemented
2380.111(c)(3)	Individual # 1's 06/01/17 physical does not include immunization records. This section was left blank.	The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.	CEO required that all information be updated on physical immediately. The Ridge ensures all individuals and future individuals will have all required information of physical exam.	01/29/2018	Implemented
2380.111(c)(6)	Individual # 2's 12/05/17 physical does not screen for communicable diseases	The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals.	CEO required that all information be updated on physical immediately. The Ridge ensures all individuals and future individuals will have all required information of physical exam.	01/29/2018	Implemented
2380.111(c)(7)	Individual #2's 12/05/17 physical does not assess health maintenance needs, medication regimen or need for blood work. Space left blank.	The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.	CEO required that all information be updated on physical immediately. The Ridge ensures all individuals and future individuals will have all required information of physical exam.	01/29/2018	Implemented
2380.111(c)(8)	Individual # 2's 12/05/17 physical does not include review/screening of physical limitations. No space on form.	The physical examination shall include: Physical limitations of the individual.	CEO required that all information be updated on physical immediately. The Ridge ensures all individuals and future individuals will have all required information of physical exam.	01/29/2018	Implemented
2380.111(c)(9)	Individual # 1's 06/01/17 physical does not include allergies. This section was left blank.	The physical examination shall include: Allergies or contraindicated medication.	CEO required that all information be updated on physical immediately. The Ridge ensures all individuals and future individuals will have all required information of physical exam.	01/29/2018	Implemented
2380.111(c)(10)	Individual # 1's 06/01/17 physical does not include information pertinent to diagnosis in case of an emergency. Space left blank. Individual # 2's 12/05/17 physical does not include information pertinent to diagnosis in case of emergency. (No space on form reviewed).	The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.	CEO requested all physicals be updated immediately with medical information pertinent to diagnosis and treatment in case of an emergency. The Ridge ensures that any individuals will have correct information on physicals upon entering the program.	01/29/2018	Implemented
2380.111(c)(11)	) Individual # 2's 12/05/17 physical does not identify special instructions for individual's diet. Lifestyle education regarding diet, giving encouragement to exercise' is written.	The physical examination shall include: Special instructions for an individual's diet.	Program specialist instructed parent to have physical updated with Individuals diet included.	03/20/2018	Implemented
2380.113(a)	Staff # 3 had a physical exam on 09/14/15. No other physical exam contained in record. Staff # 3 Date of Hire is 01/15/17. Staff # 1 began work on 07/25/17. No physical exam contained in record.	A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.	Staff #1 brought copy of physical in 01/29/2018. CEO will provide documentation. Staff #3 is no longer employed with The Ridge.	01/29/2018	Implemented
2380.113(b)	Staff # 1 began work on 07/25/17. No physical exam contained in record.	The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant.	Staff #1 brought copy of physical in 01/29/2018. CEO will provide documentation	01/29/2018	Implemented
2380.113(c)(1)	Staff # 1 began work on 07/25/17. No physical exam contained in record.	The physical examination shall include: A general physical examination.	Staff #1 brought copy of physical in 01/29/2018. CEO will provide documentation.	01/29/2018	Implemented
2380.124(a)	Medication logs for Individual # 2 from 11/07/17 to 01/24/18 do not indicate who administered the prescription medication. On 01/19/18, 01/22/18, 01/23/18 and 01/24/18, the medication logs indicate dosage, date and time but no medication name is listed to show what medication was administered. On 11/27/17, 11/28/17, 11/29/17 and 11/30/17 the dosages of medications are not listed.	A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication.	CEO updated Medication log immediately to reflect medication name, time, date the meds were administered and who administered the meds. Weekly checks will be conducted by CEO to ensure compliance.	01/26/2018	Implemented
2380.127(a)(4)	Per president verbal information at site inspection, Staff # 1 administered clonidine to Individual # 2. Staff # 1 did not pass Medication administration course.	Prescription medications and injections of a substance not self-administered by individuals shall be administered by one of the following: A staff person who meets the criteria in § 2380.128 (relating to medication administration training), for the administration of oral, topical and eye and ear drop prescription medications and insulin injections.	CEO hired a Certified Med Administrator 01/29/2018. Individual #2 did not attend program 01/26/2018. The Ridge assures that a Certified Med Administrator will remain on staff. Weekly check will be made.	01/29/2018	Implemented
2380.171(a)	Individual # 2's record does not contain emergency information.	Emergency information for individuals shall be easily accessible at the facility.	Program specialist completed a Face Sheet and placed it in a folder that included emergency information. The Ridge will assures that information will be completed and updated upon change.	01/26/2018	Implemented
2380.173(1)(i)	-- Individual # 1's record does not include sex or date of admission	Each individual's record must include the following information: Personal information including: The name, sex, admission date, birthdate and social security number.	Program specialist immediately updated Face sheets to include the name, sex, admission date, birthdate and social security number. The Ridge assures that any new information will be updated immediately upon knowledge of changes.	01/26/2018	Implemented
2380.173(1)(ii)	Individual # 1's record does not contain weight, height, hair color, eye color or identifying marks	Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.	Program Specialist updated Face sheets immediately to include the race, height, weight, color of hair, color of eyes and identifying marks. The Ridge assures that any new information will be updated immediately upon knowledge of changes.	01/26/2018	Implemented
2380.173(1)(iv)	Individual # 1's record does not identify his/her religious affiliation. Individual # 2's record does not include religious affiliation.	Each individual¿s record must include the following information: Personal information including: Religious affiliation.	Program specialist updated Face sheets to include religious affiliations immediately. The Ridge will assure all information is provided upon start of program and any updates as they occur.	01/26/2018	Implemented
2380.173(1)(v)	Individual # 1 and Individual # 2's record does not contain a current dated photo.	Each individual¿s record must include the following information: Personal information including: A current, dated photograph.	Program Specialist took photos of Individuals immediately and placed into folders. The Ridge assures all individuals photos will be taken upon start of program.	01/26/2018	Implemented
2380.174(b)	Individual # 1's current ISP was not contained in the record. ISP contained in the record was last updated 11/17/17. Individual # 1 had an ISP critical revision on 12/16/17 and an annual update completed 01/09/18.	The most current copies of record information required in § 2380.173(2)¿(11) shall be kept at the facility.	CEO obtained most recent ISP revision from Individual #1 Program Specialist. The Ridge assures all individual ISPs will be current.	01/29/2018	Implemented
2380.177	-- Individual # 1 and Individual # 2's records do not contain a consent to release information.	Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.	Program Specialist had all individuals, or the individuals parent or guardian sign the release of information forms. The Ridge assures all individuals will have signed release of information forms completed upon start of program.	01/26/2018	Implemented
2380.181(a)	the initial assessment due 11/25/17 was not contained in the record. No assessment was contained in the record.	Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.	Program Specialist completed 60 day assessment and will continue to assess every 60 days. The Ridge assures that all assessments will be completed in a timely manner.	01/29/2018	Implemented
2380.181(a)	Individual # 1's record did not contain an assessment. DOA 1/18/17. Individual # 2's record does not contain hair color, eye color or identifying marks.	Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.	Program specialist immediately updated Face sheets to include the name, sex, admission date, birthdate and social security number. A 60 day assessment was updated by program specialist. The Ridge assures that any new information will be updated immediately upon knowledge of changes	01/29/2018	Implemented
2380.183(1)	) Individual # 1's ISP updated 12/26/17 did not indicate an outcome at his/her day program. There was no outcome listed for the day program until the annual ISP update on 01/09/18. According to this outcome, Individual # 1 does not start working on the outcome identified in the ISP of Puzzles' at Ridge Human Services until 02/27/18.	The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Services provided to the individual and expected outcomes chosen by the individual and individual¿s plan team.	The Ridge will assure that the team makes It a priority to include goals and outcomes. The program specialist will follow up with SC to include goals and outcomes as part of ISP. And future ISPs.	02/27/2018	Implemented
2380.183(7)(i)	Individual # 1's ISP updated 01/09/18 did not indicate his/her potential to advance in the area of vocational programming.	The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming.	CEO immediately contacted Individual #1 Program Specialist and Support Coordinator and requested that the ISP be revised to include potential to advance in Vocational Programming.	02/13/2018	Implemented
2380.183(7)(ii)	Individual # 1's ISP updated 01/09/18 does not indicate his/her potential to advance in community involvement. It states that he/she will go out into the community as part of his/her outcome but does not identify his/her potential to advance in this area.	The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Community involvement.	CEO immediately contacted Individual #1 Program Specialist and Support Coordinator and requested that the ISP be revised to include potential community involvement. Individual was taken into the community.	02/13/2018	Implemented
2380.183(7)(iii)	Individual # 1's ISP does not identify his/her potential to advance in competitive/community integrated employment. ISP states Individual has been given information about the benefits of competitive employment, the services offered by OVR to eligible individuals. Individual # 1 is ineligible'.	The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Competitive community-integrated employment.	to advance in the Competitive community-integrated employment.	02/13/2018	Implemented
2380.186(a)	No ISP reviews contained in Individual # 2's record.	The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.	Individual #2 ISP was reviewed on 02/13/2018. Program specialist will review ISP every three months. The Ridge assures all reviews will be in compliance and done in a timely manner.	02/13/2018	Implemented
2380.186(c)(1)	No monthly documentation was contained in Individual # 2's record.	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 facility licensed under this chapter.	Program Specialist has updated monthly review for individual records. The Ridge assures that monthly reviews will be done in a timely manner.	02/09/2018	Implemented

SIN-00107126

Initial review

02/03/2017

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
2380.55(a)	There were approximatley five piant stains on the carpet in Room 2. A brown water stain approximately one foot in diameter was found on the ceiting tile located in the men's bathroom.	Clean and sanitary conditions shall be maintained in the facility.	Paint stains was removed from carpet in room 2. The old stained tile was removed and replaced with a new tile. The facility personnel will check and maintain sanitary conditions and clean all spots daily.	02/07/2017	Implemented
2380.59(b)	The water temperature was 130.5 degrees Fahrenheit in the men's bathroom	Hot water temperatures in areas accessible to individuals may not exceed 120°F.	Water temperatures was reduced to 115 degrees. This will be maintained on a weekly basis to make sure temperature does not get higher than 120 degrees. Staff personnel shall maintain daily test documentation.	02/06/2017	Implemented
2380.62	Emergency telephone numbers were not posted by the telephone or in the facility.	Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.	Emergency List was created and placed by each phone within our facility where we have an outside line. This includes the nearest hospital, police department, fire department, ambulance and poison control center	02/06/2017	Implemented
2380.70(b)	The first aid room did not contain a bed or cot, a blanket, a pillow or the first aid kit.	The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit.	Cot, blanket, pillow and first aid kit was placed in the First Aid area. This area will be maintained daily by cleaning.	02/09/2017	Implemented