Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235540 Renewal 10/17/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)72A There was no screen door on the front of the home. There seems to have been one due to the hardware that is left on the frame.Windows, including windows in doors, shall be securely screened when windows or doors are open. Screen was installed on 11/15/2023 and site is in compliant for this citation 72A. Residential Director is responsible for correcting the immediate problem of getting a professional to install the screen door. This was corrected on 11/15/2023. An agency wide check was conducted to ensure all individuals are safe from any perils of not having windows, doors and windows shall be securely screened when they are opened. Target date of 11/15/2023 was accomplished. Residential Supervisor conducted monitoring of all sites which was accomplished 10/25/2023 12/12/2023 Implemented
6400.73(a)73A The railing outside of the front door was out of the cement in some places and hanging off of the wall at the top. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Railing was repaired on 11/28/2023. Site is free from obstructions. Site is in full compliant. No evidence of railing hanging off the wall. The Residential Director is responsible for correcting the immediate problem of the loose cement hanging of the wall leading to up to steps. This was corrected on 11/28/2023. An agency wide check was conducted to ensure all individuals are safe from any perils of loose stairs or handrails for citation of 73A Residential Supervisor conducted biweekly monitoring of all rails which was accomplished on a target date of 10/24/23 12/12/2023 Implemented
6400.77(b)77B The first aid kit did not have scissors or a thermometer. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Scissors and thermometer were put in first aid kit on 10/19/2023. First Aid kit on site is compliant. The Residential Director is responsible for correcting the immediate problem of ensuring that the first aid kit has all component of what is required for regulations. An agency wide check was conducted to ensure all individuals are safe from any perils and the first aid kit has scissors and a thermometer for citation of 77B Residential Supervisor conducted biweekly monitoring of all agency first aid kits which was accomplished on a target date of 10/24/23 12/12/2023 Not Implemented
6400.80(a)80A The sidewalk leading to the bottom steps outside of the front of the home was cracked and missing large portions of cement. Outside walkways shall be free from ice, snow, obstructions and other hazards. Site is free from obstructions; repairs was completed on cracks and missing portions of cement on the sidewalk 11/28/2023.The Residential Director is responsible for correcting the immediate problem of cracked and missing concrete for citation 80a. An agency wide check was conducted to ensure all individuals are safe from any perils of the walkways. All walkways are free of obstructions. Residential Supervisor conducted biweekly monitoring of all walkways which was accomplished on a target date of 10/24/23. Biweekly monitoring is continuous. 12/12/2023 Implemented
6400.110(a)110 A The smoke detectors in four of the five homes did not have a lasting alarm. When pushed to test the alarm made a beeping sound for about three seconds and then stopped. Staff did not know if this was normal and none of the staff that were present at these locations seemed to know what occurs during a drill. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. The Residential Director is responsible for correcting the immediate problem of ensuring that all homes have operable automatic smoke detectors on each home. Agency wide test was done for citation 110 A This was corrected on 10/18/2023. Residential Supervisor conducted monitoring of all alarms, and which was accomplished on a target date of 10/24/23. Inspections were completed at all homes by a licensed fire professional. This correction was done on 10/18/2023 in the presence of a State licensed audit team. All sites remain compliant. Target date of 10/18/2024 was accomplished. 12/12/2023 Implemented
6400.163(d)163 D There were medications including aspirin and antacids in the first aid kit which was kept in an unlocked cabinet.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.The Residential Director is responsible for correcting the immediate problem of ensuring all medication are locked and secured. This was corrected on 10/17/2023. An agency wide check was conducted to ensure all individuals are safe from any perils of medication that is not secured: citation 163D Residential Supervisor conducted monitoring of all sites which was accomplished on a target date of 10/24/23. All aspirins and antacids were removed form First Aid Kit on 10/17/2023. All first aid kits are checked for any medications that does not belong in the home. In accordance with 163D medication must be kept in a double locked cabinet at all times. First Aid kits are checked before they are placed in each home. Manufacturers tend to leave aspirins and antacids in their kits. ARCC will inspect each kit before it is placed in each home. 12/12/2023 Not Implemented
SIN-00223823 Renewal 04/24/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Based on the individual file it could not be determined if Individual 1 was reinstructed annually in general fire safety. Only the current training was provided dated 03/13/23. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. In order to maintain compliance, ARCC CEO will ensure all qualification is reviewed and approved prior to hire. ARCC CEO with director serving as the pick-up will review the entirety the employees training file and will schedule all applicable fire safety training to occur within the required applicable time frame. ARCC is now working with a Fire Marshall to complete fire safety for all staff and consumers within 60 days. All consumers/staff will complete fire safety training and signed consent form stating it was completed and accompanied by a fire drill. 06/05/2023 Not Implemented
6400.141(a)Ind. 1 is not being seen by a physician annually, last exam was completed 11/01/2021 and not completed again till 04/19/2023.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Program Director has reviewed all physical forms for the individual's being supported by ARCC for accuracy and yearly completion. 06/06/2023 Not Implemented
6400.141(c)(14)Info pertinent to diagnosis in case of emergency was left blank on Individual 1's physical form completed by the physician.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Program Director has taken the physical forms back to the individual's PCP to have the corrections completed. 06/06/2023 Not Implemented
6400.181(a)There is no updated assessment completed annually for Ind. 1, their current assessment was completed 04/11/2023 it could not be determined when the previous assessment was completed no documentation was provided at time of inspection. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Provider will review all consumer files for quarterly using the provider checklist. Program specialist completed the assessment. 06/06/2023 Not Implemented
6400.34(a)Informing of Rights were not explained and completed annually for Ind. 1.The home 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 home and annually thereafter.Provider created a consumer enrollment checklist to ensure that each individual understands their rights when entering the program. 06/06/2023 Not Implemented
6400.163(a)The following medication prescribed to Individual 1 was present in their medication box, however it did not have a pharmacy prescription label attached: Ashlyna 0.01 -- 0.03 -- 0.15 -- Take one tablet by mouth every day.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.The Program Director and Program Specialist visited each home to review medications, medication logs, and reported all issues to individuals prescribing doctors and pharmacy. The prescription label was obtained. from Holmesburg Pharmacy on 4/25/2023 06/06/2023 Not Implemented
6400.166(a)(11)Individual 1 is prescribed Lorazepam 0.5mg to be taken by mouth 'as needed'. There was no corresponding diagnosis information on the medication label as to what this medication is needed for.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The Program Director and Program Specialist visited each home to review medications, medication logs, and reported all issues to individuals prescribing doctors and pharmacy. Dr Shabazz changed the prescription to a standing order 5/16/2023 06/06/2023 Not Implemented
6400.207(4)(I)The 0.5mg Lorazepam prescribed to Individual 1 is to be taken as needed for anxiety. Medications to be taken as needed for a mental or behavioral condition are considered chemical restraints.A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition.The Program Director and Program Specialist visited each home to review medications, medication logs, and reported all issues to individuals prescribing doctors and pharmacy. 06/06/2023 Not Implemented
6400.213(1)(i)The current photo in Ind. 1's files are not dated.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.Program Specialist and Program Director went to each home to get a photo of each individual to place in their files. 06/06/2023 Not Implemented
SIN-00210364 Renewal 08/30/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)Kitchen Stove damaged (handle broken) Furniture and equipment shall be nonhazardous, clean and sturdy. The stove handle was repaired on September 20, 2022. (see attached receipt for parts purchased as well as photo of repaired stove handle). 09/20/2022 Implemented
6400.77(b)The first aid kit did not contain antiseptic and a thermometer A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. ARCC/The Residential Director replenished the first aid kit at all sites to ensure all required items as per 6400.77 (b) are included. On 9/13/22 ARCC/The Ridge purchased a thermometer and antiseptics that were placed into the first aid kit. Photo of the first aid kits and staff meeting notes are included. A staff meeting will be held for the Pastorius site on 9/21/22 at 9:30am to address all citations and plans of corrections. 09/21/2022 Implemented
6400.77(c)There was no first aid manual located in the first aid kit A first aid manual shall be kept with the first aid kit.ARCC/The Residential Director replenished the first aid kit at all sites to ensure all required items as per 6400.77 (c) are included/ On 9/13/22 ARCC/The Ridge purchased an American Red Cross Emergency First Aide Guide that was placed into the first aid kit. Photo of the first aid kits are included. A staff meeting will be held for the site on 9/21/22 at 9:30am to address all citations and plans of corrections. 09/21/2022 Implemented
6400.181(e)(10)The record for Ind. #5 did not include a lifetime medical history.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 #5 on September 19, 2022. LTMH is attached via email. 09/15/2022 Implemented
6400.181(e)(12)The annual assessment did not include any information as it relates to recommendations for specific areas of training, programming and services for Ind. #5.The assessment must include the following information: Recommendations for specific areas of training, programming and services. On September 16, 2022 ARCC/The Director has updated our annual assessment form to include recommendations for specific areas of training. programming and services. See attached updated assessment for Individual #5 09/16/2022 Not Implemented
6400.166(b)Logging error for Ind #5, Medication METFORMIN Tab 500mg, was not recorded on the MAR on 8/22/22 at 8am dose and on 8/27/22 for 8pm dose. Medication CLONAZEPAM 5mg was not logged as administered on 8/27/22 8pm dose. Medication TRAZODONE 100mg not logged for 8pm dosage on the 8/27/22. Medication FLUOROMETHLONE was not logged on 8/22/22 for 8am dose and on 8/27/22 for 8pm dosage.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.ARCC Residential Director has entered an incident in EIM for this area of non compliance. The EIM number is 9092708 for optional reporting. This will help ARCC Track and assess areas where our program and employees can improve as it relates to medication administration errors. 09/21/2022 Not Implemented
6400.181(f)The record for Ind. #5 did not include information to show that the annual assessment was provide to the individual and the plan team.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.On September 16, 2022 ARCC/The Director has updated our annual assessment form to include a space for Team Distribution and verification at the end of the Annual assessment. The Program Specialist updated and sent individual #5 assessment on 9/16/22 to the team. The verification is attached via email. 09/16/2022 Not Implemented
6400.195(b)The record did not include an updated behavior support at the time of the review for Ind. #5.The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews.ARCC failed to provide the BSP for Individual #5 at the time of the audit but submitted it the day after as requested by the auditor. Our plan of correction is to ensure we have all documents available at the time of the audit. On September 15, 2022 The Residential Director went through each of the individuals files to ensure all updated and relevant information is included in the file (see attached BSP) 09/15/2022 Implemented
SIN-00192321 Renewal 08/31/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(a)There was no complete first aid kit present at the home at time of inspection, that includes no Manual. A home shall have a first aid kit. The first aid kit was replenished with the following items; assortment of adhesive bandages, scissors, tape, thermometer, tweezers, antiseptic, sterile gauze pads, syrup of Ipecac, and manual per 6400.77 (a) (c) regulatory guidelines 09/01/2021 Implemented
6400.46(a)Staff member #3 was not trained in fire safety prior to working with individuals. Agency documentation shows a fire safety training certification dated 8/7/21, but their hire date was 1/20/21.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 home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.ARCC attest that all new employees moving forward will receive new hire orientation prior to working with individuals serve. Fire safety is one of those required trainings as outlined per 6400.46 (a) regulatory guidelines that will be reviewed in new hire orientation. 09/01/2021 Implemented
6400.46(d)It cannot be determined that staff member #3 first aid/CPR training was completed within six months of their hire date. Their training date is listed in agency records as 8/7/21, but their hire date was 1/20/21.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.ARCC attest that all new hires will receive new hire orientation prior to working with individuals served CPR/Fire safety is one of those subject matter required trainings as outlined per 6400.46 (d) that will be reviewed in new hire orientation. 09/01/2021 Implemented
SIN-00174532 Initial review 08/03/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(e)The home had 3 levels, a basement, main floor, and second floor, and the smoke detectors were not interconnected.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. All audible units were installed on each floor including the basement. The audible units were programed and interconnected so as to have coverage on all floors. 1)Program Director is responsible for making corrections and also for future problems. 2)Smoke /Fire detectors will be programmed so they all will be audible and can be heard throughout the house. 3) ARCC Program Director will conduct a quarterly inspection to make sure all are in good working order. Staff will be trained to recognize any problems and report them immediately to their supervisor. 08/05/2020 Implemented