Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC 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 |