Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.15(a) | The agency's self-assessment was completed 3/1/22 which is not within the 3 to 6 month required timeframe prior to the expiration of the agency's certificate of compliance, which is 3/28/22. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | The CEO has put into a place a reminder on November 1st of each year to complete ARKM's self-assessment which is 3-to-6-months prior to ARKM's licensing expiration date. |
03/25/2022
| Implemented |
6400.21(a) | The criminal history checks for staff person#3 was completed 3/14/22, date of hire 12/3/21.
The criminal history check for staff person #4 was completed 3/14/22, date of hire 12/3/21. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the home who will have direct contact with individuals, including 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 CEO completed an audit of all personnel files to ensure that employee's criminal history record checks were completed within 5 working days after the person's date of hire. |
03/25/2022
| Implemented |
6400.21(b) | it could not be determined if staff persons #'s2,3,4,5,6, were residents prior to employment and no FBI checks were completed for these staff person's. | If a prospective employee who will have direct contact with individuals resides outside 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 ARKM employment application has been revised to include a statement of the prospective employee's residency status in the state of Pennsylvania. |
03/25/2022
| Implemented |
6400.22(d)(1) | It could not be determined if there was an up to date financial record for individual#1, as the provided documents were illegible. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | ARKM will send legible financial statements for individual #1. |
03/25/2022
| Implemented |
6400.62(d) | In the cabinet beneath the sink there was comet bleach and dawn dish detergent being stored intermingled with along with canned food. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | The CEO has removed the stored poisonous materials from beneath the kitchen sink so that they are no longer intermingled with the house hold's canned food items. |
03/28/2022
| Implemented |
6400.64(d) | A large city-provided blue recycle bin with no lid was being used as a kitchen trash can. | Trash in the bathroom, dining and kitchen areas shall be kept in cleanable receptacles that prevent the penetration of insects and rodents. | A kitchen trash with a lid has been purchased to prevent penetration of insects and rodents. |
03/28/2022
| Implemented |
6400.72(b) | Two screens had holes in them, both several inches in size. Those screens were located in the rear first floor window and in the front unoccupied bedroom. | Screens, windows and doors shall be in good repair. | ARKM will repair the two screens located in the rear first floor window and in the front unoccupied bedroom window. |
03/28/2022
| Implemented |
6400.73(a) | The stairwell leading to the basement had a section of approximately 4 stairs which did not have a handrail. There were short handrails at the top and bottom of the stairwell which left roughly 4 stairs in the middle with no handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | The hand rail leading to the basement has been ordered with an installation date of 3/29/22. |
03/29/2022
| Implemented |
6400.110(a) | There was no smoke detector present in the basement of the home. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | On 3/29/22 ARKM purchased an additional interconnected smoke detector for the basement of the home. |
03/29/2022
| Implemented |
6400.110(e) | The home contained 3 floors (2 floors and a basement) however none of the smoke alarms were 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. | ARKM interconnected smoke detectors have been purchased and installed at the home. |
03/29/2022
| Implemented |
6400.113(c) | There was no signed documentation showing a fire safety training was performed with individual#1. | A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. | ARKM shall forward a copy of individual # 1 fire safety training as proof that the individual did receive fire safety training. |
03/29/2022
| Implemented |
6400.141(b) | The annual physical examination for individual#1 was incomplete. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | A copy of Individual #1 physical examination has been completed with all pages included for review. |
03/29/2022
| Implemented |
6400.142(a) | There was no dental exam on file for individual#1. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Individual #1 completed dental form shall be forwarded as proof of a dental cleaning exam. |
03/30/2022
| Implemented |
6400.151(a) | Physical exam was requested but not provided for staff member#1 acting as program specialist. | 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, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | ARKM will provide a copy of staff member #1 physical examination acting as program specialist. |
03/29/2022
| Implemented |
6400.151(c)(3) | The physical exam dated 2/19/22 for staff member#2 did not indicate if the staff person was free of communicable diseases. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | ARKM will provide documentation that staff member #2 is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. |
03/29/2022
| Implemented |
6400.181(a) | There was no assessment present in the record for individual #1. | 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. | ARKM will forward a copy of the initial self-assessment for individual #1. |
03/30/2022
| Implemented |
6400.217 | There was no signed documentation showing that individual#1 consented to release of personal information. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| ARKM will forward a copy of individual #1signed consent of release of information. |
03/30/2022
| Implemented |
6400.24 | Under the 1970 Controlled Substances Act, all class c medications must be double locked and counted at each administration of the medication. Individual#1 is prescribed Klonipin which is a controlled substance. This medication was not being counted prior to inspection. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | A controlled substance count sheet has been implemented for individual #1 prescribed Klonopin controlled medication. |
03/30/2022
| Implemented |
6400.34(b) | There was no signed documentation showing that individual rights were reviewed with individual#1. | The home 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. | ARKM will provide a copy of individual #1 signed individual rights statement. |
03/30/2022
| Implemented |
6400.165(b) | There are inconsistencies between the MAR and the prescription label for Individual#1's Hydroxyzine 50 MG.
The bottle states 'Take one tablet by mouth every 8 hours as directed' however the MAR shows the administration times as 9am, 3pm and 6pm which does not line up with the 8 hours as written on the bottle. | A prescription order shall be kept current. | ARKM will correct the MAR for individual #1's Hydroxyzine 50 MG to align with pharmacy label. |
03/30/2022
| Implemented |
6400.165(g) | There were no psych med reviews on file for individual#1. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | ARKM will provide a copy of individual #1's psychotropic medication management reviews. |
03/30/2022
| Implemented |
6400.213(1)(i) | Photograph of individual #1 on face sheet is 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. | The date of individual #1's photo has been labeled with the date the photo was taken of the individual. |
03/30/2022
| Implemented |