Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00181126 Renewal 01/04/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone numbers to the nearest hospital, police department, fire department, ambulance and poison control center were not posted on or near the telephone in Individual #1's kitchen apartment area of the home.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The agency received this citation because there were not emergency numbers located on or by the outside telephone line in the individuals apartment. As stated in the discussion section of the Regulation Compliance Guide under Emergency Telephone numbers, it is important for emergency numbers to be located on the phone to facilitate a quick response for the appropriate agency in the event of an emergency. Although this individual utilizes a cell phone, in an emergency situation, the individual and staff need immediate access to emergency contact numbers. Upon licensors discovery of the emergency numbers missing from the individual¿s landline phone, staff immediately posted the numbers on the back of the phone. Photos were taken of the phone console and back of the portable phone. See attachment # 30 of emergency numbers on the phone. Program Managers will continue to monitor emergency numbers when they complete monthly site monitorings at each group home. Site monitorings completed by Program Managers are monitored monthly for completion by the Community Living Administrator and Director of PA Programs. All staff will be retrained on the importance of this regulation via email. See attachment # 2- email sent to all residential staff. The residential supervisors will be retrained on this regulation during the next supervisor meeting on April 14, 2021. 04/14/2021 Implemented
6400.110(f)Individual #1 is unable to hear the fire alarm or see the strobes lights in her home. The smoke detectors and fire alarm system in the home is not equipped so that she is alerted in the event of a fire when she is any room of her house, with the exception of her bedroom. Her bedroom was the only room in the house equipped with a bed-shaker to notify her in the event of a fire. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. This citation was received because the only place the individual that is blind and hearing impaired could be alerted to the smoke detectors was in her bedroom where she had a bed shaker. It is important for everyone to be alerted immediately to emergency situations. On February 16, 2021 at 9am, BFPE along with Penn-Mars Maintenance Department, installed the Vibra-Call Body Worn portable alerting device for the individual #1. The Vibra-Call device is interconnected with the pre-existing fire alarm system. The device is charged every night in the base and has a back-up battery system in case of power failure. The portable device is checked every morning to ensure it is operational before being worn by the individual. Fire drills are completed monthly, and the device is again checked to ensure it is working properly. See attachment # 31 -receiver base, transmitter, and the device Supervisors and Program Managers are to monitor homes for safety and request modifications as needed. During monthly site monitoring in the home, managers are expected to inspect the home for safety concerns. All residential supervisors and program managers have been retrained on this regulation and the importance of safety concerns being addressed immediately via email. see attachment #2 - email sent to all residential team members. A review of this regulation will also be completed with the Residential Supervisors again at their next team meeting on April 14, 2021. 04/14/2021 Implemented
SIN-00120665 Renewal 11/07/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Individual #1's bedroom had six stains on the carpet measuring approximately 3 inches wide.Floors, walls, ceilings and other surfaces shall be in good repair. The carpet in the bedroom has been spot cleaned and the stain was removed from the carpet. See Attachment #34 All Program Managers have reviewed this regulation and will monitor the wear of carpets and repair of homes during their monthly monitoring (attachment # 2). Program Manager understand the expectation to notify our maintenance department when the home needs repair. Residential Supervisors will be retrained on this regulation during the Residential Supervisor meeting on 12/13/17 (attachment #3). 12/13/2017 Implemented
6400.71Repeat 10/5/16: There were no emergency phone numbers on Individual #1's landline.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Emergency numbers were placed on the telephone. See attachment #33 Program Specialists were re-trained that all phone numbers must be on the telephone and to be more mindful of this when telephones are replaced (attachment #2). Program Specialists ensured that all telephones in all other residential settings were labeled properly during their November site visit. All Residential Supervisors will be re-trained on this regulation at the upcoming supervisors meeting on 12/13/17. 12/13/2017 Implemented
6400.106Repeat 10/05/16: The furance was cleaned on 10/6/16 and not again. There is documentation the furance was replaced however it was not replaced until 10/24/17. A furance cleaning was due on 10/6/17.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The furnace at the Matthews Court home was replaced on 10/24/17. As a result of this citation and furnace cleanings not being completed within the required timeframe, we have assigned the monitoring of this task to the Community Living Manager, whom we feel has the skills to ensure furnace cleanings are completed on time in the future. 12/13/2017 Implemented
6400.112(a)Repeat 10/5/16: There was no fire drill conducted in the month of March 2017. An unannounced fire drill shall be held at least once a month. As a result of this citation, Penn-Mar has evaluated and made changes to the process. Fire drills will now be submitted to the Operations Support Specialist, whom we feel has the skills to monitor and ensure that fire drills are completed for every home each month and that the form is completed in its entirety and complies with state regulations. In addition, Program Managers have completed an audit of drills for November 2017, which have been completed for each home. Program Managers have been re-trained on this regulation (attachement #2). Residential Supervisors will be trained re-trained on this regulation at the Residential Supervisor meeting on 12/13/17 (Attachment #3). 12/13/2017 Implemented
SIN-00102844 Renewal 10/05/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Febreeze and laundry detergent were unlocked in Individual #1's bedroom.Poisonous materials shall be kept locked or made inaccessible to individuals. The laundry detergent and febreeze were moved to the laundry room, which is kept locked. See attachment L All Residential Supervisors and Program Specialists were re-trained that despite the fact that the laundry detergent was on a high shelf in the individual¿s bedroom, that they could not assume that another individual in the home who does not have adequate awareness of poisonous materials could not gain access if they tried. They were re-trained to simply keep everything locked that could be considered poisonous. Program Specialists will monitor this during site visits. See attachment A 10/12/2016 Implemented
6400.67(a)Individual #2's dresser was missing a knob on the fourth drawer.Floors, walls, ceilings and other surfaces shall be in good repair. Knob was replaced on the dresser. See attachment K All Residential Supervisors and Program Specialist level staff were trained on the need to be more mindful of furniture knobs. Program Specialists now look for this during their monthly site visits. See attachment A 10/12/2016 Implemented
6400.110(f)Individual #1's bedshaker was inoperable when the smoke detectors were set off. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. When this was discovered during the licensing inspection Penn-Mar¿s maintenance team was immediately contacted. The unit was assessed and it was determined that it could not be repaired and that a new unit needed to be purchased. The new unit arrived and was installed on October 18, 2016. During the time that the shaker was not working and the new unit arrived, staff checked on Individual #1 and did a walk-through of the home every 15 minutes to ensure that the home was safe. There is documentation of these 15 minute checks. See attachment B & J Attached you will find October and November 2016¿s fire drill form which shows the shaker was working during the fire drill in November. See attachment I Bed shakers are checked every month by staff during fire drills and by Program Specialists during house inspections. The bed shaker was working when it was checked in September. Regardless of this fact, all Residential Supervisors and Program Specialists were reminded that they need to be checking these adaptive devises each month and documenting that on the fire drill form and the site monitoring form. The protocol for what needs to occur if a unit is not functioning was also reviewed. See Attachment A 10/18/2016 Implemented
6400.112(d)The 10/14/15 fire drill log indicated an evacuation time of 2 minutes and 45 seconds. The 4/14/16 fire drill log indicated an evacuation time 2 minutes and 46 seconds. The 8/24/16 fire drill log indicated an evacuation time of 2 minutes and 36 seconds. An extended evaucation time of 3 minutes and 30 seconds was not implemented until 9/1/16. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. On August 24, 2016 a fire inspector came to the home to inspect the home to determine a safe fire evacuation time. We received this letter on September 1, 2016. September, October, and November¿s fire drills show that the drills were successfully completed within the new fire evacuation time. See attachment I All Residential Supervisors and Program Specialist staff were trained on the process that needs to occur if a home is struggling to evacuate within 2 ½ minutes or within the approved extended evacuation time. There needs to be a timelier dialog so that extended evacuation times can either be requested or if individuals are struggling to be evacuated within the extended evacuation time, there needs to be immediately intervention to assist with this problem. Interventions may need to include adding staffing hours if the situation is severe enough. See attachment A 11/27/2016 Implemented
SIN-00202395 Renewal 03/29/2022 Compliant - Finalized
SIN-00177814 Renewal 05/07/2021 Compliant - Finalized
SIN-00070779 Initial review 10/30/2014 Compliant - Finalized
SIN-00070895 Renewal 07/28/2014 Compliant - Finalized