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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The exterior egress by the sliding glass doors leading onto the deck, were not equipped with a light to light area for safety and to avoid accident when using the egress. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| This citation was received because there was not a light directly outside of the back door leading to the deck.
It is important to ensure walkways are lit to avoid falls and injuries.
A light was installed directly outside of the back door leading to the deck. See attachment # 24 installation of light
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 people being able to navigate safely in and around their home via email. see attachment #2 - email sent to all
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 |
| 6400.112(d) | During the 10/29/19 fire drill held at 5AM, the individuals did not evacuate the home within 2 and a half minutes. The home recorded that it took the individuals 4 minutes and 15 seconds to evacuate the home. Another fire drill was not held in October 2019 where the individuals evacuated the home in the regulatory requirements. The home did not have record of written documentation from a fire safety expert designating a specific time for evacuation over 2 and a half minutes. This was not completed until 8/11/2020.
The home noted that it took individuals 3 minutes and 56 seconds to evacuate the home during the 3/10/2020 fire drill. The individuals evacuated the home in 6 minutes and 22 seconds during the 4/20/2020 fire drill. The individuals evacuated the home in 4 minutes and 57 seconds during the 5/13/2020 fire drill. The individuals evacuated the home in 3 minutes during the 6/7/2020 fire drill. The home did not have record of written documentation to extend the fire evacuation time by a fire safety expert during this time. | 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. | This citation was received due to not having an assessment conducted by a fire safety expert in a timely manner to grant the needed extended evacuation time for the home.
The agency understands the importance of receiving an assessment of the home by a fire safety expert if an extended evacuation time is needed to ensure safety of the individuals supported in the home.
The home did have an extended evacuation time of 7 minutes at the time the October 29, 2019 fire drill was conducted. See attachment # 25- letter from the safety expert dated 5/7/2019 and 8/11/2020. These letters place the home in compliance with the drills that occurred on 3/10/2020 and 4/20/2020. We recognize that the 5/13/2020 drill is not in compliance because the fire safety expert did not assess the home again until 8/11/2020 due to the pandemic, at which time they determined that it was safe to evacuate the home within 7 minutes.
Program managers had additional training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. Program Managers will work with the Quality Supports Specialist to ensure a fire safety expert assess the home at least annually if an extended evacuation time is needed. In addition to having several conversations with program managers surrounding the citations received since this licensing exit on January 11, 2021, they will review the regulation again during the residential supervisors meeting on April 14, 2021. |
04/01/2021
| Implemented |
| 6400.50(a) | At the time of the 1/4/2021 inspection, Staff person #1's training record did not include the content of the training, the trainer, or the training source and occasionally didn't include the date of trainings or the time frame associated with how long the training took. | 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. | Penn-Mar failed to keep on file the content of trainings along with the signature sheets that show the source, dates, and length of training.
This regulation is important to ensure team members are properly trained to support the individuals they are working with and are able to meet their needs.
Program Managers and Supervisors were retrained on the need to ensure all team members review ISPs, protocols, support plans, behavior plans, and assessments prior to working with individuals. A new process was put in place in November 2020 to have Program Managers review weekly training reports for team members that have worked in each program to ensure all team members have completed the training requirements for each program. Weekly audits are also conducted by the Director and Administrator to provide another level of oversight to ensure that staff working have completed all required individual specific training prior to working with individuals.
A new process was put into place in November requiring Managers and Nurses to meet with teams to review protocols together. These meetings are held virtually and recorded. The protocol videos along with a Microsoft Word document of the protocol will then be uploaded into UltiPro (training platform). This will show the content of each protocol training. Protocol trainings include content, dates, length of training and staff persons attending. If team members are unable to attend the team meeting, they are required to review the recorded training at the start of their next shift. New protocols or updated protocols are immediately written and reviewed with team members. See attachment # 11 -Protocol Training Guide.
For staff training on things such as hospitalization discharge documents, the Learning and Development department will save staff signature sheets with the content they reviewed so they we are able to provide training information when required. See attachment # 12- in-person training guide. |
04/01/2021
| Implemented |
| 6400.51(b)(5) | Staff person #1 was hired with the agency on 11/18/2019 and per agency report during the 1/4/2021 inspection, started working directly with individuals within the two weeks following her date of hire. The agency reported she has been working at the home with Individuals #2-#5. There are no records maintained that Staff person #1 received orientation specific to Individuals #2-#5's specific plans and the individual's health and safety needs prior to working with them. Individual #2-#5's specific plans and protocols provide staff with the knowledge and job skills needed to ensure the individual's health and safety is properly managed while living at the residence. Failing to orient staff to the specific job skills and knowledge needed prior to working with individuals creates an environment conducive to negligence. Staff person #1 didn't receive training in Individuals #2-#5's specific plans and protocols until July and October 2020. | The orientation must encompass the following areas: Job-related knowledge and skills. | The program manager failed to ensure the staff was properly trained to support the individual prior to working with him.
It is important to ensure staff are thoroughly trained on plans and protocols for an individual prior to working with them to ensure they have the knowledge and job skills needed to ensure the individuals health and safety is properly managed.
Program Managers and Supervisors were retrained on the need to ensure all team members review ISPs, protocols, support plans, behavior plans, and assessments prior to working with individuals. Supervisors have been retrained on the need to email their Program Manager to let them know when new substitute team members are scheduled to work at a group home. The Program Manager will then ensure that team members are assigned all trainings that team member is required to complete prior to working with individuals. A new process was put in place in November 2020 to have Program Managers review weekly training reports for team members that have worked in each program to ensure all team members have completed the training requirements for each program. Previously, the training system used did not allow managers to see the training records of the people who did not directly report to them. We have since discovered a work around to this and these reports are now sent weekly via email from the Director of PA programs to the Program Managers. Weekly audits are also conducted by the Director and Administrator to provide another level of oversight to ensure that staff working have completed all required individual specific training prior to working with individuals. |
04/01/2021
| Implemented |
| 6400.169(a) | The agency documented that Staff person #1 completed the initial medication administration training and was certified to administer medications to individuals on 12/10/2019. However, according to the information documented by the agency's (Penn-Mar Human Services) medication administration trainer, Staff person #1 never completed the Department's approved medication administration course correctly in order to be certified to administer medications.
In order to correctly pass the Department's initial medication administration training course, staff must take and complete with passing grades a serious of in-class examinations (multiple choice, written, handwashing, and gloving examinations) then pass four observations within 30 days of passing the in-class examinations. The initial medication administration training course also defines parameters to meet should the staff taking the course be unable to have four observations completed within 30 days of passing their in-class examinations. The parameters are defined as: 6 observations need to be completed within 75 days of passing the examinations, or 7 observations need to be completed within 105 days of passing the examinations, or 8 observations need to be completed within 135 days of passing the examinations, or 9 observations need to be completed within 175 days of completing the examinations, and if not completed by then, the student would have to retake all in-class examinations again.
When the agency's medication trainer documented that Staff person #1 was certified to start administering medications to individuals effective 12/10/2019, Staff person #1 had only completed 2 of the 4 required medication observations. The additional two observations weren't completed until March 2020. There were no records maintained that a medication trainer reviewed the additional requirement and certified the staff person to administer medications with a new effective date. Additionally, there were 93 days between Staff person #1's in-class completion of examinations and the last observations completed in March 2020. Due to this, Staff person #1 should have had 7 observations completed prior to a medication trainer certifying her to administer medications. Additional observations were never completed. Staff person #1 has been administering medications to individuals for over a year without completing and passing the Department approved medication administration trainer course.
There were no records maintained that Staff person #1 completed the Department's modified medication administration training course and it's requirements during the COVID-19 pandemic in leu of the complete medication administration training course. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | The medication trainer responsible for ensuring the medication observations were completed in the required time frame did not follow the medication administration guidelines.
It is important for medication administration trainers ensure that staff completed their medication administration observations on time to keep their medication certification current. Its also important for medication administration trainers to observe medication administrations to ensure staff are properly trained to administer medications in an effort to prevent medication errors.
Following the licensing exit on January 11, 2021, the agency nurses completed an audit to ensure all medication administration certifications are in compliance. In addition, this team member did not administer medications from 1/11/2021 until she completed the medication administration course. See attachment # 26 -medication administration certification completed 1/28/2021.
Program managers and nurses have had training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. Effective 3/22/2021, the Community Living Administrator will begin to conduct monthly audits of medication administration certifications. |
04/01/2021
| Implemented |
| Article X.1007 | Penn-Mar Human Services (the agency) is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff person #1 was hired by the agency on 11/18/2019. An application for a Pennsylvania criminal history record check was never submitted to the Pennsylvania State Police. At the time of the 1/4/2021 inspection, the agency only had records of a third-party background check, that did not meet the regulatory requirements of submitting an application to the Pennsylvania State Police, was completed. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | This citation was received because Penn-Mar had records of a third-party background check instead of a physical copy of the Pennsylvania criminal history check that was submitted to the Pennsylvania State Police on file.
Penn-Mar understands the importance of completing criminal record checks on staff. The vendor that we used HireRight, did submit background checks to PA State Police and would indicate on the report that they sent us the outcome of the PATCH report, however they did not send us a copy of the actual PATCH document. Since this was brought to our attention during our licensing, Penn-Mars Director of HR has been working closely with our vendor to change the terms of our agreement so that we will not only receive their comprehensive report but also a copy of the PA PATCH report. He has talked to numerous people at this company in an attempt to get copies from previously submitted staff but has not been successful. We have been successful at changing our agreement moving forward and have started to receive the PA PATCH document for all staff who have been extended offers of employment. Please see attachment #10 which is the actual PA PATCH document for a new staff recently hired.
Moving forward we will receive the PA PATCH report from HireRight for all new staff. We are also in the process of submitting for a PA background check (PATCH) through the PSP system for any staff previously hired that we only have the comprehensive report for, given our previous arrangement with HireRight. We anticipate this to be completed by May 15th at the very latest. |
05/15/2021
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The wooden wardrobe in Individual #1's bedroom was missing a knob on one of the doors. | Floors, walls, ceilings and other surfaces shall be in good repair. | Knob was replaced on the dresser. The broken knob was taken home by staff to be fixed so that the individual could keep the knob that matched the dresser. See attachment # 19
Program Specialists were trained on the need to be more mindful of furniture knobs (attachment #2). Program Specialists now look for this during their monthly site visits.
Residential Supervisors will review this regulation at the upcoming Residential Supervisor meeting on 12/13/17 (attachment #3). |
12/13/2017
| Implemented |
| 6400.74 | The stairs leading to the basement do not have a non skid surface. | Interior stairs and outside steps shall have a nonskid surface.
| Nonskid treads have been placed on the interior stairs leading to the basement. See attachment # 20
All Residential Program Managers have been re-trained on this regulation and will continue to monitor and ensure all interior and exterior steps have nonskid surfaces (attachment #2).
Residential Supervisors will review this regulation at the upcoming Residential Supervisor meeting on 12/13/17 (attachment #3). |
12/13/2017
| Implemented |
| 6400.81(j) | Individual #2's bedroom does not have a door for privacy. There is a curtain hanging up in the doorway instead of a door. | A bedroom shall have doors at all entrances for privacy. | Accommodations were being made for this individuals health and safety needs. Staff placed a curtain at the entry way of the new bedroom (former 2nd living room) for the individual to allow for privacy. Penn-Mar was discussing the possibility of a move for the individual to a one-floor living home. At the time, the need for a bedroom door was overlooked. There is now a door on the bedroom (attachment # 18). He will be moving to another Penn-Mar home when there is a vacancy in mid-January 2018.
All Program Managers have reviewed and understand this regulation (attachment #2). All Residential Supervisors will review this regulation at the upcoming Residential Supervisor meeting on 12/13/17 (attachment #3). |
12/13/2017
| Implemented |
| 6400.104 | A notification letter to the local fire department dated 10/24/17 states that all individuals are capable of evacuating during a fire drill within 3 minutes as assessed. According to the fire drill logs, Individual #3 requires verbal prompts on occassion to evacuate during drills and Individual #2 requires the assistance of a walker and physical assistance from staff to evacuate. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| All Program Managers have been trained on this regulation and understand that the letter to the fire company must state the specific evacuation needs for each individual residing in the home. (Attachment #2) The Program Managers have completed an audit of the fire letters for each home and have sent updated letters to the fire companies with specific evacuation needs for each individual (verbal prompts, ambulatory but uses a walker, non-ambulatory, etc.).
The Supervisors will be trained on this regulation at the Residential Supervisor meeting scheduled for 12/13/17 ( attachment # 3).
See Attachment # 17, which shows the updated fire department letter for the Heather Drive home. |
12/13/2017
| Implemented |
| 6400.110(b) | There was no smoke detector present within 15 feet of Individual #2's bedroom. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | A smoke detector was placed within 15 feet of Individual # 2¿s bedroom on 11/9/17 (Attachment #16). Program Specialists have reviewed this regulation and understand the need to immediately notify the maintenance department to install a smoke detector if an individual moves to another room in the house that was not previously utilized as a bedroom and thus not having a smoke detector within 15 feet of the room (attachment #2). Residential Supervisors will be re-trained on this regulation at the Residential Supervisor meeting on 12/13/17 (attachment # 3). |
12/13/2017
| Implemented |
| 6400.112(a) | Repeat 10/5/16: No fire drills were conducted in the months of January, February and October of 2017. | An unannounced fire drill shall be held at least once a month. | 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. 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 (attachment # 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 |
| 6400.112(c) | The fire drill conducted on 12/20/16 did not indicate that smoke detectors were operable. This section of the fire drill form was left blank. The fire drill form for the 3/23/17 drill was unclear of the exit route that was used. The exit route was marked at the top of the paper as the front door however in the comment section of the form it stated that when the alarm went off "all quickly evacuated out thru garage door as it was the closest door to them". | 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 or smoke detector was operative. | 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. 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 (attachment #2). Residential Supervisors will be re-trained on this regulation at the Residential Supervisor meeting on 12/13/17 (attachment # 3).
See attachment # 32, which shows a fire drill meeting all requirements of the regulation. |
12/13/2017
| Implemented |
| 6400.216(a) | The upstairs hall closet contained several boxes of individual purged daily logs. This closet is not locked and is utliized by Individual #4. | An individual's records shall be kept locked when unattended. | Program Specialists have reviewed this regulation and understand the need for records to be locked ( attachment # 2). As a result of this citation, the Program Specialists ensured that all records are locked up in all homes. The Supervisors will be trained on this regulation at the Residential Supervisor meeting scheduled for 12/13/17 ( attachement # 3). The records that were located in an individual¿s closet have been moved to the office, which is locked. |
12/13/2017
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.164(a) | On July 8, 2016 and January 24, 2017, Individual #1's physician's office ordered the administration of an enema for constipation. Staff #1, the agency nurse, administered the enemas. The prescribed enema was not documented on the July 2016 or the January 2017 medication administration log. | 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. | Prior to this licensing, Penn-Mar did not view an enema as a medication and that is why the licensed nurse did not document it on the medication log. The licensed nurse did write a nursing note regarding the procedure. Penn-Mar has changed its medication policy to ensure there is no confusion about how enema's are to be documented. Both licensed nurses at Penn-Mar have been trained on this matter.
The revised medication administration policy has been sent to all PA employees within Penn-Mar so that they are aware of this requirement.
See Attachment A |
04/13/2017
| Implemented |
| 6400.164(b) | On July 8, 2016 and January 24, 2017, Staff #1 administered an enema to Individual #1. The administration of the enema was not documented on the July 2016 or the January 2017 medication administration log. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | Prior to this licensing, Penn-Mar did not view an enema as a medication and that is why the licensed nurse did not document it on the medication log. The licensed nurse did write a nursing note regarding the procedure. Penn-Mar has changed its medication policy to ensure there is no confusion about how enema's are to be documented. Both licensed nurses at Penn-Mar have been trained on this matter.
The revised medication administration policy has been sent to all PA employees within Penn-Mar so that they are aware of this requirement.
See Attachment A |
04/13/2017
| Implemented |
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