Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00202392 Renewal 03/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The self-assessment completed on 6/23/21 identified regulation violations. There was no written summary of corrections completed.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. When completing the self-assessment for the program, the program manager failed to complete the plan of correction for the regulations that were not in compliance. It is important to ensure that any violation of a regulation is corrected immediately to protect the health and safety of the people supported. Program Managers are responsible with ensuring regulations are followed in the programs they are managing. Program Managers complete self-assessments annually. On 4/13/2022, all Program Managers have been retrained and understand the importance of correcting violations to regulations in a timely manner. 04/13/2022 Implemented
6400.165(c)(Repeat from Inspection dated 1/4/21) Individual #1 is prescribed Polyethylene Glycol 3350 Powder to be administered every other day for constipation. This medication was administered to Individual #1 consecutively on 3/22/22, 3/23/22, 3/25/22 and 3/26/22 instead of on the alternate days as prescribed.A prescription medication shall be administered as prescribed.This regulation is important because administering medication as prescribed ensures individuals are receiving the proper medical care. Additionally, it prevents medication errors that could result in injury. At the time of inspection, it was noticed that Individual #1 received his Polythylene Gel 3350 Powder consecutively on 3/22/2022, 3/23/2022, 3/25/2022, and 3/26/2022. This citation was received because a team member failed to ensure that the medication was entered correctly into the electronic medication administration record when the prescription changed from a once daily administration to an every other day administration. It is important for staff to correctly enter medication changes onto the medication administration record to prevent medication errors from occurring. All team members that administer medications will be provided with a reference guide with direction of all steps needing to be completed when a medication order is started, changed, or discontinued. See attachment #8. The Program Specialist filed the medication error and the Residential Supervisor received feedback during the inspection on 3/29/2022. 04/29/2022 Implemented
SIN-00161723 Renewal 09/24/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was a pungent odor from the garbage can in the garage. According to staff, an individual hid chicken until it spoiled. Individual lives in the apartment downstairs that has its own refrigerator and kitchen. Although the individual is capable of cleaning, staff should double check individual's area for clean and sanitary conditions.Clean and sanitary conditions shall be maintained in the home. This regulation is important because it's necessary for a home to be clean and sanitary for the health and safety of the folks residing in the home. The individual was trained on food safety and proper food storage. He was also coached to talk with his team when he would like to change his meal plan. Staff are now checking the cleanliness of the home with the individual each day. The individual was receptive to the training/coaching and seems to understand the importance of proper food storage and the need for his home to be clean and sanitary. Program Managers have had training regarding this regulation during the exit conference with state licensing staff on 9/25/19. Managers will continue to monitor and ensure cleanliness of the home when they complete monthly site monitoring at each group home. Site monitoring completed by Program Managers are monitored monthly for completion by the Community Living Administrator, Director of PA Program, and the PA Chief Operations Officer. A review of this regulation was completed with the Residential Supervisors at their team meeting on 10/9/19. All residential team members have reviewed this regulation. See email sent to all residential team members 10/11/19. 10/15/2019 Implemented
6400.67(a)Wheel chair accessible bathroom shower has black residue on the 3 shower walls and the trim is a yellowish color. Staff states that it is cleaned with Clorox so it is not a cleanliness issue but a repair issue where the caulking and trim will need replaced.Floors, walls, ceilings and other surfaces shall be in good repair. Maintenance has repaired the caulk and molding around the perimeter of the shower. It has been reported that the discoloration is from frequent use of the shower and is not mold. See attachment of the shower with the replaced caulking and painted trim. It is important to ensure the caulking is in good repair to prevent health hazards. All residential team members have been trained that as situations like this occur with the normal wear and tear of a home, they are to continue to submit a maintenance request for the repair. Maintenance should be able to respond in a timely manner. If they do not, residential staff are to make their Program Manager aware. See attachment of the email sent to all residential team members on 10/11/19. Program Managers have had training regarding this regulation during the exit conference with state licensing staff on 9/25/19. They will continue to monitor for all surfaces of the home when they complete monthly site monitoring at each group home. Site monitoring completed by Program Managers are monitored monthly for completion by the Community Living Administrator, Director of PA Program, and the PA Chief Operations Officer. A review of this regulation was also completed with the Residential Supervisors at their team meeting on 10/9/19. 10/15/2019 Implemented
SIN-00102842 Renewal 10/05/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(a)Staff #1, #2, and #3 were not oriented to their job responsibilities or daily operation procedures.The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. I believer there may be a misunderstanding regarding Staff #1 and Staff #3. Attached you will find the signed job descriptions for Staff #1 and Staff #3 from orientation as well as their Individual specific training packet. It does appear that Staff #2 did not sign off on a job description at orientation. This occurred in January 2016. This employee was hired as Substitute staff, and the HR department did not provide a job description to this staff. This has since been corrected, as evident by the fact that Staff #3 was also hired as a Substitute staff on June 20, 2016 and she did sign a job description. You will find all the documents for Staff #1 and #3 attached. See Attachment AI In addition, since this licensing we have had a new staff start on November 7, 2016 and sign a job description at Orientation. This staff also completed Individual specific training between November 7, 2016 and November 25, 2016 See Attachment AJ 11/25/2016 Implemented
6400.67(a)Individual #1's bedroom had numerous small holes in the walls from hanging items.Floors, walls, ceilings and other surfaces shall be in good repair. Penn-Mar¿s maintenance department patched the wall that had the small holes from previous items that had been hanging in this room. See attachment B All Residential Supervisors and Program Specialist level staff were re-trained on the fact that even small holes should be patched in a timely manner. Supervisors and Specialists were trained to report to the Director of services if the maintenance department does not respond quickly to requests. See attachment A 10/12/2016 Implemented
6400.112(a)A fire drill was not conducted in May of 2016. An unannounced fire drill shall be held at least once a month. Penn-Mar¿s previous expectation was that Residential staff turn in fire drills on the first of the month for drills completed the prior month. This policy did not allow for enough oversight to ensure that drills were done each month. Therefore, all Residential Supervisors are now required to turn in fire drills by the 20th of each month. This will allow for a 10 day review so that Program Specialist can ensure that drills are done each month. In additional, a monthly paperwork checklist was created that documents when fire drills are turned in and reviewed. Program Managers review this checklist monthly (near the end of the month) to ensure that the home they are monitoring has turned in drills for each month. This is documented on the monthly site monitoring. See attachment E Attached you will find that since May 2016, this home has completed monthly fire drills See attachment F All Residential Supervisors and Program Specialist level staff were trained on this new process so that we will not have a month in which a fire drill is missed again. See attachment A 11/26/2016 Implemented
6400.112(b)There were 5 staff present during the 9/5/16 fire drill. There were 6 staff present during the 8/31/16 fire drill. Fire drills shall be held during normal staffing conditions and not when additional staff persons are present. Attached you will find October and November fire drills for Steltz road that show that one or two staff were present during the drill. This is the normal amount of staff who are scheduled for these days. See attachment F All Residential Supervisors and Program Specialist level staff were re-trained on the fact that fire drills should not be conducted during times when more staff are present in the home than the normal staffing schedule would allow. See attachment A 11/26/2016 Implemented
6400.112(d)The 11/30/15 and 8/31/16 fire drill logs indicated evacuation times of 3 minutes and 41 seconds. The extended evacuation letter allowed a 3 minute and 30 second maximum evacuation 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. After further investigation into these drills that were not within the extended evacuation time frame, it was determined that staff were timing the drill until all individuals got to the meeting point instead of the time it took for all individuals to evacuate the home. Staff were re-trained on how to conduct fire drills. September, October and November drills were completed correctly and were within the evacuation time frame. See attachment F Penn-Mar¿s previous expectation was that Residential staff turn in fire drills on the first of the month for drills completed the prior month. This policy did not allow for enough oversight to ensure that fire drills were completed correctly and that all individuals evacuated within the required timeframe. Therefore, all Residential Supervisors are now required to turn in fire drills by the 20th of each month. This will allow for a 10 day review so that Program Specialist can ensure that drills are done correctly each month. All Residential Supervisors and Program Specialist level staff were re-trained on how to conduct fire drills and specifically how the fire drill should be timed. See attachment A 11/26/2016 Implemented
SIN-00220307 Renewal 03/14/2023 Compliant - Finalized
SIN-00177811 Renewal 05/07/2021 Compliant - Finalized
SIN-00070776 Initial review 10/30/2014 Compliant - Finalized