Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00202387 Renewal 03/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(g)The fire drill completed on 8/4/21 did not have the time of the drill documented. Fire drills shall be held on different days of the week and at different times of the day and night. This regulation is important because completing fire drills will prepare individuals and staff to evacuate quickly, safely, and efficiently in the event of a real fire. Timing a fire drill can help determine if the individuals and staff are prepared to exit as soon as possible in the event of a fire. Extended period of time to evacuate would prompt the program specialist to assess, evaluate, and provide resources where possible to increase the speed in which individuals and staff exit the home. The fire drill completed on 8/4/2021 did not have the time documented on the drill. The Residential Supervisor, Quality Supports Specialist, and Program Manager who review fire drills for compliance did not ensure the time was documented on the drill. The team member who completed the drill did not enter the evacuation time. This location did not complete the April fire drill yet. Therefore, the Hain Road fire drill is being used as an example of compliance. See attachment #14.This program received immediate feedback on March 31, 2022 regarding regulation 112(g). Additionally, all Residential Supervisors and Program Managers were retrained on April 13, 2022. All Residential Team Members will be trained by April 29, 2022. 04/29/2022 Implemented
SIN-00181118 Renewal 01/04/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The home's furnace was cleaned and inspected on 10/2/19 and not again since then. At the time of the 1/4/2021 inspection, there was no records maintained for the reason that this home did not receive a cleaning and inspection since 10/2/19.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. This citation was received because the furnace inspection and cleaning were not completed within a year of the previous inspection. Due to the COVID-19 pandemic and homes being in quarantine when staff or individuals were not feeling well, were exposed to the virus or had the virus, the furnace inspection was delayed. The furnace inspection was completed at the Walter Road home on 03/03/2021. See attachment #13-Walter Rd Furnace Cleaning 03.03.2021. Program managers and nurses have had training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. The Community Living Program Manager will ensure furnace inspections and cleanings for all of Penn-Mar group homes are completed within a year of the current inspection. 04/01/2021 Implemented
6400.50(a)At the time of the 1/4/2021 annual inspection, Staff person #1's training record didn't include the specific training content of every training, the trainer, the training source and on occasion, the length of time each training took to complete.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 has been working independently with Individuals #1-#4 in all of 2020. There are no records maintained that Staff person #1 received orientation specific to Individuals #1-#4, their specific plans, protocols and health and safety needs prior to working with them or received training on updated or new plans and protocols before working with the individuals. Individuals #1-#4'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. Examples of when staff has been working with individual's prior to being oriented to the individuals' plans are as follows: · Individual #2 had a choking plan created on 11/30/2020 and Staff person #1 wasn't oriented on this plan until 12/29/20 after working with the individual. · Individual #3 had choking and diet plans created on 11/30/20 and wasn't oriented on these plans until 12/29/20 after working with the individual. · Individual #4 had choking, c-pap usage, and fall/safety plans created on 11/30/2020 and Staff person #1 wasn't oriented on these plans until 12/29/20 after working with the individual.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
SIN-00120657 Renewal 11/07/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103Repeat 10/5/16: The written emergency evacuation plan does not include individual responsibilities. There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. As a result of this citation an audit of all homes written evacuation procedure plan was completed and any evacuation procedure plan that did not include the individual¿s responsibilities was updated to include this information. Attached you will find the new written evacuation procedure plan for the Walter Road home. See Attachment #13 Program Managers have reviewed and understand the requirements of this document. (Attachment # 2).In addition, all Supervisors will be trained on this regulation on 12/13/17. See attachment #3 12/13/2017 Implemented
6400.106Repeat 10/5/16: The furance cleaning was completed on 10/14/16 and not again. It was due on 10/14/17.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 Walter Road home has been cleaned on 11/7/17. See attachment # 12. As a result of this task 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. Program Managers were trained on this requirement. See attachment #2. Supervisors will be trained on this requirement on 12/13/17. see attachment #3. 12/13/2017 Implemented
6400.141(a)Individual #1s physical was completed on 10/17/16 and not again. A physical was due on 10/17/17.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #1 had an annual physical due 10/17/17. Staff called the PCP office to schedule the physical appointment on 8/1/17 (attachment # 7 ). However, the first available appointment was 11/15/17, which is when she obtained the physical ( attachment # 8 ). The Supervisor of this program has been trained on the importance of scheduling appointments within the appropriate time frame according to state regulations. See attachment # 6, which shows the calendar reminder for the Supervisor to schedule the physical 4 months prior to the due date next year. Program Managers have reviewed and understand the need for appointments to be followed-up within the timeframe outlined by physicians. See attachment # 2 In addition, all Supervisors will be trained to schedule appointments as early as six months in advance when appropriate (ie. 6-month follow-up, annual follow-up, 2 year follow-up, etc.) See attachment # 3 Attachment # 9 shows a physical completed within one year of the previous physical. 12/13/2017 Implemented
6400.141(c)(6)According to Individual #1's physical dated 10/17/16 he/she had a tuberculin (TB) skin test read on 9/3/15 and not again. A TB test was due 9/3/17.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Individual # 1 did not have a TB test completed within two years as required by state regulations. She did have her TB test completed at her annual physical on 10/15/17. (attachment #8) The Supervisor of this program has been trained on the importance of scheduling appointments within the appropriate time frame according to state regulations. See attachment # 6, which shows the calendar reminder for the Supervisor to schedule her physical 4 months prior to the due date next year. Program Managers have reviewed and understand the need for appointments to be followed-up within the timeframe outlined by physicians. See attachment # 2 In addition, all Supervisors will be trained to schedule appointments as early as six months in advance when appropriate (ie. 6-month follow-up, annual follow-up, 2 year follow-up, etc.) See attachment # 3 Attachment # 9 shows a TB completed within two years of the previous TB test. 12/13/2017 Implemented
6400.141(c)(7)Individual #1 had a gynecological examination on 10/13/14 and not again. According to Individual #1's primary care physician this service is to be completed every three years. One was due 10/13/17.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Individual # 1 was due to have a gynecological exam on 10/13/17. Although it was late, she did have this exam completed annually during her physical exam with her PCP. See attachment # 8 Staff called the PCP office to schedule the physical appointment/GYN exam on 8/1/17 (attachment # 7). However, the first available appointment was 11/15/17, which is when she obtained her physical/GYN exam The Supervisor of this program has been trained on the importance of scheduling appointments within the appropriate time frame according to state regulations. See attachment # 6, which shows the calendar reminder for the Supervisor to schedule Individual#1's physical 4 months prior to the due date next year. Program Managers have reviewed and understand the need for appointments to be followed-up within the timeframe outlined by physicians. See attachment # 2 In addition, all Supervisors will be trained to schedule appointments as early as six months in advance when appropriate (i.e. 6-month follow-up, annual follow-up, 2-year follow-up, etc.) See attachment # 3 Attachment # 11 shows a GYN exam completed within the time frame recommended by the physician. 12/13/2017 Implemented
6400.164(b)Repeat 3/6/17: Individual #1's medication administration record (MAR) showed that staff did not sign off after administering his/her dose of Ofloxacin on 7/22/17. Individual #1's MAR shows that on 9/4/17 staff did not inital for administering his/her Calcium D medication. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. Medications were administered. However, due to the blank space on the electronic MAR where staff initials should appear to indicate that medication was administered, it is assumed that the electronic system was not operating properly. To eliminate any future incidents of this nature, the Supervisor will print and review the electronic MAR to ensure there are no blanks on the MAR. If for some reason there is a blank space, the Supervisor will ensure staff have initialed the paper medication log, as they currently do if they are unable to access the electronic MAR. Program Managers and Nurses have reviewed and understand the regulation. See attachment # 2 This will be discussed further at the Residential Supervisor meeting on 12/13. See attachment # 3 12/13/2017 Implemented
6400.183(1)Individual #1's individual support plan (ISP) updated 8/30/17 stated he/she is working on an outcome of increasing his/her domestic skills. However Individual #1's ISP reviews dated 11/1/17, 7/28/17, 4/27/17 and 1/24/17 document that he/she is working on an outcome to increase his/her physical activity. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Services provided to the individual and expected outcomes chosen by the individual and individual's plan team. The Program Specialist has emailed the Support Coordinator regarding the need for the ISP to be updated with the current outcome. See attachment # 1 All Program Specialists were re-trained on the need to ensure they notify the Support Coordinator any time there is a change to an outcome, requesting this information to be updated in the ISP. This email will include information regarding the new outcome, a start date for the new outcome, and an end date for the current outcome. In addition, the Program Manager will work with the house Supervisors to complete an audit of the ISP for each individual to ensure the outcome in the ISP matches the outcome they are currently working toward. This Audit will be completed by 12/15/17. See attachment # 2 & 3 12/13/2017 Implemented
6400.213(11)Individual #1's individual support plan (ISP) updated 8/30/17 states that Individual #1 returns every two years for a dexa scan however there is a letter from the doctor dated 5/8/17 stating that Individual #1 is to have a dexa scan completed every three years. Individual #1's ISP states under the health promotion section for oral hygiene that Individual #1 is to see the dentist every year. A letter written from Individual #1's dentist indicates that he/she is to see the dentist every two years. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. The DEXA scan was completed on 11/16/17. See Attachment # 5 The Program Specialist emailed the Support Coordinator requesting an update to the ISP reflecting the doctor's recommendations (attachment # 4) for Individual # 1 to have a Bone Density scan every two years. See attachment # 1. The dental recommendations stated on the dental exam states the dental exam should be completed every two years. The Program Specialist emailed the Support Coordinator asking for this to be updated in the ISP. See attachment #1 The Supervisor of this home has been counseled on the importance of following recommendations from the physician and schedule appointments well in advance of the due date. See attachment # 6 All Program Managers have reviewed and understand the need for follow-up appointments to occur per physician¿s recommendations. See Attachment # 2 All Supervisors will be trained at the next Supervisory meeting on December 13, 2017 on the need to adhere to doctors¿ recommendations and submit changes to the Support Coordinators to ensure the changes in physician¿s recommendations are updated in the ISP. See Attachment # 3 12/13/2017 Implemented
SIN-00083008 Renewal 08/12/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The wallpaper by the steps going downstairs was peeling. Floors, walls, ceilings and other surfaces shall be in good repair. Violation ¿ 6400.67a Violation Description: The wallpaper by the steps going downstairs was peeling. Plan of Correction: All wallpaper in the home has been removed by Penn-Mar¿s Maintenance staff. The walls are being painted. Attachment K All Penn-Mar Program staff responsible for this requirement, were re-trained on the regulation and execution of this regulation. Attachment B Correction date: 09/8/2015 Implemented
SIN-00220302 Renewal 03/14/2023 Compliant - Finalized
SIN-00177806 Renewal 05/07/2021 Compliant - Finalized
SIN-00070771 Initial review 10/30/2014 Compliant - Finalized