| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.61(a) | Staff working directly with Individuals #1-#4 in the home have been documenting the difficulties the individuals encounter when attempting to move in and out of their home during fire drill evacuations, from September 2019 to December 2020. There are no records maintained that the agency made accommodations to the home to ensure the individuals' safety and reasonable accessibility for entrance to, movement within, and exit from the home based on each of their needs. According to the fire drill records, examples of staff documentation of Individuals #1-#4 having difficulty with entering and exiting the home are as follows:
· Staff person #1 reported on 9/18/19 that Individuals #2 and #3 required physical assistance from staff to step down 1 step from the house to the outside.
· Staff person #2 reported on 10/10/19 that 3 minutes were spent getting Individual #3 in and out of his wheelchair and up and down the step leading from the house to the outside. Staff person #2 recorded that "it is very difficult to assist all individuals at the same time during fire drill evacuations."
· Staff person #3 reported on 10/18/19 that Individuals #2 and #3 again needed assistance to get into a wheelchair (Individual #3) and getting out of bed and out of the house (Individual #2). Staff person #3 also reported, "due to the placement of the outside door and interior doors it makes it difficult for a smooth evacuation without opening the garage door which might not work in an actual fire."
· Staff person #1 stated on 11/19/19 that Individuals #2 and #3 needed physical assistance to exit the one step leading into the home.
· Staff person #2 stated on 4/10/2020, "a ramp for {Individual #3's} wheelchair would be helpful. {Individuals #1 and #2} needed held by the hand."
During the 1/8/21 onsite inspection of the home, additional steps and other obstacles were found directly outside the home making it difficult for safe ambulation with entrance to and exit from the home. Items witnessed were:
· There are two steps (one to the left of and one straight in front of the front door) leading onto the front porch of the home from ground level, and one additional step leading into the home from the front porch. The individuals are reported to require physical assistance and hand holding to ambulate the steps, yet the steps were not equipped with well-secured handrails.
· Additionally, the cement pavers at the bottom of the step off the front of the front porch, were covered in landscaping mulch preventing one's foot from stepping on an obstacle-free, flat surface.
· Two steps were located off the back porch and they were not equipped with a handrail to assist with safe entrance and exit of the home, as Individual #1 has concerns with depth perception. There was another step located off the side of the back deck that wasn't equipped with a well-secured handrail and also did not have an obstacle-free, flat surface to sept onto. After stepping off the side of the deck, the landing was only landscaping mulch. | A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. | This citation was received for the following reasons: 1. The program manager did not ensure the home was assessed by the fire safety expert in a timely manner to approve an extended evacuation time. 2. Staff did not ensure the cement pavers at the bottom of the step off the front porch were free from debris. 3. The program manager did not ensure the porch and the back deck are equipped with a handrail to assist with safe entrance and exit of the home. 4. There was not an obstacle-free, flat surface to step onto from the side of the back porch.
It is important to ensure individuals are able to navigate safely in and around their home to prevent injury.
The cement pavers at the bottom of the step off the front porch are free from debris. See attachment # 14- photo of pavers free of debris.
Hand railings have been ordered for the front porch and back deck and will be installed on Monday, 4/5/21.
An obstacle-free, flat surface will be placed on the ground at the side of the back porch for people to step onto from the back porch. This project will be completed by Penn-Mar maintenance department on Monday, 4/5/21.
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 of the 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 |
| 6400.67(a) | Individual #1's bathroom did not have a holder for the toilet paper in his bathroom. The toilet paper roll was sitting on the bathroom vanity countertop during the 1/8/21 inspection and the toilet paper holder could not be located. | Floors, walls, ceilings and other surfaces shall be in good repair. | This citation was received because the toilet paper was sitting on the side of the sink and not on a toilet paper holder.
It is important for toilet paper to be placed on the toilet paper holder to ensure ease of access for the individual and to maintain sanitary conditions.
Supervisors are expected to monitor homes to ensure they are in good repair. If there is something that needs to be repaired or replaced, supervisors are expected to submit a request for the repair or replacement to our maintenance department. During monthly site monitoring in the home, program managers are expected to inspect the home to ensure it is in good repair.
All residential supervisors and program managers have been retrained on this regulation and the importance of the home being in good repair and maintaining sanitary conditions 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 |
| 6400.106 | At the time of the 1/4/21 annual inspection, the furnace in the home was last cleaned and inspected on 10/2/19 and not again since then. There is no records maintained for the why the home did not have a furnace cleaning and inspection completed. This is outside the annual time frame requirements of having the furnace cleaned and inspected annually. | 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.
It is important to ensure furnaces are inspected and cleaned annually to prevent fires.
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 Ashwood Drive home on 03/03/2021. See attachment # 15 Ashwood Furnace cleaning.
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-Mars group homes are completed within a year of the current inspection. |
04/01/2021
| Implemented |
| 6400.112(d) | The individuals did not evacuate the home within 2 and a half minutes during any fire drill held in October 2019; drills held on 10/10/19 and 10/18/19. The home did not receive written documentation from a fire safety expert of an extension on the evacuation time of fire drills until 8/11/2020. | 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 because the program manager failed to see that her request for a fire expert to assess the home for an extended evacuation time was met. The staff responsible for making the appointment did not follow through with obtaining an appointment in a timely manner.
It is important for the organization to ensure that safety concerns are addressed in a timely manner to prevent injury.
Supervisors are to report concerns with fire drills when it takes longer than 2.5 minutes for everyone to evacuate the home. Program Managers are then expected to work closely with the Quality Supports Specialist to ensure a fire safety expert assesses the home and provides an approve extended evacuation time.
Program managers have had training regarding this regulation during the exit conference with the state licensing team on January 11, 2021.
All residential team members received training via email regarding this regulation and the importance of reporting safety concerns and the need to ensure a fire safety expert assess the home in a timely manner if an extended evacuation time is needed. 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. |
04/01/2021
| Implemented |
| 6400.141(c)(1) | Individual #1's current, 12/11/2020 physical examination record did not include a review of his previous year's medical history. The examination record stated that his medical history information is attached to the physical form. However, the medical history information attached was last updated on 2/7/2019 and mostly included information from 2018. According to recent hospitalization records and his 2020 records, he is mostly incontinent of bowel and bladder now and this isn't addressed on his physical examination. Individual #1 has had two physical examinations, on 12/11/20 and 12/10/2019, since the last time his medical history was reviewed and completed with his physician. It has been over two years since a review of his medical history was completed and reviewed with his physician. | The physical examination shall include: A review of previous medical history. | This citation was received because the medical history dated 2/7/2020 should have been attached to the physical exam. Instead, staff attached the medical history dated 2/7/2019. Therefore, the physician was not able to review the individuals most recent medical information. Also, staff should have informed the physician of the individual being incontinent. In turn, the physician would have noted this on the physical exam document.
It is important to ensure the physician is reviewing the most recent medical history during the annual physical exam to ensure the doctor is aware of current medical needs. It is also important for the physician to know the physical limitations an individual has such as incontinent concerns to ensure medical needs are met. Each individuals medical history is updated annually by the agency nurses.
Program managers and nurses have had training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They understand the importance of thoroughly reviewing all medical documents, including physical exam forms to ensure that all required information is documented, and that the most recent medical history is attached to the physical and has been reviewed by the physician.
All residential team members received training via email regarding this regulation. 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.
The physical exam record has been revised to specifically indicate whether the individual is continent/incontinent. See attachment # 16 - revised annual physical form. |
04/14/2021
| Implemented |
| 6400.141(c)(4) | Individual #1's 12/10/19 physical examination record did not include the results of a hearing screening. His current, 12/11/2020 physical examination record did not include a hearing screening. The physician recorded on 12/11/2020 that his hearing could not be assessed at the physical examination appointment "due to {the individual's} cooperation and mental disability." Exempting a person from a physical examination requirement based on their intellectual ability does not meet regulatory requirements. There are no records maintained that Individual #1 received a hearing examination annually, any time between 9/27/19 to current, 1/4/2021. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The individual declined the hearing test during his physical that occurred on 12/11/2020. Staff attempted to make a follow up appointment for the hearing screening on 12/13/2020. The doctor was on rotation at the hospital at that time and staff were instructed to call early in January to reschedule. Staff called to make the appointment on 1/5/2021. The appointment was scheduled and occurred on 1/13/2021. See attachment # 17- hearing screening.
It is important to ensure individuals are receiving necessary medical screening to address and prevent further health issues.
Program managers have had training regarding this regulation during the exit conference with state licensing team on January 11, 2021. They will continue to monitor health screening needs to ensure they are completed in the required time frames 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 and the Director of PA Program. All residential supervisors and program managers have been retrained on this regulation 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 |
| 6400.141(c)(9) | Individual #1's 12/10/19 physical examination record did not include a prostate examination or the results of the examination. His 12/11/20 physical examination record indicated that as of 12/11/2020 a prostate examination was not needed. The licensing review period for the annual inspection was 9/27/19-1/4/2021 and included a review of both physical examinations. There is no evidence that Individual #1, who is over the age of 40, had a prostate examination completed annually. | The physical examination shall include: A prostate examination for men 40 years of age or older. | It is important to meet each individuals needs by following recommendations made by physicians and following state regulations concerning the health of the people we support.
Program managers and agency nurses have been retrained on the need to thoroughly review medical documents and ensure there is follow up for each recommendation noted. The nurses and program managers were retrained on the need to coach or provide feedback to the program supervisor if there is missing documentation on submitted appointment records.
Reviewing documents following a medical appointment has always been an expectation of the agency nurses and program managers. They have been reminded on several occasions since this licensing for the need for them to thoroughly review medical documents and to do so as the appointments occur. Effective immediately, the Administrator and Community Living Manager will conduct weekly audits of appointments to ensure follow up appointments and recommendations occur as recommended.
Since the licensing in January 2021, there have been physical examinations completed in other CLAs that included proper documentation for a prostate examination for men 40 years of age or older. See Attachment # 5 02.25.2021 annual Physical - prostate exam. |
04/01/2021
| Implemented |
| 6400.141(c)(14) | Individual #1's current, 12/11/2020 physical examination record stated that there was no information to include in the section titled, "medical information pertinent to diagnosis and treatment in case of an emergency." On 2/3/2020 with the implementation of the updated regulations and Regulatory Compliance Guide distributed to providers for immediate implementation, The Department defined this to mean any emergency medical intervention that may be required in response to an acute or chronic medical condition. According to the individual's record, on 3/4/2020 he received an implanted pace-maker device in his chest to assist with his diagnosis of Bradycardia and should avoid large magnets due to his pace-maker. His need to avoid large magnets is not identified as medical information pertinent to know in the even he requires emergency medical treatment. Additionally, he has been prescribed Diazepam rectal gel to administer for time-sensitive seizures and this information is not notified as medical intervention that might be needed for treatment and when. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | This citation was received because staff that took the individual to his physical appointment did not ensure the physician noted all required information on the physical exam record. Also, the nurse and program manager that reviewed the annual physical documents did not notice that pertinent information regarding the pacemaker and administration of Diazepam was not noted on the document.
It is important for the doctor to discuss medical needs with staff caring for individuals to ensure staff understand the individuals needs. Its also important to have this information documented to share with emergency personnel when needed.
Program managers and nurses have had training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They understand the importance of thoroughly reviewing all medical documents, including physical exam forms to ensure that all required information is documented on the form.
All residential team members received training via email regarding this regulation. 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.
The physical exam record has been revised to specifically indicate whether the individual is continent/incontinent. See attachment # 16 - revised annual physical form. |
04/14/2021
| Implemented |
| 6400.141(c)(15) | According to Individual #1's current, 11/17/2020 Individual Support Plan (ISP) developed by the individual, agency (Penn-Mar Human Services), and other support persons, Individual #1 has difficulty eating hard foods and meats that are not tender and his food should be cut into bite-sized pieces as aspiration is a health concern. His ISP also states that he uses an adaptive plate for meals so that he can continue to feed himself. This information was not included on his 12/11/2020 physical examination record. His ISP also says his food needs to be cut depending on texture. This information isn't addressed with his physician at his physical examination appointment or defined what textures need cut up. Dietary information included on his 12/10/2020 physical examination record only stated to follow a low fat, low sodium (2000mg daily), and no concentrated sweets diet. | The physical examination shall include:Special instructions for the individual's diet. | This citation was received because the physical exam document for the individual lacked important information regarding the individuals diet/food consistency.
It is important to ensure accurate information is documented on the physical exam document to ensure staff understand the individuals needs and are following all dietary recommendations in order to prevent further health concerns.
Program managers and nurses have had training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They understand the importance of thoroughly reviewing all medical documents, including physical exam forms to ensure that all required information is documented on the form.
All residential team members received training via email regarding this regulation. 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.
The physical exam record has been revised to specifically indicate what consistency of food the individual is required to have. See attachment # 16 - revised annual physical form. |
04/14/2021
| Implemented |
| 6400.144 | Health services such as medical, nursing, pharmaceutical, dental, dietary, psychological, specialist and other medical services that are planned for or prescribed for the individual shall be arranged for or provided. There were many times from September 2019 to January 2021 where such services were not planned for or provided to the Individual by the agency, Penn-Mar Human Services. Examples of this are as follows:
· Individual #1's dentist recommends 6-month dental examinations and cleanings, the individual use an electric toothbrush, floss once a day and brush his teeth twice a day. There is no evidence of the individual brushing and flossing as recommended or if he, with staff assistance, is using an electric toothbrush.
· Staff person #1 recorded on 10/20/20 that eye-glasses were ordered for Individual #1 to "correct issues with vision." She reports that after he receives his glasses, the individual is to try them for 2 weeks and if he is still having difficulty a cataract specialist will be referred. There are no records maintained for when the individual received his glasses, if he wore them for 2 weeks as ordered, or if he was having difficulty with his vision that required a cataract specialist.
· On 9/16/2020 the individual's primary care physician (pcp) stated that the pain the individual was experiencing in his knee and neck could be musculoskeletal and the pcp recommended the individual continue taking Acetaminophen, to apply heating pads to affected areas, and continue to encourage fluid intake. At the time of the 1/4/2021 inspection, the agency documented as administering Acetaminophen to Individual #1 almost twice daily for the previous few months. There are no records maintained that the agency also applied a heating pad to his areas of pain or offered a heating pad to the individual. There are also no records maintained that the agency encouraged fluids or the individual's refusal to drink fluids after the physician's recommendation.
· Individual #1 was seen by his podiatrist on 8/18/2020 due to a red and swollen toenail on his right foot. The individual is diagnosed with a history of Diabetes and diagnosed with Type 2 Diabetes Mellitus with complication, without long-term current use of insulin, which requires monitoring of the feet to prevent injury, infection, and in extreme cases, loss of feet/limbs due to Diabetes. On 8/18/2020 his podiatrist started him on an antibiotic due to an abscess on his right foot and prescribed Neosporin ointment every other day. There is no evidence the Neosporin was applied.
· The individual's physician ordered the addition of Diazepam gel to be administered rectally at the onset of seizures. The home did not obtain this medication until 7/18/20 without record of why the medication was not available to the individual until 3 days after it was prescribed.
· On 7/15/2020 Individual #1's physician ordered 5mg of Diazepam rectal gel to be administered to the individual into the rectum as needed for onset of a seizure and also reported a back-up plan to administer Diazepam rectally for prolonged seizures for a period of time greater than 3 minutes and then call 911. The individual's current, 7/27/2020 seizure protocol states if a seizure last longer than 5 minutes to call 911. This does not match the physician's notes from 7/15/2020.
· Individual #1 saw his pcp on 6/24/2020 for Encephalophathy, depth perception issues and confusion and was to return in two weeks, on 7/8/2020. The doctor stated a Magnetic Resonance Imaging (MRI) and to monitor the individual for any worsening symptoms. The individual did not return to his pcp until 7/15/2020 without explanation for the late appointment. There are no records maintained that the agency attempted to coordinate the MRI for individual #1 or contact the individual's guardian after the physician's request to have an MRI completed for Individual #1. The agency reported during the 1/4/2021 inspection, that Individual #1's guardian notified the agency on 8/19/20 that he did not want Individual #1 to receive the MRI, as the guardian was the person in contact with the individual's physician's not the agency.
· The individual's Ear, Nose and Throat (ENT) specialist stated on 6/22/2020 that the individual was seen to have ear wax removed bilaterally and the ENT will mail a card in 6 months for his return appointment. At the time of the 1/4/21 inspection, there were no records maintained of when the individual's return ENT appointment was scheduled for.
· On 12/30/19 Individual #1's Nephrologist documented that the individual is in chronic kidney disease state 3 and is to keep good hydration. There is no evidence that the agency was offering individual liquids daily, monitoring his hydration, if the individual was refusing drinks, or if the individual had good hydration, etc. His Nephrologist also stated that the individual needed a renal function panel and urinalysis completed before 12/30/2020 to monitor the individual's kidney disease status. At the time of the 1/4/2021 inspection there are no records maintained that either were completed.
· Attached to Individual #1's 12/30/19 Nephrology appointment record summary, was a definition of the different states of chronic kidney disease and steps to take when one is in each stage of the disease. According to this chart, the individual's current diagnosed stage, stage 3, is defined as moderate kidney function and one is to manage their risk factors of progression in hypertension, diabetes mellitus, proteinuria, smoking, hyperlipidemia, avoid nephrotoxins, and to discuss: bone health, anemia, dietary history, dietary modification, and consider referral to dietician. The individual's weight was documented as 100 pounds at his 12/30/12 Nephrology appointment. A year later at his physical examination appointment on 12/11/2020, the individual's weight was recorded as 83 pounds. The agency documented throughout 2020 that the individual had lost a lot of his mobility abilities. There is no evidence a dietician was contacted or requested after the individual's Nephrologist provided the agency with the kidney disease checklist on 12/30/19 or after physician's documentation of the individual losing 17 pounds in 2020.
· Individual #1's 12/10/19 physical examination record states the individual is to have his A16, a Glycated Hemoglobin test to measure his blood sugar, levels checked in 6 months. At the time of the 1/4/21 inspection, Individual #1 did not have his A1C levels checked in 6 months. He did not have this completed until 12/9/2020, a year later. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| This citation was received because there is no evidence that staff followed through with recommendations from physicians.
It is important to follow all physicians recommendations to ensure optimal care is provided to the people we support. It is important to document all care provided to ensure the persons needs are being met.
Moving forward, Dental recommendations such as using an electric toothbrush, floss once a day and brush his teeth twice a day will be documented in the e-mar system. This will be scheduled as a task that staff will need to sign off on when the task is completed.
Staff have been trained to complete appointment records when picking up glasses. Also, in situations when we are to monitor the use of adaptive equipment for a specific timeframe, staff will be trained to complete required documentation in the e-mar system. This will be scheduled as a task that staff will need to sign off on when the task is completed.
Recommendations such as the use of a heating pad will be entered in the e-mar system as an option for use. This way, when items such as this are used, there will be clear documentation of the implementation.
Staff have been retrained to inquire with physicians when PRN medications are prescribed about how frequently the medication is safe to be administered and the duration the medication should be administered prior to contacting the physician.
On the appointment record dated 7/15/2020, it is noted that the 7/8/2020 appointment was missed due to the individual being admitted to the hospital. The 7/15/2020 appointment was a combination of a follow up from the 6/24/2020 and the hospitalization follow up appointments. The individual was admitted to the hospital from 7/8/2020 through 7/12/2020. See attachment # 18 PCP appointment record 07.15.2020
The agency recognizes that they should have connected with the legal guardian regarding the MRI immediately following the appointment rather than waiting to hear from the hospital.
All staff have been retrained on the need to schedule follow-up appointments as recommended to ensure the individual is receiving the required medical care.
In the description of this citation, it states, His Nephrologist also stated that the individual needed a renal function panel and urinalysis completed before 12/30/2020 to monitor the individual's kidney disease status. The renal function panel and urinalysis were completed on 12/9/2020. See attached document # 22 renal function panel and urinalysis 12.09.2020
Staff have been retrained to ensure medications such as Diazepam or an antibiotic that are immediately needed are obtained the day the medication is prescribed. Staff were also retrained to ensure that there is clear documentation of the correspondence with the pharmacy and the ordering physician when there is a delay in obtaining a medication.
Program managers and nurses have had training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They understand the importance of thoroughly reviewing all medical documents while ensuring follow up appointments are scheduled as recommended and medical protocols match the physicians order.
All residential team members received training via email regarding this regulation. 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 |
| 6400.181(e)(4) | Individual #1's current, 2/11/2020 assessment states he is allowed to have unsupervised time in a vehicle, unsupervised time in a public bathroom, unsupervised time in his home and the bathroom, and receives hourly checks from staff at home. However, his assessment also states that he shows confusion daily and doesn't know where he is most days and his individual plan also states that he could elope or wonder off in the community. The level of supervision noted in his 2/11/2020 assessment is not an applicable assessment of the supervision needs he requires based on his confusion and agency concerns for his declining health.
Additionally, Individual #1's 11/19/2020 Electroencephalogram (EEG) report stated that the individual has mild seizure tendency seen during his sleep. The individual's supervision levels during his sleeping hours were never re-assessed or re-adjusted by the agency, after this medical report, to monitor his seizures or health concerns during his sleep. | The assessment must include the following information: The individual's need for supervision.
| The program manager failed to update the annual residential assessment when the individuals needs changed.
It is important to document accurate information in the individuals annual assessment to ensure that everyone is aware of the individuals current health and supervision needs. In addition, any time there is a change to the care provided or supervision needs, it is important to update the assessment to reflect these changes.
Program managers will work with the supervisors of each home to review annual assessments and ensure the information accurately reflects the individuals needs. If there are changes that need to be made to the assessment, an addendum will be sent to the individuals team. The review of all assessments by program managers will be completed by April 30, 2021 to ensure the information is accurate. .
Program managers received training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They understand the importance of ensuring documentation in assessments are accurate and that addendum of the assessment must be sent to the individuals team any time there is a change in care provided to the individual or their supervision needs change.
All residential team members received training via email regarding this regulation 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 |
| 6400.181(e)(6) | Individual #1's current, 2/11/2020 assessment is unclear of the individual's ability to be safe use or avoid all poisonous materials. His assessment states due to his progressed Dementia, he has little awareness to poisonous materials. Yet, his assessment also states that he is safe around personal hygiene products. Personal hygiene products do occasionally contain labels that indicate they are poisonous and to contact poison control center if ingested. His individual support plan states that he is not aware of poisonous substances and would ingest them due to his Dementia and that poisonous substances are kept locked and out of reach in his home. At the time of the 1/4/2021 inspection, the individual's record documented a decline in his health and confusion symptoms. His ability to use or avoid poisonous materials was not re-assessed as his confusion as increased throughout the year. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The program manager failed to update the annual residential assessment when the individuals needs changed.
It is important to document accurate information in the individuals annual assessment to ensure that everyone is aware of the individuals current health and supervision needs. In addition, any time there is a change to the care provided or supervision needs, it is important to update the assessment to reflect these changes.
Program managers will work with the supervisors of each home to review annual assessments and ensure the information accurately reflects the individuals needs. If there are changes that need to be made to the assessment, an addendum will be sent to the individuals team. The review of all assessments by program managers will be completed by April 30, 2021 to ensure accuracy of the information noted in the document.
Program managers received training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They understand the importance of ensuring documentation in assessments are accurate and that addendum of the assessment must be sent to the individuals team any time there is a change in care provided to the individual or their supervision needs change.
All residential team members received training via email regarding this regulation 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 |
| 6400.181(e)(7) | Individual #1's current, 2/11/2020 assessment does not include his current level of ability to understand and move away quickly from heat sources. His assessment states he understands heat sources and can move away quickly from them. However, the individual's team members (which includes Penn-mar Human Services), met on 10/13/2020 to discuss the individual's declining ability to ambulate and that he now requires additional adaptive equipment to ambulate along with staff full assistance. The individual's 2/11/2020 assessment was not updated to include his current level of assistance needed to move away from heat sources as he now requires full assistance. Additionally, the individual's individual support plan states that he has no awareness of heat sources. This current level of awareness of heat sources was not included in his current, 2/11/2020 assessment. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The program manager failed to update the annual residential assessment when the individuals needs changed.
It is important to ensure the annual residential assessment is updated as changes in ability occur to ensure that everyone working with the individual understands their supervision needs around heat sources.
Program managers will work with the supervisors of each home to review annual assessments and ensure the information accurately reflects the individuals needs. If there are changes that need to be made to the assessment, an addendum will be sent to the individuals team. The review of all assessments by program managers will be completed by April 30, 2021 to ensure accuracy of the information noted in the document.
Program managers received training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They understand the importance of ensuring documentation in assessments are accurate and that addendum of the assessment must be sent to the individuals team any time there is a change in care provided to the individual or their supervision needs change.
All residential team members received training via email regarding this regulation. 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 |
| 6400.181(e)(8) | Individual #1's current, 2/11/2020 assessment does not include his current level to evacuate the home in the event of a fire. His assessment states he's independent with evacuation and only requires occasional verbal reminders. According to home's fire drill records, Individual #1 required constant verbal prompts "due to Dementia" for all fire drills from September 2019 to December 2020 and mostly physical assistance to evacuate the home during the drills from September 2019-December 2020. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | The program manager failed to update the annual residential assessment when the individuals needs changed.
It is important to ensure the annual residential assessment is updated as changes in ability occur to ensure that everyone working with the individual understands their supervision needs around heat sources.
Program managers will work with the supervisors of each home to review annual assessments and ensure the information accurately reflects the individuals needs. If there are changes that need to be made to the assessment, an addendum will be sent to the individuals team. The review of all assessments by program managers will be completed by April 30, 2021 to ensure accuracy of the information noted in the document.
Program managers received training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They understand the importance of ensuring documentation in assessments are accurate and that an addendum of the assessment must be sent to the individuals team any time there is a change in care provided to the individual or their supervision needs change.
All residential team members received training via email regarding this regulation 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 |
| 6400.212(b) | Staff person #6 wrote "took off leads 2 hours did not complete the test" on Individual #1's 1/16/2020 medical appointment. Staff person #6 was not the accompanying staff at said appointment. There are no records maintained for when Staff person #6 made this entry onto the individual's record regarding a medical test or what test the staff's note was referring to.
There are many occasions where notes and information is included by agency staff at the bottom of many of Individual #1's medical appointment summary forms. There are no records maintained for the staff who is making the entry or when. For example the note at the bottom of a 9/9/2020 primary care physician appointment form states "next available vision is 10/20/20 at 1:10pm." | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| This citation was received because when staff documented on appointment records, they failed to sign and date the entry.
It is important for staff to sign every entry on any document so that anyone can easily identify the person making the notation in the event there are questions surrounding the note.
Program managers received training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They understand the importance of signing and dating every entry on any document that pertains information related to the people we support.
All residential team members received training via email regarding this regulation 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 |
| 6400.32(r) | Individual #1's bedroom door was not equipped with a locking mechanism that the individual could operate. There are no records maintained stating the individual was offered his right to lock his bedroom door, if he wished to have his bedroom door locked and provided the key or other access device to open the door, or if his guardian was notified of the individual's right to lock his bedroom door and/or the guardian's wishes regarding the individual's right. | An individual has the right to lock the individual's bedroom door. | The program manager failed to have a conversation with the individual, the guardian, and the team regarding the individual having a lock on his bedroom door.
It is important to provide the individuals residing in the home with the option to lock their bedroom door to keep their things safe and to maintain privacy.
Program managers received training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They understand the importance of offering individuals the right to lock their bedroom door and provide the person with a device to unlock their door if they choose to have a lock.
To ensure this regulation is met, managers will meet with individuals and have correspondence with each individuals team regarding the individuals decision about a door lock on their bedroom door. If the individual chooses to have a lock on their bedroom door, the lock will be installed by April 30, 2021. Program managers will ensure the individuals ISP is updated to reflect this information.
All residential team members received training via email regarding this regulation. 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. |
04/30/2021
| Implemented |
| 6400.32(s) | Individual #1 was not provided a key or other entry mechanism to lock and unlock an entrance door of the home. There are no records maintained stating the individual was offered his right to have access to lock and unlock an entrance door in his home, if he wished to have a key or other locking mechanism provided to open the door, or if his guardian was notified of the individual's right to have a key or other entry mechanism to an entrance door of his home and/or the guardian's wishes regarding the individual's right. | An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home. | The program manager failed to have a conversation with the individual, the guardian, and the team regarding the individuals desire to have a key to enter the home.
It is important to provide the individuals residing in the home with the option to have access to a mechanism that would allow them to gain entry to their home.
Program managers received training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They understand the importance of the individuals right to have access to a mechanism that would allow them to gain entry to their home.
To ensure this regulation is met, managers will meet with individuals and have correspondence with each individuals team regarding the individuals decision of whether they would like to have access to a mechanism that would allow them to gain entry to their home.
If the individual chooses to have access to a mechanism that would allow them to gain entry to their home, they will receive access immediately. Program managers will ensure the individuals ISP is updated to reflect this information regarding the individuals decision by April 30, 2021.
All residential team members received training via email regarding this regulation. 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. |
04/30/2021
| Implemented |
| 6400.50(a) | At the time of the 1/4/2021 inspection, Staff person #4's training record didn't include the content of the training, the trainer, the training source and occasionally the length of the training for all of the trainings she completed. | 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 that 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 #4 started working independently with Individuals #1-#4 within a week or two after her date of hire on 9/28/2020 per agency report. There are no records maintained that Staff person #4 received orientation specific to Individuals #1-#4, their specific plans, protocols, and health and safety needs prior to working with them. 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.
Staff person #4 didn't receive training in Individual #1's assessment until 11/4/20, Individual #1's seizure and choking protocol until 11/24/20, Individual #4's assessment until 11/9/20, Individual #4's social, emotional and environmental needs plan until 12/31/20, Individual #4's protocols until 11/9/20, Individual #2's protocols until 11/4/20, Individual #3's protocols until 10/16/20.
Individual #1 had pace-maker implanted in March 2020 to attempt to correct his Bradycardia that caused him to pass out on 12/10/2019. At the time of the 1/4/2021 inspection there were no records provided that any staff working with the individual was oriented to the individual's new medical pace-maker device that was implemented or any plans or protocols around the device and how to monitor the individual's health. | The orientation must encompass the following areas: Job-related knowledge and skills. | It is important for all staff to be thoroughly trained to meet the needs of an individual prior to working with them to maintain the individuals health and safety.
The supervisor and program manager failed to ensure staff were properly trained prior to working with individuals.
The nurse and manager failed to ensure there was a written protocol to follow regarding the pacemaker.
Program managers and nurses have been retrained on the need for an individual to have a protocol for any adaptive equipment or medical devises needed. Program managers will complete an audit by April 15th to ensure that any individual that has adaptive medical equipment or medical devices has a protocol explaining the use of the equipment.
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. |
04/15/2021
| Implemented |
| 6400.165(b) | During the 1/8/2021 inspection of the home, Individual #1's prescription order on the medication label of his prescribed Levothyroxine and the individual's medication administration records (mars) from September 2020 to current, January 2021, stated to administer the medication once per day. However, this was not the current, physician's order for how to administer the medication. The individual's record contained a note from staff stating that on 9/9/2020 the individual's prescribing physician would like Levothyroxine to be administered at least 30 minutes prior to other medications and breakfast so the medication is better absorbed in his stomach. The physician did provide the home with a written script of this order on 9/15/2020 and also stated on the individual's 12/11/2020 physical examination record that Levothyroxine should be administered at least 30 minutes prior to food and other medications. At the time of the annual inspection of the home, the home did not have the current physician's order for administration of Levothyroxine included on the medication label or the mars. | A prescription order shall be kept current. | It is important to clearly understand when medications are to be administered to avoid interactions with other medications or food that would decrease the effectiveness or contraindicate the effectiveness of other medications.
Staff failed to send the updated script to the pharmacy to get an updated label to indicate that the Levothyroxine is to be administered 30 minutes prior to food and other medications. This medication was scheduled to be administered at 6am daily and all other am medications were scheduled to be administered at 8am.
Program managers received training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They understand the importance of receiving written physicians orders for prescribed medication administration.
To ensure this regulation is met, program managers will ensure that medication orders match the label on the medication during monthly audits at the group home.
All residential team members received training via email regarding this regulation. 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 |
| 6400.165(c) | Individual #1 is prescribed Acetaminophen 325mg tablets, take 2 tablets (650mg) orally every 6 hours as needed for pain or fever. In December 2020, staff administered Acetaminophen once a day for 9 total days, and twice a day for the rest of the days in December. For each administration logged on a calendar-look-a-like-layout record, staff recorded "Acetaminophen 325mg" as the medication administered. There were no records provided by the agency at the time of the 1/4/2021 inspection that included the dosage that was administered to Individual #1 for any of the 53 administrations of Acetaminophen in December 2020, that matched his prescribed dosage.
Staff administered Acetaminophen 57 times in November 2020 to the individual and recorded the administration the same as stated above, "Acetaminophen 325mg" and didn't include records of the dosage being administered as prescribed. | A prescription medication shall be administered as prescribed. | It is important to ensure all information is visible on the printed MAR in order for anyone viewing the MAR to see the persons name, route, dose, medications, and time the medication was administered.
The dosage of the Acetaminophen administered was not visible on the printed MAR report. However, the dosage is visible on the e-MAR when staff are administering the medication. See attachment # 19 - November 2020 MAR and attachment # 20 - December 2020 MAR that shows the dose of the medication, the date, and the time the medication was administered.
A change was made in the way that PRN medications are entered into the e-MAR system to ensure that when a PRN medication is administered, all of the required information can be viewed on a printed MAR report.
Program managers and nurses received training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They understand the importance of ensuring PRN medications are entered correctly in the e-mar system so that administrations can easily be viewed on the MAR.
To ensure this regulation is met, the nurses will thoroughly review MARs to ensure PRN medication administration are documented as required. In addition, program managers will review MARs during monthly monitoring of the home.
All residential team members received training via email regarding this regulation. 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 |
| 6400.166(a)(11) | Individual #1's December 2020 and January 2021 medication administration record did not include the reason for prescribing his Levocetrizine. He is prescribed this for allergies. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | It is important for staff and the individual to have an understanding of why a medication is prescribed.
Staff did not ensure the reason for prescribing his Levocetirizine was entered onto the MAR.
The MAR was corrected to include the reason Levocetirizine was prescribed on January 1/12/2021. See attachment# 21 - January 2021 MAR
Program managers and nurses received training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They understand the importance of ensuring the reason a medication is prescribed is entered on the MAR.
To ensure this regulation is met, the nurses will thoroughly review MARs to ensure all 5 rights are documented as required. In addition, program managers will review MARs during monthly monitoring of the home.
All residential team members received training via email regarding this regulation 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 |
| 6400.166(b) | Staff person #4 administered medications to Individual #1 throughout the entire month of November 2020. At the time of the 1/4/2021 annual inspection, Staff person #4 did not sign her name and initials on the individual's November 2020 medication administration record to indicate who the staff person was that was administering medications to the individual in November. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | This citation was received because the signature of a staff person that administered medications was not visible on the printed November 2020 MAR.
It is important for signatures of the staff that administered medications to be recorded on the MAR so that it is clear who administered the medication.
The staff's signature was uploaded incorrectly in the e-MAR system and therefore not visible on the printed MAR. This issue was corrected during Penn-Mar licensing. See attachment # 19 - November 2020 MAR.
Program managers and nurses received training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They understand the importance of ensuring the signature of a staff person that administered medications is on the MAR.
To ensure this regulation is met, the nurses will thoroughly review MARs to ensure signatures of staff administering medications is documented as required. In addition, program managers will review MARs during monthly monitoring of the home.
All residential team members received training via email regarding this regulation 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 |
| 6400.167(a)(4) | Individual #1 is prescribed Ammonium lactate lotion, Flonase Sensimist nasal spray, and Vitamin D3 to be administered at 8AM. Staff did not administer the medications until 3:09PM on 8/4/2020 with no indication of why the medication wasn't administered at 8AM or an hour before or after 8AM.
In December 2020 Individual #1 was to have Levothyroxine a75mcg administered at 6AM. This wasn't administered until 7:21AM on 12/4/20 and 7:43AM on 12/17/20, which was more than one hour before or after the scheduled administration times. | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | This citation was received due to staff failing to sign-off on the electronic MAR at the time medications were administered.
It is important to ensure documentation of the medication administration is completed at the time the medication is administered to prevent potential medication errors.
All staff will be retrained on the expectation to utilize the paper MAR when they do not have internet access. In addition, all staff will be retrained on how to properly document on the electronic MAR when documentation of a medication administration is written on the paper MAR. This training has occurred via email. see attachment # 3- medication administration documentation email.
All team members administering medication are also required to take a video training created by the agency nurses regarding medication administration documentation by 4/16/2021. See attachment #4 -medication documentation training.
Program managers and nurses have had training regarding this regulation during the exit conference with state licensures on January 11, 2021. Program managers will continue to monitor MARs during monthly site monitoring's at each group home. Site monitoring completed by Program Managers are monitored monthly for completion by the Community Living Administrator and the Director of PA Program. Effective 3/22/2021, the nurses will start to complete weekly audits of MARs to ensure medications are being administered as ordered. |
04/14/2021
| Implemented |
| 6400.169(a) | Individual #1 has been prescribed Diazepam rectal gel to be administered at the onset of a seizure since 7/15/2020. On 2/3/2020 the Department distributed a Regulatory Compliance Guide for the 6400 regulations to all providers for immediate implementation. This guide states that medication administered rectally is a route of administration that requires staff to receive additional training on said route via a licensed medical professional or by a medication administration trainer who has been trained in said topic by a licensed medical professional. The agency, Penn-Mar Human Services, was unable to provide the Department record that any staff working directly with Individual #1 has received the training as instructed. The agency submitted a rectal medication training sign in sheet but it didn't include the instructor (was left blank), the qualifications of the trainer, the date the training took place (there were multiple dates on the form but none denoting the date the training took place), the content of the training, nor did it include training provided to Staff persons #4 and #5 whom the agency reported works with Individual #1. | 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). | This citation was received because the nurse that provided training to staff for the administration of Diazepam rectal gel did not sign their name indicating that they were the instructor on the training sign-in sheet. The date that the training took place was also not clear on the training sign-in sheet. In addition, the training content was not kept saved with the sign-in sheet. 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.
It is important that staff are properly trained to administer medications. Penn-Mar understands that training content is required to be kept with the sign-in sheet to show the information staff were trained on.
Program managers and nurses have had training regarding this regulation during the exit conference with the state licensing team on January 11, 2021.
Weekly audits are being 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 for to ensure all sign-in sheets and training content is saved together so that we are able to show when staff were trained and what the training encompassed.
See attachment # 12- in-person training guide. |
04/01/2021
| Implemented |
| 6400.181(b) | A revision meeting was held with Individual #1 and his team members on 10/13/2020 for Individual #1 due to a revision of services needed. Penn-mar Human services, the agency, never updated Individual #1's 2/11/2020 assessment prior to the 10/13/2020 meeting to reassess his need and revise services.
The most current assessment in the individual's record was created on 2/11/2020. Since then, the individual has had multiple, significant health changes that required the change in need of services while he resides with the agency at his home. Changes in his health that have occurred since 2/11/2020 includes: he has had a pace-maker implanted on 3/4/2020, increased choking concerns and specific dietary changes with cutting his food, a new seizure that required hospitalization on 7/11/2020, a new seizure diagnosis, the addition of new seizure medications that include a daily medication and an as needed rectal medication, a loss of almost ten pounds from the year prior, vision depth concerns that now require complete assistance to ambulate, and he is experiencing a complete decline in his health with his dementia and confusion symptoms that now require complete assistance from staff with all daily living skills at all hours of the day. None of this information was included in his 2/11/2020 assessment, nor is an updated and current assessment available for staff to reference for the specific care needs Individual #1 has. | If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have an assessment completed as required under this section. | The program manager failed to update the annual residential assessment when the individuals needs changed.
It is important to ensure the annual residential assessment is updated as the health and care needs of the individuals change to ensure that everyone working with the individual understands the supports the person requires.
Program managers will work with the supervisors of each home to review annual assessments and ensure the information accurately reflects the individuals needs. If there are changes that need to be made to the assessment, an addendum will be sent to the individuals team. The review of all assessments by program managers will be completed by April 30, 2021.
Program managers received training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They understand the importance of ensuring documentation in assessments are accurate and that an addendum of the assessment must be sent to the individuals team any time there is a change in health, care provided, or supervision needs.
All residential team members received training via email regarding this regulation. 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. |
04/30/2021
| Implemented |
| 6400.181(f) | Individual #1's 2/11/2020 assessment was sent to his plan team members on 2/11/2020. However, this was not at least 30 days prior to his annual individual support plan meeting that was held on 3/10/2020. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The program manager failed to forward the individuals annual assessment 30-days prior to the ISP meeting.
It is important to ensure the annual residential assessment are sent to the team 30-days prior to the meeting so that the team has adequate time to review the updated information prior to the meeting.
Program managers received training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They understand the importance of forwarding the annual assessment to the teams of individuals at least 30-days prior to the ISP meeting date.
A review of this regulation will also be completed with the Residential Supervisors again at their next team meeting on April 14, 2021. |
04/01/2021
| Implemented |
| 6400.186 | Individual #1's 2/7/2020 lifetime medical history attached to his current, 2/11/2020 assessment states that due to his chronic kidney disease stage III, he is to keep good hydration. There are no records maintained that the home is offering the individual multiple drinks throughout the day to keep him hydrated or if the individual is refusing said drinks. | The home shall implement the individual plan, including revisions. | This citation was received because there is no evidence that staff followed through with recommendations from physicians.
It is important to follow all physicians recommendations to ensure optimal care is provided to the people we support. It is important to document all care provided to ensure the persons needs are being met.
Program managers and nurses have had training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They understand the importance of thoroughly reviewing all medical documents while and ensuring recommendations are being followed.
All residential team members received training via email regarding this regulation. 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 |
| 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 #4 was hired by the agency on 9/28/2020. 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-Mar 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 |