Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00188623 Unannounced Monitoring 06/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.143(a)Individual #1 is not consistently following the recommendation to limit soda intake to 1 a day or to drink 64 fluid ounces of water daily. There is no documentation that Individual #1 has been educated on the importance of following the recommendations.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. While staff document the amount of water and soda intake per day, they failed to document attempts to educate the individual about the importance of limiting her soda intake to one per day and drinking at least 64 ounces of water each day. Staff working in this program have been trained and are now documenting their attempts to educate the individual in these areas. The documentation is completed daily in the e-mar system. See attachment- 26 Independence Drive- documentation of physicians recommendations and education It is important for staff to assist individuals with following recommendations from physicians to educate them on the importance of following recommendations to aid in improving the individuals overall health. Program Managers have had training regarding this regulation during the exit conference with the state licensing team on June 9, 2021. All residential staff have been retrained on this regulation via email. see attachment citation review. This regulation has been reviewed with Residential Supervisors on June 23, 2021, during their team meeting. See attachment RS meeting agenda 06/29/2021 Implemented
6400.166(a)(2)The MAR for Individual #1 did not list all of the prescriber's for Individual #1's medications on the medication administration record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.Staff did not ensure all prescribing physicians were included on the medication administration record. It is important to note the physician that prescribes each medication so that staff know which physician to contact in the event there are questions surrounding the medication. The prescribing physician has been added to the medication administration record for every medication prescribed. See attachment 26 Independence drive MAR with prescribing physicians Program Managers have had training regarding this regulation during the exit conference with the state licensing team on June 9, 2021. All residential staff have been retrained on this regulation via email. see attachment citation review. This regulation has been reviewed with Residential Supervisors on June 23, 2021 during their team meeting. See attachment RS meeting agenda An audit of medication records for all individuals residing in a Penn-Mar CLA has been completed and records have been updated to include the prescribing physician for each medication prescribed. When staff enter medications onto the electronic MAR, they will include the prescribing physician. When nurses review MARs they will ensure the prescriber is listed. Program Managers will review MARs during site monitoring and ensure prescribing physicians are listed for each medication prescribed. 06/29/2021 Implemented
SIN-00143493 Renewal 10/15/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Garage has buildup of needles and leaves.Floors, walls, ceilings and other surfaces shall be in good repair. It has been windy and the leaves that have fallen from the trees have blown into the garage when the door was open. It is important to keep floors clean to prevent slips, trips, and falls which could lead to injuries. The leaves have been swept out of the garage on 10/30/18. See attachment of the garage floor with the leaves swept out. All residential teammates have been trained to ensure that all floors are clean and safe. Program managers have had training regarding this regulation during the exit conference with state licensures on 10/17/2018. They will continue to monitor surfaces of the home to ensure they are in good repair when they complete monthly site monitorings at each group home. Site monitorings completed by Program Managers are monitored monthly for completion by the Community Living Administrator, Director of PA Program, and the PA Chief Operations Officer. A review of this regulation will also be completed with the Residential Supervisors again at their next team meeting on 12/12/2018. See attachment of the email sent to all residential team members on 10/31/18. 10/31/2018 Implemented
6400.73(b)The third joint of the railing on the right of exterior ramp was not attached.Each porch that has over an 18-inch drop shall have a well-secured railing.The joint of the railing was missing due to wearing of the railing. It is important for railings to be secure to prevent injury. The joint of the railing on the right of the exterior ramp was fixed on 10/30/18. See attachment with the fixed railing. All residential team members have been trained that as situations like this occur with the normal wear and tear of a home, they are to continue to submit a maintenance request form. Maintenance should be able to respond in a timely manner. If they do not, staff are to make their Program Manager aware. Program Managers have had training regarding this regulation during the exit conference with state licensures on 10/17/2018. They will continue to monitor railings to ensure they are secure when they complete monthly site monitorings at each group home. Site monitorings completed by Program Managers are monitored monthly for completion by the Community Living Administrator, Director of PA Program, and the PA Chief Operations Officer. A review of this regulation will also be completed with the Residential Supervisors again at their next team meeting on 12/12/2018. See attachment of the email sent to all residential team members on 10/31/18. 10/31/2018 Implemented
SIN-00083014 Renewal 08/12/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186(e)Individual #1's record did not include the option to decline the ISP review documentation. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. Individual#1's team was contacted about their option to decline the ISP review after licensing. Attachment J All Penn-Mar Program staff responsible for this requirement, were re-trained on the regulation and execution of this regulation. Attachment B 09/01/2015 Implemented
SIN-00070901 Renewal 07/28/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(e)The trash can in Individual #1's bedroom is over 18 inches and did not have a lid. Trash receptacles over 18 inches high shall have lids. This individual has a tendency to throw away the transcan lids on her trashcans. She has also occasionally thrown out lids on other trashcans. The individual has been asked to stop doing this, and explained why a lid is important and a new trashcan has been purchased. Program Staff have asked that this information be added to the individuals ISP. See attachment K Physical site inspections is part of the monthly site mountings completed by Program Managers monthly. All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014 See attachment A 12/03/2014 Implemented
6400.67(a)Individual#1's bedroom door has a fist size hole in the right corner and the paint is chipping off of the door in different areas on the inside. Floors, walls, ceilings and other surfaces shall be in good repair. The hole in the bedroom door was patched and the door was painted. See attachment F. Physical site inspections is part of the monthly site mountings completed by Program Managers monthly. All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014 See attachment A 09/15/2014 Implemented
6400.67(b)The porch on the back of the home is warping over the stairs causing a tripping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.The back deck was completely removed and replaced with a new deck. See attachment F. Physical site inspections is part of the monthly site mountings completed by Program Managers monthly. All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014 See attachment A 10/30/2014 Implemented
6400.80(b)On the back porch by the sliding glass door the house is rotting & the paint is chipping. The ramp going into the garage is chipping & the seal to the door is coming off. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The wood around the sliding glass door was replaced. The ramp going into the garage was repainted and the seal on the door was replaced. See attachment F Physical site inspections is part of the monthly site mountings completed by Program Managers monthly. All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014 See attachment A 11/15/2014 Implemented
6400.82(f)In Individual #1's bathroom did not contain any toilet paper or indivdual wipes. Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. The individual who uses this bathroom keeps her toilet paper in the closet outside of her bathroom. She is independent in the area of ensuring that toilet paper is in the bathroom when she needs this. Staff have been trained to provide more oversight in this area, without taking away the individuals independence. Physical site inspections is part of the monthly site mountings completed by Program Managers monthly. All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014 See attachment A 08/13/2014 Implemented
6400.168(a)Staff person #1 medication training was completed on 4/1/14. The 2013 medication training had not been completed and this staff person was administering medications. Staff person #2 had not been trained on medication administration and was administering medications. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. Annual recertification for Staff person #1 did take and pass the did occur in 2013, however the appropriate documentation to prove this was missing from the file. This individual is currently being monitored as part of the ongoing medication monitoring process (quarterly MAR reviews and 2 annual med passes). There is no way to go back and recreate the paperwork from their annual training, therefore the staff will continue to receive annual monitoring. Staff person #2 did take and pass the Medication Administration course. The appropriate documentation to prove this was missing from the file. This individual is currently being monitored as part of the ongoing medication monitoring process (quarterly MAR reviews and 2 annual med passes). There is no way to go back and recreate the paperwork from their annual training, therefore the staff will continue to receive annual monitoring. All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014 See attachment A A new process was developed to ensure that copies of medication administration packets are kept once turned into Penn-Mar's training department. This will help to ensure that paperwork is not lost or misfiled. This information is also tracked as part of Penn-Mar's Quality Management plan. Data is kept on this information as part of the Quality Management pla 08/13/2014 Implemented
SIN-00220321 Renewal 03/14/2023 Compliant - Finalized
SIN-00177825 Renewal 05/07/2021 Compliant - Finalized
SIN-00070887 Initial review 10/31/2014 Compliant - Finalized