Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.104 | The Fire notification letter sent to the local fire department was not updated to reflect that Individual #1 was no longer residing in the home. . | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Program Managers have been re-trained to ensure that when there is a change in the home, the local fire department needs to be notified of the change, immediately. They should not wait until a new person moves in. Two separate letters at two separate times will need to be done in this scenario. (Attachment # 2)
In addition to the Program Specialists being re-trained on this regulation, Penn-Mar has started a new process. The Operations Support Specialist, whom is now monitoring the fire drills for completion and compliance will email the Program Specialists monthly inquiring about changes in each program that may require an updated letter to a fire department.
There has not been a home that has had an individual move out since this licensing period. We anticipate that an individual will be moving to a new home mid-January and will complete appropriate letters at that time. |
12/13/2017
| Implemented |
6400.112(a) | Repeat 10/05/16: No fire drill was condcuted in the month of November 2016. | An unannounced fire drill shall be held at least once a month. | Penn-Mar has evaluated and made changes to the process. Fire drills will now be submitted to the Operations Support Specialist, whom we feel has the skills to monitor and ensure that fire drills are completed for every home each month and that the form is completed in its entirety. In addition, Program Managers have completed an audit of drills for November 2017, which have been completed for each home.
Program Managers have been re-trained on this regulation ( attachment # 2). Residential Supervisors will be trained re-trained on this regulation at the Residential Supervisor meeting on 12/13/17 (Attachment #3). |
12/13/2017
| Implemented |
6400.181(a) | Individual #2 had an assessment completed on 7/8/16 and not again until 7/26/17. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Program Specialists have been retrained and understand that an annual assessment is to be completed within one year prior to the last annual assessment. See Attachment # 2. As a result of this citation, the Community Living Administrator will review upcoming assessment dates with the Program Specialist during their bi-weekly meetings to ensure assessments are completed in accordance to the state regulation.
Please see attachment # 31, which shows and assessment completed within one year of the previous assessment. |
12/13/2017
| Implemented |
6400.186(a) | Repeat 10/05/16: Individual #2 had an ISP review completed on 11/1/16 and not again until 3/7/17. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | Program Specialists have reviewed and understand that the ISP review is to be completed quarterly based on the ISP date. As a result of this citation, the Community Living Administrator will review upcoming quarterly review dates with the Program Specialist during their bi-weekly meetings to ensure quarterly reviews are completed in accordance to the state regulation.
See Attachment #2
See attachment #26, which shows a quarterly report completed within the appropriate timeframe. |
12/13/2017
| Implemented |
6400.213(11) | Individual #2's assessment dated 7/26/17 states that he/she does not have any alone time in the community, however, Individual #2's ISP updated 9/19/17 states that he/she can be left alone for up to 15 minutes in the van while out in the community. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | Program Specialists were trained on the importance of ensuring information in the annual assessment matches the information in the ISP (attachment # 2). As a result of this citation, the Program Specialist has sent an addendum to the assessment dated 7/27/17 ( attachment # 15) to the Support Coordinator with the corrected information. Moving forward, Program Specialists will review the ISP and assessment with the Residential Supervisor during their weekly meeting after each annual ISP to ensure the information is the same in the documents. |
12/13/2017
| Implemented |