Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00221234 Unannounced Monitoring 03/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The self-assessment completed on 6/4/22 identified the following violations but did not have an acceptable plan of correction developed for the violations: 67a, 141c4, 141c6, and 181f.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. This regulation is important because it allows Penn-Mar to track performance and avoid noncompliance and repeated violations. In addition, it demonstrates good-faith effort to comply with ODP regulations. During the inspection, the self-assessment completed identified violations for 67a, 141c4, 141c6, and 181f. The violations did not have an acceptable plan of correction developed. This violation occurred because the Program Specialist failed to provide an acceptable plan of correction for the violations. In addition, the PA Assistant Director failed to thoroughly review the self-assessment when it was completed to ensure compliance with regulation 15(c). The Program Specialist responsible for completing the self-assessment received retraining on 3/28/2023 regarding an acceptable plan of correction by the PA Assistant Director. The Program Specialist and the PA Assistant Director reviewed the violations and developed an acceptable plan of correction of violation 67a, 141c4, 141c6, and 181f. Although the acceptable plan of correction cannot fix the violation, it demonstrates an understanding of what is expected for future self-assessments. See Attachment #5 for proof of training and understanding of what is expected of regulation 15(c). 03/29/2023 Implemented
6400.110(b)A smoke detector was not located within 15 feet of Individual #1's bedroom door.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. This regulation is important because it alerts individuals of smoke or fire before the smoke or fire enters the room, allowing the individual time to wake and react. During the inspection, it was noticed that a smoke detector was not located within 15 feet of Individual #1's bedroom door. This occurred because the agency failed to ensure that there was a smoke detector within 15 feet of Individual #1's door. In addition, during self-assessments and monthly site monitoring, the Program Specialist failed to identify this as a violation. Immediately following the recognition of there not being a smoke detector within 15 feet of Individual #1¿s door, the Program Specialist contacted maintenance and a smoke detector was installed. See Attachment #9. 03/29/2023 Implemented
SIN-00120660 Renewal 11/07/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104The 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
SIN-00070891 Renewal 07/28/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(b)There is a large amount of peeling paint on the exterior door to the basement and also around the trim of the door. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.This exterior door was sanded and painted. See attachment F All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014 See attachment A. Compliance with this area in all houses will be monitored by the appropriate Program Manager each month during site monitoring. 08/13/2014 Implemented
6400.101The door leading out of the garage was obstructed by the cat litter box and the cat food/water dish. The refrigerator in the garage is close to the door where it would be difficult to get a wheelchair through the door. Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. These issues were discussed during the licensing process. The cat food/water dish and litter box were moved while the licensing representative was still at the home. The refrigerator was also moved at this time to allow for more room for a wheelchair to get through the door. All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014 See attachment A Compliance with this area in all houses will be monitored by the appropriate Program Manager each month during site monitoring. 08/13/2014 Implemented
6400.168(a)Staff person #1 was administering medications without being trained in the Medication Administration course. 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. Staff person #1 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 plan. 08/13/2014 Implemented
SIN-00177809 Renewal 05/07/2021 Compliant - Finalized
SIN-00181121 Renewal 01/04/2021 Compliant - Finalized
SIN-00070774 Initial review 10/30/2014 Compliant - Finalized