| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | On 1/5/21, Individual #1 purchased $10.30 worth of health and beauty products. On 3/1/21, Individual #1 purchased $17.30 in health and beauty products. These products should be covered by Penn Mar. Individual #1 purchased gas for the company vehicle on 5/26, 6/26, 7/9, 7/24, 9/25, and 10/23. | Individual funds and property shall be used for the individual's benefit. | This regulation is important because it ensures the individual's benefit from their money and property in a manner of their choosing while preventing situations that could lead to exploitation. As a result of this citation, an incident was filed in EIM and an investigation is being completed for the hygiene products as well as gas. The Individual will be reimbursed for any funds use to purchase hygiene products as well as gas.
It is believed that these instances were prior to the new incident management training that was done organizationally in July 2021 which emphasizes financial exploitation.
The gas for company vehicles was a result of policies and procedures that do not align with 6100 or 6400 regulations.
Program Specialists were informed on 3/30/2022 that no individuals should be paying for gas expenses for traveling until the investigation and plan of correction are completed for this incident.
Program Specialists and Residential Supervisors will be retrained regarding Penn-Mar's responsibility in paying for hygiene products and gas expense. This will occur on 4/13/2022.
Individual #1 will be reimbursed for the items he purchased.
An organizational review of finances will take place to ensure other individuals are reimbursed accordingly. This will be completed by May 30, 2022. |
05/30/2022
| Implemented |
| 6400.74 | The steps leading down the back patio did not include nonskid surfaces. | Interior stairs and outside steps shall have a nonskid surface.
| This regulation is important because it promotes safety on outside steps when they become slippery. At the time of inspection, the patio steps did not include nonskid surfaces. This was because the maintenance team thought the type of wood met this requirement.
Non-skid tape was added to the steps on 4/6/2022. See attachment #12.
Program Specialists will complete an audit of all programs have nonskid surfaces on interior stairs and outside steps. This will be completed by 4/22/2022.
Program Specialists and Residential Supervisors were retrained on regulation 6400.74 on 4/13/2022.
All residential team members will be retrained by 4/29/2022. |
04/29/2022
| Implemented |
| 6400.82(e) | The bathroom with the walk-in shower, was not equipped with a non-slip mat. | Bathtubs and showers shall have a nonslip surface or mat. | This regulation is important because it promotes safety in bathtubs and showers where floors become slippery. At the time of inspection, the bathroom and showers did not have a nonslip surface or mat. This was because the maintenance team thought the type of floor installed met this requirement.
Non-slip tape was purchased and will be installed as soon as it arrives to the program. See attachment # 11.
Program Specialists will complete an audit of all programs to ensure the bathtubs and showers have a nonslip surface or mat. This will be completed by 4/22/2022.
Program Specialists and Residential Supervisors were retrained on regulation 6400.82(e) on 4/13/2022.
All residential team members will be retrained by 4/29/2022. |
04/29/2022
| Implemented |
| 6400.214(b) | Individual #2, did not have a current assessment available at the home. The most recent assessment for Individual #2 at the home was dated 2/12/21. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| This regulation is important because the annual assessment serves as a useful guide to help team members know individuals' abilities, strengths, needs, and other crucial information to maintain health and safety. At the time of the inspection, Individual #2's most recent assessment was not available at the home. This is because the Program Manager and Residential Supervisor failed to ensure the updated annual assessment was put in Individual #2's site file upon completion.
The assessment has been placed in the file.
An audit will be completed by the Program Specialist by 4/22/22 to ensure all individuals have the most current assessment at the homes.
Program Specialists and Residential Supervisors are responsible for ensuring this happens. They have been retrained on regulation 6400.214(b) on 4/13/2022. |
04/29/2022
| Implemented |
| 6400.163(h) | The Acetaminophen in the home at the time of the inspection expired on 4/3/21. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | This regulation is important because all medications prescribed should be up to date to work as prescribed. The Acetaminophen in the home expired on 4/3/2021. This is PRN for Individual #1.
Individual #1 has not been given Acetaminophen since it expired.
The Residential Supervisor sent a request for a new prescription from Individual #1's PCP upon receiving this citation.
The new Acetaminophen has not been received yet.
This happened because the Residential Supervisor and Program Specialist did not check for expired medications during monthly site monitoring and there was no tracking system in place for PRN's.
An audit will be completed by Program Specialist to ensure all medications are up to date. This will be completed by 4/22/2022.
All Program Specialists and Residential Supervisors will be retrained on 4/13/2022.
All residential team members will be retrained on regulation 6400.163(h) by 4/29/2022.
The Program Specialist and Residential Supervisors will establish a tracking process for PRN medications. This process will be established by 4/22/2022. |
04/29/2022
| Implemented |
| 6400.166(a)(2) | (Repeat from Inspection dated 6/8/21) The prescriber for the Vitamin B12 and Vitamin D on the MAR was not the correct prescriber. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | This regulation is important because having the correct prescriber listed will ensure staff are able to track all medications an individual receives to ensure all medications are administered as prescribed.
At the time of the inspection, Individual #1's Vitamin B12 and Vitamin D did not have the correct prescriber listed on the MAR. This happened because when the pharmacy sent the prescription to the PCP for review, the original PCP was not present in the office and another prescriber signed the prescription. Additionally, team members did not notice this discrepancy and correct it on the MAR.
This has been corrected. See attachment #13.
Program Specialists will complete an audit by 4/22/22 to ensure the correct prescriber is listed on the MAR for all individuals.
Program Specialists and Residential Supervisors were retrained on 4/13/2022 on regulation 6400.166(a)(2).
All team members will be retrained by 4/29/2022. |
04/29/2022
| Implemented |
| 6400.166(b) | The Reguloid SF Orange given on 4/17/21 was not documented until 4/20/21. The Reguloid SF orange given on 9/9/21 was not documented until 9/27/21. The Reguloid SF Orange given on 11/4/21 at 2pm was not documented until 11/11/21. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | This regulation is important because administering medication at the right time ensures that medications are being administered as prescribed. Medications have a time to be administered to ensure effectiveness and limit unintended interactions with other prescribed medications. Documentation that the medication is given on time is part of the 15 Medication Administration Steps.
The Reguloid SF Orange given on 4/17/21 was not documented until 4/20/21. The Reguloid SF orange given on 9/9/21 was not documented until 9/27/21. The Reguloid SF Orange given on 11/4/21 at 2pm was not documented until 11/11/21.
It is unknown why this occurred. However, it is evident that the 15 Medication Administration Steps were not followed.
Residential Supervisors and Program Specialists will be retrained on 4/13/2022 regarding the 15 steps of medication administration.
All residential team members will be retrained by April 29, 2022 regarding the 15 steps of medication administration. |
04/29/2022
| Implemented |
| 6400.167(a)(4) | (Repeat from Inspection dated 1/4/21) 1/23/21 and 1/30/21 the 8am meds were not given until 12:50pm in the afternoon. On 2/9/21 and 2/28/21, the 4pm meds were not administered until 7:09pm. The 8am meds given on 1/2/22 were not given until 12:11pm. | 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 regulation is important because administering medication at the right time ensures that medications are being administered as prescribed. Medications have a time to be administered to ensure effectiveness and limit unintended interactions with other prescribed medications. Individual #1's 1/23/21 and 1/30/21 the 8am meds were not given until 12:50pm in the afternoon. On 2/9/21 and 2/28/21, the 4pm meds were not administered until 7:09pm. The 8am meds given on 1/2/22 were not given until 12:11pm.
Unfortunately, there was not a note on the Medication Administration Record that states why the medication was late. It is believed by the team members that the medication was given on time but the Medication Administration process was not followed correctly by clicking off the medication as administered.
Residential Supervisors and Program Specialists will be retrained on 4/13/2022 regarding the 15 steps of medication administration.
All residential team members will be retrained by April 29, 2022 regarding the 15 steps of medication administration. |
04/29/2022
| Implemented |