Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00220312 Renewal 03/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(6)At the time of the walkthrough, poisons were not locked in Individual #1 apartment on the lower level. The most recent Assessment completed 2/19/23 states "Individual #1 would not ingest poisonous materials but would need to be reminded to wash their hands after using them; they not aware that the poisons could burn the skin, eyes, etc.". Staff in the home at the time of the 3/15/23 physical site inspection stated that Individual #1 was completely safe with poisons.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. This regulation is important because it ensures that the individual plan is up to date and accurately reflects individual's needs, specifically around poisonous materials. At the time of the inspection, poisons were not locked in Individual #1's apartment. The most recent assessment indicates that the individual would not ingest poisonous materials but would need to be reminded to wash their hands. Staff in the home during the inspection stated that Individual #1 was completely safe with poisons. This occurred because Individual #1 has not demonstrated unsafe behavior around poisonous materials and the Program Specialist did not understand that reminders to wash hands after the use of poisonous materials would mean that they are not safe around the materials. On 3/29/2023, there was an addendum created for Individual #1's assessment to indicate their safety around poisonous materials. An email was sent to the ISP team to ask that the ISP be updated. Based on Individual #1's safety level, the poisonous materials will be locked. Hygiene products will be accessible to Individual #1 because there has not been an identified safety risk with these products. The cleaning products were relocated on 3/29/2023 to a locked area until maintenance is able to install a lock on the cabinet in the apartment. See Attachment #20 for assessment addendum and maintenance request. On 3/20/2023, Program Specialists were retrained on what determines someone as safe around poisonous materials. This retraining included the importance of locking poisonous materials if the individual is not safe. See Attachment #4 for proof of training. 03/29/2023 Implemented
6400.15(b)The self-assessment completed on 6/28/22 did not review regulation 67b for Individual #1.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.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, it was determined that the self-assessment completed on 6/28/22 did not review regulation 67b. This occurred because the Program Specialist failed to ensure the self-assessment was fully completed. In addition, the Assistant Director failed to thoroughly review this self-assessment. On 3/20/2023, the Program Specialists were retrained on the importance of ensuring self-assessments are completed thoroughly. The program specialist responsible for this violation is no longer employed with the agency. Therefore, direct feedback was not provided to the program specialist responsible for the violation. 03/29/2023 Implemented
6400.165(b)During the physical site inspection, the Clindamycin Phosphorous 1% Lotion was not available at the home. The Reorder was sent 2/3/23.A prescription order shall be kept current.This regulation is important because it prevents medication errors that could result in injury. At the time of the inspection, the Clindamycin Phosphorous 1% Lotion PRN was not available at the home. There was a reorder sent on 2/3/2023. This occurred because the Program Specialist failed to ensure that the reordered medication was received from the pharmacy. Prior to the inspection, there was discussion regarding the potential of discontinuing this PRN due to lack of use. The Program Specialist consulted with the medical provider and the medication was discontinued. See Attachment #14. On March 20, 2023, the Program Specialists were retrained on the expectations regarding ensuring all medications are available for the individuals. This retraining included the expectation that reordered medications are monitored to ensure they are retrieved as soon as possible. See Attachment #4 for proof of training. 03/29/2023 Implemented
6400.165(g)The appointments for Individual #1 were not scheduled timely and the appointment dates are beyond the 3-month requirement. The 11/02/2022 appointment does not include the name of the medication, or the dosage required for Individual #1.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.This regulation is important because it ensures that medications prescribed for treatment of a psychiatric illness are used exclusively for the treatment of the illness. At the 11/2/2022 psychiatric appointment, the review of medications or dosage required for Individual #1 was not documented as being reviewed. In addition, the psych appointments were not scheduled within the 3-month timeframe and there is no supporting documentation. This happened because the staff accompanying Individual #1 to the appointment did not ensure that the medications were reviewed and documented accordingly. The appointment was not completed within the 3-month timeframe because the Program Supervisor, Program Specialist, and Agency Nurse failed to acknowledge that the appointment was scheduled out of the 3-month window. In addition, the Agency Nurse and Program Specialist did not ensure that regulation 165(g) was met when they reviewed the appointment record. On 3/20/2023, the Program Specialist and Agency Nurse were retrained on regulation 165(b). See Attachment #4 for proof of training. In addition, there was a psychiatric appointment for another individual that demonstrates compliance. See Attachment #15. 03/29/2023 Implemented
SIN-00202397 Renewal 03/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The self-assessment completed on 6/9/21 identified violations of the regulations. There was no written summary of corrections completed.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. When completing the self-assessment for the program, the program manager failed to complete the plan of correction for the regulations that were not in compliance. It is important to ensure that any violation of a regulation is corrected immediately to protect the health and safety of the people supported. Program Managers are responsible with ensuring regulations are followed in the programs they are managing. Program Managers complete self-assessments annually. On 4/13/2022, all Program Managers have been retrained and understand the importance of correcting violations to regulations in a timely manner. 04/13/2022 Implemented
SIN-00120667 Renewal 11/07/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Individual #1's bathroom and bedroom smelled strongly of urine.Clean and sanitary conditions shall be maintained in the home. The individual residing in the apartment of this home has unique needs and routines which limit the ability for staff to remove soiled clothing or linens and launder them in a more timely manner. The Program Specialist and staff will continue to work with the individual¿s Behavior Support Specialist and the rest of his team to create ways to encourage that this is happening in a timelier manner. His team will continue to attempt and analyze ways to dissipate the unfavorable odor in the apartment. Staff will open the window a crack to allow for air flow as long as it is tolerated by the individual. Staff will continue to clean his apartment with a variety of cleaners in an attempt to eliminate the unfavorable odor of urine. An air purifier has been purchased and placed in the apartment. See attachment #40 Program Managers were trained on this requirement. See attachment #2. Supervisors will be trained on this requirement on 12/13/17. see attachment #3. 12/13/2017 Implemented
6400.64(e)The trash receptacle in the hallway before entering into Individual #1's apartment was over 18 inches tall and did not have a lid.Trash receptacles over 18 inches high shall have lids. The trash receptacle was replaced. See attachment # 41 Residential Program Mangers have reviewed this regulation and understand that trash receptacle height should be monitored and those over 18 inches are required to have a lid (attachment #2). Residential Supervisors will review this regulation at the monthly Residential Supervisor meeting on 12/13/17 (attachment #3). 12/13/2017 Implemented
6400.68(b)Repeat 10/05/16: The water temperature of the bathtub in the full bathroom on the main living floor measured 125.1 °F. Hot water temperatures in bathtubs and showers may not exceed 120°F. A metering valve has been placed on the hot water heater. The water temperature has been tested several times since the valve has been in place and has not gone above 120 degrees F. See Attachment # 39 Program Managers have reviewed and understand this regulation (attachment #2). Residential Supervisor will review this regulation during the Supervisor meeting on 12/13/17 (attachment # 3). Program Specialists monitor the water temperature at each home on a monthly basis. 12/13/2017 Implemented
6400.101Individual #1 was asleep in his/her recliner in the living room with the chair reclined. The foot rest of the recliner was blocking the exit leading out of the living room to the back yard. Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Staff attempted to move the recliner further away from the exit so that the footrest would not block the exit when it was in use. Unfortunately, the individual will not allow for the recliner to be moved. He moves it back to the place where he prefers it. When the individual is not utilizing the footrest, the chair does not block the exit. The Program Specialist and staff will continue to work with his Behavioral Support Specialist and team to attempt creative ways to place the chair in an effort for the individual to allow for the change. Program Managers have reviewed and understand this regulation (attachment #2). Residential Supervisor will review this regulation during the Supervisor meeting on 12/13/17 (attachment # 3). 12/13/2017 Implemented
6400.104The fire notification letter dated 2/11/16 stated that all individuals are capable of evacuating during a fire drill within two and half minutes. However Individual #1 requires assistance to evacuate as he/she will not evacuate independently and Individual #2 utilizes a bed shaker.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. All Program Managers have been trained on this regulation and understand that the letter to the fire company must state the specific evacuation needs for each individual residing in the home (attachment # 2). The Program Managers have completed an audit of the fire letters for each home and have sent updated letters to the fire companies with specific evacuation needs for each individual (verbal prompts, ambulatory but uses a walker, non-ambulatory, refusals to evacuate, etc.). Residential Supervisors will be re-trained on this regulation at the Supervisors meeting on 12/13/17 (attachment #3). See Attachment # 36, which is the updated letter to the fire department for the Boundary Avenue home. 12/13/2017 Implemented
6400.112(h)Repeat 10/05/16: Individual #1 did not evacuate during any of the fire drills conducted from 10/01/2016 to 10/31/2017. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Individual #1 refuses to evacuate for fire drills. This has been indicated in the updated fire letter sent to the fire department (attachment # 36). He does have a plan in place regarding his refusal to evacuate the home during fire drills. See attachment # 37 During the licensing of this home, it was brought to our attention that Penn-Mar must request a waiver of regulation for him to continue residing in his current placement. This waiver request was submitted on November 21, 2017. See attachment #38 The Program Specialist and staff will continue to work with his Behavior Support Specialist to create ways to attempt assisting him to comply with evaluating during fire drills. Program Managers have reviewed and understand this regulation (attachment #2). Residential Supervisor will review this regulation during the Supervisor meeting on 12/13/17 (attachment # 3). 12/13/2017 Implemented
6400.195(a)Individual #1 did not have toilet paper and soap available to him/her in the bathroom due to behavioral concerns. Individual#1 has a behavior support plan but there are no restrictive procedures currently in place. For each individual for whom restrictive procedures may be used, a restrictive procedure plan shall be written prior to use of restrictive procedures. Staff give Individual #1 toilet paper as he needs it in an attempt to keep the toilet from clogging every time he uses the bathroom. When he has a roll of toilet paper, he attempts to flush the entire roll down the toilet, thus clogging the toilet. Program Specialists have reviewed this regulation and understand the procedure for restrictive plans (attachment #2). The Residential Supervisors will review this regulation at the Residential Supervisor meeting on 12/13/17 (attachment #3). The Program Specialist has written a restrictive plan for the toilet paper not being kept in his bathroom that will be reviewed by our Quality Assurance team on 12/21/17. See attachment # 35 12/13/2017 Implemented
SIN-00070897 Renewal 07/28/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Front bathroom had exposed drywall tape above shower stall & the caulking is peeling off. The 2nd bathroom caulking is cracking and peeling off. There is paint peeling off the ceiling above the shower stall. Floors, walls, ceilings and other surfaces shall be in good repair. Both bathrooms walls and ceilings were repaired. All areas were re-caulked 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
SIN-00177816 Renewal 05/07/2021 Compliant - Finalized
SIN-00161728 Renewal 09/24/2019 Compliant - Finalized
SIN-00070781 Initial review 10/30/2014 Compliant - Finalized