Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00202398 Renewal 03/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(d)Staff person #11 resided out of state prior to their 2/14/22 date of hire with Penn-Mar Human Services. While an FBI background check was completed on 2/2/22, there is no record on file of the results of the background check.A copy of the final reports received from the State Police and the FBI, if applicable, shall be kept. The team member started the FBI background check, but Penn-Mar did not ensure a copy of the background check was on file. For the safety of the people we support and our team members, it is important to ensure the organization receives a copy of the FBI background check in a timely manner. Penn-Mar has obtained a copy of the team member's FBI background check. See attachment #7 of the background check. The Human Resource department completed an audit by April 30th to ensure there is follow up with any outstanding background checks. 04/30/2022 Implemented
6400.112(e)There was only one sleep drill that took place from March 2021 to the present and that was on 10/13/21.A fire drill shall be held during sleeping hours at least every 6 months. This regulation is important because it provides an opportunity to practice fire safety and evacuation while individuals are sleeping. It is important that all individuals respond to the fire alarm and that staff are prepared to assist where needed. There was a sleep drill completed on 4/9/2021. However, because the time of the drill was not documented, the drill does not count. The team member responsible for the drill, the residential supervisor, and the quality supports specialist who reviews the documentation for completion did not ensure the time was included. The team member responsible for the drill, the residential supervisor, and the quality supports specialist who reviews the documentation for completion did not ensure the time was included. A sleep drill was completed on April 7, 2022, at Hain Road. The Fire Drill Form was completed in its entirety, including the evacuation time. See Attachment #14. The Program Managers and Residential Supervisors were retrained on 4/13/2022 on regulation 6400.112(e). 04/29/2022 Implemented
6400.112(g)The fire drill completed on 4/9/21 did not have the time of the drill documented. Fire drills shall be held on different days of the week and at different times of the day and night. This regulation is important because completing fire drills will prepare individuals and staff to evacuate quickly, safely, and efficiently in the event of a real fire. Timing a fire drill can help determine if the individuals and staff are prepared to exit as soon as possible in the event of a fire. Extended period of time to evacuate would prompt the program specialist to assess, evaluate, and provide resources where possible to increase the speed in which individuals and staff exit the home. There was a sleep drill completed on 4/9/2021. However, because the time of the drill was not documented, the drill does not count. The team member responsible for the drill, the residential supervisor, and the quality supports specialist who reviews the documentation for completion did not ensure the time was included. The team member responsible for the drill, the residential supervisor, and the quality supports specialist who reviews the documentation for completion did not ensure the time was included.A sleep drill was completed on April 7, 2022, at Hain Road. The Fire Drill Form was completed in its entirety, including the evacuation time. See Attachment #14. The Program Managers and Residential Supervisors were retrained on 4/13/2022 on regulation 6400.112(g). 04/29/2022 Implemented
6400.141(c)(13)The allergies and contraindicated medications section on Individual #1's most recent annual physical examination completed on 11/1/21 was left blank.The physical examination shall include: Allergies or contraindicated medications.This regulation is important because accurate medical information is essential to develop accurate assessments and individual plans. Knowing accurate information would ensure that Individual #1 is receiving proper medical support and that their needs are being met. The allergy and contraindicated medication section was left blank on Individual #1's annual physical examination. Individual #1's family has full involvement with the Individual's medical care. The family is very private and reserved and does not want support from Penn-Mar with Individual #1's medical appointments. Therefore, the family took Individual #1 to the physical appointment and the paperwork was not completed in its entirety. When the Residential Supervisor informed the family that the allergy section needed to be completed, they were not responsive with getting this information added to the physical. Additionally, the family did not want the Residential Supervisor to contact the PCP directly. Feedback was received in the exit conference regarding how Penn-Mar can approach the situation. Given that Individual #1 is their own legal guardian and Penn-Mar is responsible for the Individual's care and implementing recommendations, a meeting will be held with the family to help them understand why Penn-Mar needs to be involved in the medical care moving forward. This meeting is scheduled for 4/29/2022. Additionally, in the meantime, the Residential Supervisor will continue to ask the family to get the annual physical updated to include allergies and contraindicated medications. Program Specialists will be completing an audit by 4/22/2022 to ensure all annual physicals include allergies and contraindicated medications. Since this inspection, an Annual Physical was completed on 4/5/2022 and includes the allergies and contraindicated medications. See attachment #6. 04/29/2022 Implemented
6400.141(c)(14)(REPEAT VIOLATION FROM 1/4/21) -- The medical information pertinent to diagnosis or treatment in the event of an emergency section on Individual #1's most recent annual physical examination completed on 11/1/21 was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. This regulation is important because accurate medical information is essential to develop accurate assessments and individual plans. Knowing accurate information would ensure that Individual #1 is receiving proper medical support and that their needs are being met. The information pertinent to diagnosis or treatment in the event of an emergency section was left blank on Individual #1's annual physical examination. Individual #1's family has full involvement with the Individual's medical care. The family is very private and reserved and does not want support from Penn-Mar with Individual #1's medical appointments. Therefore, the family took Individual #1 to the physical appointment and the paperwork was not completed in its entirety. When the Residential Supervisor informed the family that the information pertinent to diagnosis or treatment in the event of an emergency section needed to be completed, they were not responsive with getting this information added to the physical. Additionally, the family did not want the Residential Supervisor to contact the PCP directly. Feedback was received in the exit conference regarding how Penn-Mar can approach the situation. Given that Individual #1 is their own legal guardian and Penn-Mar is responsible for their care and implementing recommendations, a meeting will be held with the family to help them understand why Penn-Mar needs to be involved in her medical care moving forward. This meeting is scheduled for 4/29/2022. Additionally, in the meantime, the Residential Supervisor will continue to ask the family to get the annual physical updated to include medical information pertinent to diagnosis or treatment in the event of an emergency. Program Specialists will be completing an audit by 4/22/2022 to ensure all annual physicals include medical information pertinent to diagnosis or treatment in the event of an emergency. Since this inspection, an Annual Physical was completed on 4/5/2022 and includes medical information pertinent to diagnosis or treatment in the event of an emergency section is completed. See attachment #6. 04/29/2022 Implemented
6400.142(a)Individual #1's dentist indicates that they need exams every 6 months. As of the 3/29/22 inspection, Individual #1 has not had a dental examination since 8/19/21.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. This regulation is important because it ensures individuals receive necessary dental care to prevent illness and serious health conditions. Individual #1 had a dental examination on 8/19/2021 and the recommendation was to follow up in 6 months. The 6-month appointment was cancelled because Individual #1's family thought the staff sounded like they had a cold. The dental appointment was rescheduled for 3/30/2022. However, the medical appointment record has not been received because Individual #1 has not returned home and the family took the Individual to the appointment. Individual #1's family is very private with the Individual's medical care and does not want Penn-Mar staff taking the Individual to appointments. This is another citation which is a result of the family taking ownership of the Individual's medical care. Feedback was received in the exit conference regarding how Penn-Mar can approach the situation. Given that Individual #1 is their own legal guardian and Penn-Mar is responsible for the Individual's care and implementing recommendations, a meeting will be held with the family to help them understand why Penn-Mar needs to be involved in her medical care moving forward. This meeting is scheduled for 4/29/2022. Program Specialists will be completing an audit by 4/22/2022 to ensure all dental exams are scheduled as recommended. 04/29/2022 Implemented
6400.151(c)(2)Staff person #1's tuberculin test dated 1/20/21 was not read by a registered nurse, licensed practical nurse, licensed physician, licensed physician's assistant or certified nurse practitioner. Staff person #4's tuberculin test dated 6/26/21 was read by a medical assistant. Staff person #8's had a tuberculin test on 4/2/19 and not again until 9/3/21. This test was also read by a medical assistant. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. This citation was received because Penn-Mar failed to ensure that when team members received their TB test, it was completed by a registered nurse, licensed practical nurse, physician, licensed physician's assistant or certified nurse practitioner. In addition, a team member failed to complete their bi-annual physical within the required timeframe. It is important to ensure that the appropriate medical professionals complete the TB test as required by this regulation. In addition, for the safety of team members and the people we support, It is important to ensure team members complete their bi-annual physical in the required timeframe. 04/11/2022 Implemented
6400.151(c)(3)Staff person #3's most recent physical examination completed on 2/25/22 did not address if staff person #3 has a communicable disease. Staff person #5's most recent physical examination completed on 10/1/20 did not address if staff person #5 has a communicable disease. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. This citation was received because on two occasions Penn-Mar failed to ensure staff physicals addressed if staff were free from a communicable disease, or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that prevent the spread of the disease to individuals. For the safety of the people supported by Penn-Mar, it is important to know if team members have a communicable disease to ensure proper precautions are taken to prevent the spread of a disease.The Human Resources Manager contacted the medical provider who failed to document if the staff has a communicable disease. The provider was asked on 4/18/2022 to include this information on the physical examination for staff person #3 and staff person #5. In the event they are unwilling to update the documentation without seeing the team members, the team members will receive a new physical examination and be assessed for communicable diseases. 04/11/2022 Implemented
6400.211(b)(1)There is not an address listed for Individual #1's emergency contact.Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. This regulation is important because having the address and phone number of Individual #1's emergency contact and emergency consent will ensure critical health information is available in the event of a medical emergency. Individual #1's emergency information did not include the address of the emergency contact or emergency consent person. The Residential Supervisor, Direct Support Professionals, and Program Specialist that support Individual #1 did not ensure the emergency information was completed in its entirety. Individual #1's emergency information has been updated to include the address of their emergency contact and emergency consent person. See Attachment 10. Additionally, Program Specialists will be completing an audit of all individual's emergency information to ensure it includes the address and telephone number of their primary care physician. The Program Specialist will make changes as needed to ensure this information is listed. This audit will be completed by April 22, 2022. 04/29/2022 Implemented
6400.46(b)Staff person #1 was trained in fire safety on 2/1/21 and not again until 3/4/22. Staff person #2 was trained in fire safety on 2/1/21 and not again until 3/7/22. Staff person #3 was trained in fire safety on 2/2/21 and not again until 3/4/21. Staff person #4 was trained in fire safety on 2/10/21 and not again until 3/15/22. Staff person #5 on 2/2/21 and not again until 3/8/22. Staff person #6 was trained in fire safety on 2/11/21 and not again until 3/11/22. Staff person #7 was trained in fire safety on 2/11/21 and not again until 3/7/22. Staff person #8 was trained in fire safety on 2/1/21 and not again until 3/7/22. Staff person #9 was trained in fire safety on 2/3/21 and not again until 3/7/22.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Penn-Mar failed to ensure that team members completed fire safety training within one year of their previous training. In 2021, team all team members received annual fire safety training in February 2021. This year, team members received fire safety training in March 2022. It is important for team members to be trained annually on fire safety training to ensure they understand evaluation procedures of the program. 04/12/2022 Implemented
6400.46(d)Staff person # 10's CPR and First Aid certification expired on 4/30/21. They did not complete recertification until 2/25/22.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.Penn-Mar failed to ensure that a team member completed their CPR and First Aid recertification within the required timeframe. For the safety of the people we support, it is important for program specialists, direct service workers and drivers of and aides in vehicles to receive CPR and First Aid recertification as required by regulation. After receiving this citation, Penn-Mar realized that we did not have a tracking system in place to monitor CPR/First Aid trainers certification expirations 04/11/2022 Implemented
6400.166(a)(11)(REPEAT VIOLATION FROM 1/4/21)-- Individual #1's Medication Administration Records do not list the diagnosis/purpose for the following medications: famotidine, fluticasone, levothyroxine, prebiotin, and Preparation H Cream Max.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.This regulation is important because the same medications may be used to treat different conditions and the certified medication administrator needs to know what medications they are given to the individual, as well as the diagnosis associated with the medication. Knowing this information supports the 15 steps of medication administration and ensures medications are administered as prescribed. The Medication Administration Record did not include the diagnosis or purpose for famotidine, fluticasone, levothyroxine, prebiotin, and Preparation H Cream Max. The Residential Team Member did not ensure the Medication Record included diagnosis or purpose for the medication. Additionally, the team members who administered Individual #1's medications did not notice or communicate that the diagnosis or purpose for medication was not listed on the MAR. The Program Specialist will complete an audit of all individual's MAR's to ensure the diagnosis or purpose for the medication is listed on the Medication Administration Record. In the event it is not listed, the Program Specialist will update the MAR. The audit will be completed by April 22, 2022. Unfortunately, Individual #1 has not been in program since the inspection. Therefore, their MAR has not been updated because the labels are not at the program to ensure they match. However, another individual was cited for the diagnosis/purpose not being listed and her log has been updated. See attachment #4. 04/29/2022 Implemented
6400.167(a)(4)(REPEAT VIOLATION FROM 1/4/21)-- Individual #1's Levothyroxine, which is to be administered at 6am, was administered more than an hour late on the following dates: 2/25/21, 3/2/21, 6/21/21, 12/9/21, 2/1/22, 2/7/22.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 Levothyroxine was administered late on 2/25/21, 3/2/21, 6/21/2, 12/9/21, 2/1/22, and 2/7/22. After review of the instances in which Levothyroxine was delivered late, it is unknown as to why this happened. 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
6400.169(a)(REPEAT VIOLATION FROM 1/4/21)-- At the time of the 3/29/22 inspection, staff person #7's Medication Administration Training recertification was signed as complete and pre-dated with the date 4/17/22.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).This citation was received because the medication trainer pre-dated and signed a team member's medication recertification packet with the date by which the team member needed to complete the recertification. It is important to ensure documentation is not pre-dated to prevent falsifying records. To prevent this error from occurring in the future, all medication administration trainers have been retrained on this regulation. Following the licensing exit on March 31, 2022, the agency nurses completed an audit to ensure all medication administration certifications are in compliance. 04/11/2022 Implemented
SIN-00161729 Renewal 09/24/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(2)On 8/28/19 Individual # 1's balance ledger documented $35.89, then on 8/29/19 $10.05 was spent at Infinito's pizza and then new balance recorded was $25.85 when it should have read $25.84. The ending balance for the month should have been $218.04 but the ledger documented $218.05. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: For a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. It is important to keep an accurate record of funds to ensure the funds of the individuals we support are spent appropriately. The Program Manager trained the staff on the need to ensure they are counting funds accurately and accurately documenting deposits and withdrawals onto the money transaction form for each transaction. The Program Manager re-programmed the calculation on the form to automatically calculate changes. The $0.01 that was found was added to the ledger and the balance has been corrected. See attachment of the corrected money transaction forms for August and September. All residential team members have reviewed this regulation and understand the need to ensure money is counted and recorded accurately. See attached email sent to all team members on 10/11/19. Program managers have had training regarding this regulation during the exit conference with state licensing staff on 9/25/19. They will continue to monitor funds for each individual when they complete monthly site monitoring at each group home. Site monitoring 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 was also completed with the Residential Supervisors at their team meeting on 10/9/19. 10/15/2019 Implemented
SIN-00102845 Renewal 10/05/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(1)The program specialist did not complete Individual #1's assessment; the house manager did.The program specialist shall be responsible for the following: Coordinating and completing assessments. The process for completing assessments at Penn-Mar has changed as a result of this clarification. House supervisors had previously completed the assessment and Program Specialists reviewed and made changes as needed. Program Specialists now complete the assessment; however, they still rely on information obtained from the house supervisor as the house supervisor has the best first-hand knowledge about the individual. Attached is a completed assessment that was completed with this new process. See attachment X 12/16/2016 Implemented
6400.67(a)Individual #2's third dresser drawer is missing a handle. The second drawer had two detached handles.Floors, walls, ceilings and other surfaces shall be in good repair. Handles were replaced on the dresser. See attachment AH All Residential Supervisors and Program Specialist level staff were trained on the need to be more mindful of furniture knobs/handles. Program Specialists now look for this during their monthly site visits. See attachment A 10/12/2016 Implemented
6400.77(b)The first aid kit did not include tape. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. The first aid kit does now include tape. See Attachment AG All Residential Supervisors and Program Specialists were re-trained on the need to ensure that the first aid kit is stocked with the items required by regulations. Supervisors are to inform all their staff that if they use a required item they must inform the supervisor so that a replacement can be purchased. This is to be checked on a monthly basis by the Program Specialist during their site inspection. See Attachment A 10/12/2016 Implemented
6400.103The written evacuation plan did not include individual and staff responsibilities and means of transportation.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. As a result of this citation an audit of all homes written evacuation procedure plan was completed and it was determined that as Penn-Mar has grown, an issue has also grown that too many Supervisors were creating their own written evacuation procedure plan and it was becoming too easy for the information that is required to get missed. Therefore, a master template was created to address the written evacuation procedure plan. This template was given to all Supervisors of all Penn-Mar residential homes. All homes have now completed this updated standardized form. Attached you will find the new written evacuation procedure plan for the Stewartstown home. See Attachment AF 11/01/2016 Implemented
6400.141(c)(9)Individual #1's 2/29/16 prostate exam was completed. The previous exam was completed on 10/29/14.The physical examination shall include: A prostate examination for men 40 years of age or older. Attached are the past two year annual physicals for an individual which shows that the prostate exam was completed on time. See Attachment AE All Residential Supervisors and Program Specialists were retrained on this regulation and received specific guidance on how to proceed if a prostate exam should fall off the annual physical cycle. The issue with this situation is that the doctor deferred a prostate at the individuals annual physical because a colonoscopy had been done 4 months prior. In the future if this happens, Staff will need to keep track of the prostate exam date separately from the physical. See Attachment A 11/25/2016 Implemented
6400.141(c)(11)Individual #1's 2/29/16 physical exam did not include health maintenance needs. The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Attached is a physical exam that was completed since licensing that includes the health maintenance needs section being completed. See Attachment AE All Residential Supervisors and Program Specialists were re-trained on the need for all sections of the physical to be completed. See Attachment A & U 11/25/2016 Implemented
6400.141(c)(14)Individual #1's 2/29/16 physical exam did not include information pertinent to diagnosis and treament in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Attached is a physical exam that was completed since licensing that includes the information pertinent to diagnosis and treatment in case of emergency section being completed. See Attachment AE All Residential Supervisors and Program Specialists were re-trained on the need for all sections of the physical to be completed. See Attachment A & U 11/25/2016 Implemented
6400.181(e)(13)(i)Individual #1's 2/29/16 assessment did not include progerss over the past year in health.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. Attached you will find an addendum to Individual #1¿s assessment that includes his progress over the past year in health. See Attachment AD In addition, there is an attachment from an assessment that was completed since our licensing inspection, for a different individual, that documents this information as part of the assessment. See Attachment X All Program Specialists were re-trained on the need to ensure that assessments document specific progress over the past year rather than simply reiterating information from last year. Even if the individual has not made any significant improvement or regression, Program Specialists are being tasked with ensuring that a thorough assessment is completed. See Attachment A 12/16/2016 Implemented
6400.181(e)(13)(ii)Individual #1's 2/29/16 assessment did not include progerss over the past year in motor and communication skills.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. Attached you will find an addendum to Individual #1¿s assessment that includes his progress over the past year in motor and communication skills. See Attachment AD In addition, there is an attachment from an assessment that was completed since our licensing inspection, for a different individual, that documents this information as part of the assessment. See Attachment X All Program Specialists were re-trained on the need to ensure that assessments document specific progress over the past year rather than simply reiterating information from last year. Even if the individual has not made any significant improvement or regression, Program Specialists are being tasked with ensuring that a thorough assessment is completed. See Attachment A 12/16/2016 Implemented
6400.181(e)(13)(iii)Individual #1's 2/29/16 assessment did not include progerss over the past year in residential living.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. Attached you will find an addendum to Individual #1¿s assessment that includes his progress over the past year in residential living See Attachment AD In addition, there is an attachment from an assessment that was completed since our licensing inspection, for a different individual, that documents this information as part of the assessment. See Attachment X All Program Specialists were re-trained on the need to ensure that assessments document specific progress over the past year rather than simply reiterating information from last year. Even if the individual has not made any significant improvement or regression, Program Specialists are being tasked with ensuring that a thorough assessment is completed. See Attachment A 12/16/2016 Implemented
6400.181(e)(13)(iv)Individual #1's 2/29/16 assessment did not include progerss over the past year in personal adjustment.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. Attached you will find an addendum to Individual #1¿s assessment that includes his progress over the past year in personal adjustment. See Attachment AD In addition, there is an attachment from an assessment that was completed since our licensing inspection, for a different individual, that documents this information as part of the assessment. See Attachment X All Program Specialists were re-trained on the need to ensure that assessments document specific progress over the past year rather than simply reiterating information from last year. Even if the individual has not made any significant improvement or regression, Program Specialists are being tasked with ensuring that a thorough assessment is completed. See Attachment A 12/16/2016 Implemented
6400.181(e)(13)(v)Individual #1's 2/29/16 assessment did not include progerss over the past year in socialization.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. Attached you will find an addendum to Individual #1¿s assessment that includes his progress over the past year in socialization. See Attachment AD In addition, there is an attachment from an assessment that was completed since our licensing inspection, for a different individual, that documents this information as part of the assessment. See Attachment X All Program Specialists were re-trained on the need to ensure that assessments document specific progress over the past year rather than simply reiterating information from last year. Even if the individual has not made any significant improvement or regression, Program Specialists are being tasked with ensuring that a thorough assessment is completed. See Attachment A 12/16/2016 Implemented
6400.181(e)(13)(vi)Individual #1's 2/29/16 assessment did not include progerss over the past year in recreation.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. Attached you will find an addendum to Individual #1¿s assessment that includes his progress over the past year in recreation. See Attachment AD In addition, there is an attachment from an assessment that was completed since our licensing inspection, for a different individual, that documents this information as part of the assessment. See Attachment X All Program Specialists were re-trained on the need to ensure that assessments document specific progress over the past year rather than simply reiterating information from last year. Even if the individual has not made any significant improvement or regression, Program Specialists are being tasked with ensuring that a thorough assessment is completed. See Attachment A 12/16/2016 Implemented
6400.181(e)(13)(vii)Individual #1's 2/29/16 assessment did not include progerss over the past year in financial independence.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. Attached you will find an addendum to Individual #1¿s assessment that includes his progress over the past year in financial independence. See Attachment AD In addition, there is an attachment from an assessment that was completed since our licensing inspection, for a different individual, that documents this information as part of the assessment. See Attachment X All Program Specialists were re-trained on the need to ensure that assessments document specific progress over the past year rather than simply reiterating information from last year. Even if the individual has not made any significant improvement or regression, Program Specialists are being tasked with ensuring that a thorough assessment is completed. See Attachment A 12/16/2016 Implemented
6400.181(e)(13)(viii)Individual #1's 2/29/16 assessment did not include progerss over the past year in managing personal property.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. Attached you will find an addendum to Individual #1¿s assessment that includes his progress over the past year in managing personal property. See Attachment AD In addition, there is an attachment from an assessment that was completed since our licensing inspection, for a different individual, that documents this information as part of the assessment. See Attachment X All Program Specialists were re-trained on the need to ensure that assessments document specific progress over the past year rather than simply reiterating information from last year. Even if the individual has not made any significant improvement or regression, Program Specialists are being tasked with ensuring that a thorough assessment is completed. See Attachment A 12/16/2016 Implemented
6400.181(f)Individual #1's 9/26/16 assessment was sent to plan team members on 9/26/16 for a 10/12/16 Individual Support Plan meeting.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Since this licensing inspection another individual has an ISP meeting scheduled for 1/19/2017. This individual¿s assessment was sent to plan team members on 12/16/16, thus meeting the requirement. See Attachment X All Program Specialists were re-trained that even though they may encounter an issue with a Supports Coordinator who is not responsive to emails about scheduling the ISP meeting, they should plan to have the assessment completed within one year of the last assessment and they could always send the assessment to plan team members even if the ISP meeting is not yet scheduled. In doing this they can ensure that the assessment is sent within 30 days of the ISP meeting, even if the ISP meeting is not scheduled yet. Program Specialists were also trained to reach out to an SC supervisor if the SC is not responsive to emails about the need to schedule the ISP meeting. See Attachment A 12/16/2016 Implemented
6400.186(a)The program specialist did not complete Individual #1's Individual Support Plan (ISP) reviews; a direct care staff member did.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. The process for completing ISP reviews at Penn-Mar has changed as a result of this clarification. House supervisors had previously completed the ISP reviews and Program Specialists reviewed and made changes as needed. Program Specialists now complete the ISP reviews; however, they still rely on information obtained from the house supervisor as the house supervisor has the best first-hand knowledge about the individual. Attached is new ISP review template that will be completed by Program Specialists moving forward. See Attachment Y 12/21/2016 Implemented
6400.186(c)(1)Individual #1's 4/11/16 and 7/10/16 Individual Support Plan (ISP) reviews did not include progress and participation towards the independence outcome in the ISP.The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. Attached is the ISP review for October for Individual #1 which does include his progress and participation towards the independence outcome in the ISP. See Attachment AB All Program Specialists were trained on the need to ensure that ISP reviews are completed thoroughly and that all progress on outcomes is reviewed. See Attachment A 10/20/2016 Implemented
6400.186(c)(2)Individual #1's social, emotional, environmental needs (SEEN) plan was not reviewed in the Individual Support Plan (ISP) reviews. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. Attached is the ISP review for October for Individual #1 which does include a review of the SEEN plan. See Attachment AB All Program Specialists were trained on the need to ensure that ISP reviews are completed thoroughly and include a review of the SEEN plan if the person has one. See Attachment A 10/20/2016 Implemented
6400.186(e)Individual #1's plan team members were not given the option to decline the Individual Support Plan reviews. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. Individual #1¿s team members have since been sent the option to decline the ISP reviews. See Attachment AC All Program Specialists were trained on the need to ensure that a letter is sent to all team members giving them the option to decline the ISP review. See Attachment A 10/12/2016 Implemented
SIN-00177817 Renewal 05/07/2021 Compliant - Finalized
SIN-00070782 Initial review 10/30/2014 Compliant - Finalized