Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC 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 |
6400.103 | The 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 |