| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | On 08/18/23 Individual #1's funds were used to purchase sheet sets and comforters. These are items that are to be included with room and board. On 08/22/23, Individual #1's money was used to purchase items that are to be included with room and board. | Individual funds and property shall be used for the individual's benefit. | This regulation is important because it prevents exploitation and misuse of funds.
Individual #1 used their funds to purchase sheet sets and comforters.
This occurred because the individual prefers picking out their comforter and the team did not believe it was necessary for Penn-Mar to pay for this. However, there was not proper documentation to support the education to the person supported and the team decision to support this purchase.
An audit will be completed for Individual #1 to ensure that they did not pay for items that are to be provided as part of room and board.
Individual #1 will be reimbursed for anything they spent on these items in the April 2024 Room & Board Statement.
In addition, Program Specialists will complete an audit to ensure that other people supported are not paying for items that are part of room and board, unless the team determines it is important to and for them, and this is documented in their ISP.
Anyone who has paid for items through the restitution process will be reimbursed.
The audit will be completed by March 31st, and reimbursements will occur on the April room and boards for people supported. |
03/04/2024
| Implemented |
| 6400.22(d)(1) | Individual #1's financial record is not current and up to date. The ending balance in July 2023 was $2.69. The beginning balance in August was $2.79. The ending balance for December 2023 was $81.35. The beginning balance for January 2024 was $60.89. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | This regulation is important because people supported by Penn-Mar rely on staff members to ensure their personal finances and property are being managed appropriately.
During the inspection, there were 2 months where the end of month balance was not transferred correctly to the following month.
It was determined this occurred as a result of the Program Supervisor incorrectly transferring the balance, followed by the Program Specialist incorrectly reviewing monthly financials, as it should be compared to the previous month.
Program Specialists completed an audit of monthly financials for all PA Residential Individuals. It was found that there were 8 unaddressed discrepancies. Program Specialists have been made aware of the discrepancies and have provided feedback to the teams. Reimbursement requests will be completed by March 8, 2024. |
03/04/2024
| Implemented |
| 6400.64(a) | At the time of the inspection, the bathroom that Individual #1 uses had a strong smell of urine. | Clean and sanitary conditions shall be maintained in the home. | The regulation is important because it provides standard policies and routine practices to minimize the risk of illness, infection, or injury and provide for a dignified living environment.
The violation for smell of urine occurred because the individual chooses to not urinate in the toilet. They choose to urinate in the corner of the bathroom which is part of their routine.
Following the inspection, the Program Specialists did a walkthrough of each program to ensure that regulation 6400.64(a) was met. At the time of the walkthrough, one other program had a strong odor of urine in the bathroom. The Program Specialist has been informed and the program is utilizing new cleaning supplies to address the odor.
Odoban and Urine be gone cleaner was ordered on 2/8/24 to attempt to eliminate the smell of urine. It was utilized in the bathroom, but the smell of urine was still present in the bathroom after utilizing it. Program Manager ordered electric scrub brush on 2/16/2024 to see if that would aid in the elimination of the urine smell.
If the ongoing attempts to clean the bathrooms does not eliminate the odor smell, it is likely that the bathroom will need to be re-modeled, or at least a new floor will need to be placed. The Assistant Director will work with the maintenance lead to see what options exist for this fiscal year. |
03/04/2024
| Implemented |
| 6400.67(a) | At the time of the inspection, the sink in Individual #1's bathroom drained extremely slowly. | Floors, walls, ceilings and other surfaces shall be in good repair. | Safe surfaces help to maintain sanitary conditions in the home, minimize the risk that individuals will suffer an injury while ambulating, and provide dignified living conditions.
While testing the water temp, the inspector noticed that the sink was draining very slowly.
This occurred due to the individual having a ritual that includes putting their med cup into the drain, therefore causing a backup of water.
A maintenance request was submitted on 2/13/2024 to address the slow draining sink. Maintenance fixed the sink on 2/16/2024 so the water now drains as it should. An audit was completed of all sinks in all 27 programs so see if there were any additional drains moving slowly. No other sinks were found to have issues with draining. |
03/04/2024
| Implemented |
| 6400.77(c) | At the time of the inspection, there was no first aid manual located in the first aid kit. | A first aid manual shall be kept with the first aid kit. | This regulation ensures that homes have the equipment needed to provide first aid in the event of an injury.
While reviewing first aid kit contents during the inspection, the inspector noticed there was no manual present.
The kit contents were not thoroughly checked on a regular basis by the Residential Supervisor nor Program Manager to ensure that all required materials were available.
A first aid manual was purchased on 2/16/2024 and was placed in the first aid kit on 2/18/2024 upon arrival. An audit was completed of first aid kits in all 27 programs. All programs had a first aid manual except for one home who will received one on 2/18/2024. See attachment #8. |
03/04/2024
| Implemented |
| 6400.103 | The emergency medical plan for Individual #1 does not identify a specific emergency shelter. It simply says "hotel." | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| This regulation is important because it ensures that staff and individuals are prepared in the event of an emergency.
During the inspection, the individual's emergency evacuation plan did not specify what hotel they would go to in the event of an emergency.
The organization did not recognize the importance of specifying the hotel.
In order to immediately fix the issue, the emergency evacuation plan was updated to specify which hotel should be used in the event of an emergency. See attachment #9.
An audit was completed, and all emergency medical and evacuation plans have the specified address of the relocation plan. |
03/04/2024
| Implemented |
| 6400.141(a) | Individual #1 had a physical exam completed on 10/11/22 and not again until 11/07/23, outside of the annual timeframe. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | This regulation is important to ensure health and safety for all individuals receiving services at Penn-Mar Human Services.
Individual #1 had a physical exam completed on 10/11/22 and not again until 11/7/23, outside of the annual timeframe.
The person supported is extremely routine oriented. In addition, they establish rituals, which interferes with their ability to attend medical appointments.
The annual physical was due at a time in which the individual would not have attended the appointment based on where they were at in their rituals. Therefore, the annual physical occurred late.
The issue identified through the inspection was that the Residential Supervisor, Program Specialist, and Nurse failed to ensure that proper documentation was in place to support the lack of compliance. There was also not a refusal plan established, which has since been implemented. See attachment #10.
During the monthly site monitoring in February and March, Program Specialist will ensure that annual physicals are scheduled to be completed within the required timeframe. |
03/04/2024
| Implemented |
| 6400.141(b) | Individual #1's most recent physical exam was conducted on 11/07/23. The CRNP did not sign the document until 11/17/23. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | This regulation is important to ensure health and safety for all individuals receiving services at Penn-Mar Human Services.
Individual #1's most recent physical exam was conducted on 11/7/23. The CRNP did not sign the document until 11/17/23.
The staff member attending the appointment with the individual left the paperwork with the physician to complete after the appointment. The physician then mailed the completed document back to the program after dating the documents 11/17/2023.
The individual struggles with being outside of their routine, home or dressed as normal social standards require when being out of their home. Therefore, they could not wait for the document to be completed at the time of the appointment.
The Program Specialist is working with the Program Supervisor of the home to determine what additional support may be necessary during medical appointments to ensure that adequate time is available for paperwork to be completed and reviewed. |
03/04/2024
| Implemented |
| 6400.141(c)(3) | Individual #1 had TDAP administered 03/11/23 and not again until 11/07/23, outside of the required timeframe of every 10 years. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | This regulation is important to ensure health and safety for all individuals receiving services at Penn-Mar Human Services.
Individual #1 had TDAP administered 3/11/13 and not again until 11/7/23, outside of the required timeframe of every 10 years. Tdap immunization was not scheduled and was only requested at the annual physical appointment.
The person supported is extremely routine oriented. In addition, they establish rituals, which interferes with their ability to attend medical appointments.
The TDap was due at a time in which the individual would not have attended the appointment based on where they were at in their rituals. Therefore, the Tdap was administered late.
The issue identified through the inspection was that the Residential Supervisor, Program Specialist, and Nurse failed to ensure that proper documentation was in place to support the lack of compliance. There was also not a refusal plan established, which has since been implemented. See attachment #10.
The Quality & Compliance Department will complete an audit of all people supported to ensure their TDAP is in compliance. This audit will be completed by April 12, 2024. |
03/04/2024
| Implemented |
| 6400.141(c)(4) | Individual #1 has not had a vision exam or hearing exam. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | This regulation is important to ensure health and safety for all individuals receiving services at Penn-Mar Human Services.
Individual #1 has not had a vision exam or a hearing exam. The exam did not take place at the annual physical. The appointment for the exams has been scheduled for March 19, 2024.
This program supervisor, program specialist, and nurse failed to ensure that Individual #1 had an annual vision and hearing exam.
All Program Specialists will audit each person supported to ensure that they have had a vision and hearing exam completed per regulation. This will be completed during site monitoring in February and March. |
03/04/2024
| Implemented |
| 6400.141(c)(6) | Individual #1 had a TB test conducted on 07/07/21 and not again until 11/09/23; outside of the required timeframe of every two years. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | This regulation is important to ensure health and safety for all individuals receiving services at Penn-Mar Human Services.
The person supported is extremely routine oriented. In addition, they establish rituals, which interferes with their ability to attend medical appointments.
The TB test was due at a time in which the individual would not have attended the appointment based on where they were at in their rituals. Therefore, the TB test was administered late.
The issue identified through the inspection was that the Residential Supervisor, Program Specialist, and Nurse failed to ensure that proper documentation was in place to support the lack of compliance. There was also not a refusal plan established, which has since been implemented. See attachment #10.
The Quality & Compliance Department will complete an audit of all people supported to ensure their TB test is in compliance. This audit will be completed by April 12, 2024. |
03/04/2024
| Implemented |
| 6400.141(c)(9) | Individual #1 had a prostate exam on 12/16/21 and not again until 12/29/23, outside of the annual timeframe. | The physical examination shall include: A prostate examination for men 40 years of age or older. | This regulation is important to ensure health and safety for all individuals receiving services at Penn-Mar Human Services.
Individual #1 had a prostate exam on 12/16/21 and not again until 12/29/23, outside of the annual timeframe. The prostate exam was not completed at the annual physical or independently scheduled.
This occurred because the residential supervisor, program specialist, and agency nurse did not ensure that a prostate exam occurred within the required timeframe. This was not caught during the development of medical history, or during monthly site monitoring.
Program Specialists will audit all people supported who are required to have a prostate examination per regulation 6400.141(c)(9). The audit will be completed by March 31, 2024. |
03/04/2024
| Implemented |
| 6400.143(a) | Individual #1 refuses their Gold Bond medication essentially every day. No documentation was provided verifying the individual was educated on the importance of following recommendations | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | This regulation promotes self-direction, choice, and control while protecting individual health and safety.
Individual #1 refused their Gold Bond medication essentially every day. No documentation was provided verifying the individual was educated on the importance of following recommendations.
The violation occurred because staff failed to educate and document the education to the individual on the importance of receiving medications daily and following recommendations. On the monthly site monitoring form, there is a section that reviews what medications are not given often to prompt Program Specialists and Residential Supervisors to determine why it is not being successfully administered, ensure there is proper documentation to support the refusals and education to the person supported, and ultimately determine if the medication could be discontinued or if there are alternatives that might be more successful. The Residential Supervisor and Program Manager failed to address the excessive refusals of this medication.
After receiving the violation on 2/2/2024, the staff of that specific program were trained on 2/28/2024 on the importance of educating and documenting that they educated the individual on the importance of following medical recommendations. There has been a refusal plan created, which staff will utilize to document refusals and education to the individual. See attachment #10.
On February 1, 2024, the PCP was contacted regarding Individual #1's refusals for Gold Bond Lotion. Individual #1 refuses this medication because they will not allow staff to apply the lotion once they get dressed. Since the individual is ritualistic and will get dressed at various times throughout the day, staff are unable to apply the medication within the specified timeframe.
On February 22, 2024, the medication was changed to PRN. Staff will attempt to apply the Gold Bond when the individual is not dressed, which will likely increase the frequency of it being applied. This will be reviewed on April 1, 2024, to determine if the change has increased the frequency of successful attempts. |
03/04/2024
| Implemented |
| 6400.144 | (Repeat from Inspection from 03/14/23) Per the psych visit conducted on 12/12/23 GH is to provide vital signs for virtual visits. Did this happen? As per Individual #1's medical appointment with their PCP on 09/01/23, a referral was made to neurology for low sodium, hypertension, and an abnormal MRI. F/U was also to be completed with a neurosurgeon due to a compression fracture of L1. At the time of inspection, Individual #1 has not seen a neurologist or neurosurgeon. Additionally, a referral was made for nephrology for Individual #1 at that appointment. As of the inspection, Individual #1 has not seen a nephrologist. On 10/18/23, it was recommended that Individual #1 follow-up with Orthopedics and with Cornerstone for In-Home Supports. As of the time of inspection, this has not occurred. Individual #1 is to have their feet and blood pressure checked daily. There is no documentation this occurred. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| This regulation is important because failure to arrange or provide for health services or to implement recommendations may lead to individual harm.
Per the psych visit conducted on 12/12/23 GH is to provide vital signs for virtual visits. There was no proof that the Group Home provided vital signs during this appointment.
As per Individual #1's medical appointment with their PCP on 9/1/23, a referral was made to neurology for low sodium, hypertension, and an abnormal MRI. Follow up was also to be completed with a neurosurgeon due to a compression fracture of L1. At the time of inspection, Individual #1 did not see a neurologist or neurosurgeon. Additionally, a referral was made for nephrology for Individual #1 at that appointment. As of the inspection, Individual #1 has not seen a nephrologist. On 10/18/23, it was recommended that Individual #1 follow-up with Orthopedics and with Cornerstone for In-Home Supports. As of the time of inspection, this has not occurred. Individual #1 is to have their feet and blood pressure checked daily. There is no documentation this occurred.
On 12/12/23, a psych appointment was changed from in person to virtual because the individual refused to get dressed due to their rituals and routines. Due to the appointment being changed to virtual, the doctor requested staff to provide vital signs during the appointment. Staff attempted to get vital signs from the individual, but the individual refused to comply. Staff failed to document the individual's refusals and educate them on the importance of following recommendations.
On 9/1/23, a referral was made to neurology, nephrology, and neurosurgeon but staff did not reach out to the specialist to follow up on scheduling an appointment. Staff were waiting for the specialist to reach out to the program to schedule an appointment.
On 10/18/23, a recommendation was made for the individual to follow up with Cornerstone and Orthopedics for in-home support. Staff did not ask the doctor to fill out an appointment record after discussing with staff and the individual's mom that they would not benefit from receiving these services.
The doctor recommended the individual have feet and blood pressure checked daily. There was no tracking documented staff were checking the individual's feet daily.
The entire team of staff at this location received retraining on 2/28/2024 regarding the need to follow medical recommendations and document recommendations that are being followed. Paperwork that was completed from the time of the inspection until the re-training was submitted to the Program Manager, Program Nurse, and Assistant Director immediately after the appointment to ensure the paperwork is thoroughly reviewed and referrals and recommendations are being followed. Staff reached out to the neurology and nephrology specialist 2/7/24 to follow up.
On January 30, 2024, during the inspection, the Program Supervisor contacted the PCP regarding the referrals. The PCP indicated that the referrals had been authorized and provided the phone numbers to call. The program supervisor placed the call and was informed that they are not taking routine referrals and to contact the PCP to determine if it needed to be an urgent referral. The PCP indicated that the referral to the Neurosurgeon was for further evaluation of the spine and asked if Individual #1 returned to baseline. The program supervisor informed the PCP that they had returned to baseline. The PCP asked if a urine sample could be obtained for nephrology, and the program supervisor had this done and submitted to the lab. On February 23, 2024, the PCP indicated that the testing was normal and if Nephrology did not contact the program in 2-3 weeks to follow up with the PCP. As of March 4, 2024, the program has not received a call from Nephrology. If there is no call received by March 8, 2024, the program supervisor will follow up with the PCP. Despite numerous attempts to get the follow up scheduled with Neurologist and the Neurosurgeon, the program supervisor has not been successful. These attempts will continue until there is an appointment scheduled or clear documentation that the appointments are no longer necessary, with explanation of signs to look for that would prompt immediate medical care. See attachment #16 for communication with PCP and attachment #17 with results from the urine testing.
Individual #1 went to orthopedics on 2/10/2024 and was sent for an ultrasound. The ultrasound came back negative and was instructed to follow up with PCP for signs of redness or cellulitis. See attachment #17 for information pertaining to the results of the ultrasound.
Individual #1 has an appointment with their psych on 3/5/2024. At that appointment, the program supervisor will obtain clear instructions on specific information regarding the recommendation to follow up with Cornerstone.
The Nurse developed a protocol for routine feet checks after receiving parameters from the Doctor on 2/28/2024. Immediately following the development of the protocol with parameters, staff started tracking feet checks for 3 times per day. See Attachment #12 for the task sheet and Attachment #13 for the protocol.
The Nurse developed a protocol for blood pressure checks after receiving parameters from the Doctor on 2/28/2024. Immediately following the development of the protocol with parameters, staff started tracking blood pressure checks daily. See Attachment #15 for the task sheet and Attachment #14 for the protocol.
In addition to the aforementioned, Penn-Mar determined that the series of violations for 6400.144 constituted for a neglect incident to be filed on behalf of the individual. An incident was filed, and the investigation took place to better identify where the issues are, given that this program in particular is not following medical recommendations. Corrective action was established as part of the investigation, which includes individualized feedback and intensive retraining for the program supervisor and program specialist. |
03/04/2024
| Implemented |
| 6400.181(c) | Individual #1's most recent assessment completed on 06/26/23 does not document that it was based on instruments, interviews, notes, or observations. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | This regulation is important because assessments are essential to maximizing personal growth and development, the person's ability to self-direct through choice and control over decisions affecting them directly while protecting the health and safety of the individual. It is important they are based off of most recent and accurate information.
At the time of inspection, it was discovered that the most recent assessment completed on 6/26/23 does not include documentation or proof that it was based on instruments, interviews, notes, or observations. An addendum will be completed by March 8, 2024.
It was determined that there was a technological error resulting in the statement on the document to disappear when it was being completed on SharePoint, whereas it was showing up when it was being edited on the Desktop Microsoft Application.
Program specialists met with the PA Quality Administrator on 2/7/24 to review a new Annual Assessment Form to ensure the proper components would be added to the form to stay in compliance. This statement was reformatted on the new form that Program Specialists started using immediately. |
03/04/2024
| Implemented |
| 6400.181(e)(9) | Individual #1's most recent assessment does not address disability, functional, or medical limitations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | This regulation is important because assessments are essential to maximizing personal growth and development, the person's ability to self-direct through choice and control over decisions affecting them directly while protecting the health and safety of the individual. It is important they are based off of most recent and accurate information.
At the time of inspection, it was discovered that the most recent assessment completed on 6/26/23 does not address disability, functional, or medical limitations.
It was determined that the program specialist failed to attach the medical history with the assessment, which includes the persons disability, functional, or medical limitations. An addendum will be completed by March 8, 2024.
The Program Specialist responsible for the error received immediate feedback regarding the need for the medical history to be attached to the assessment. |
03/04/2024
| Implemented |
| 6400.181(e)(10) | Individual #1's most recent assessment does not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | This regulation is important because assessments are essential to maximizing personal growth and development, the person's ability to self-direct through choice and control over decisions affecting them directly while protecting the health and safety of the individual. It is important they are based off of most recent and accurate information.
At the time of inspection, it was discovered that the most recent assessment completed on 6/26/23 did not have a medical history attached to the assessment.
It was determined that the program specialist failed to attach the medical history with the assessment.
The Program Specialist responsible for the error received immediate feedback regarding the need for the medical history to be attached to the assessment. An addendum will be completed by March 8, 2024. |
03/04/2024
| Implemented |
| 6400.181(e)(11) | Individual #1's most recent assessment does not include a psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | This regulation is important because assessments are essential to maximizing personal growth and development, the person's ability to self-direct through choice and control over decisions affecting them directly while protecting the health and safety of the individual. It is important they are based off of most recent and accurate information.
The psychological evaluation was not attached to the Annual Assessment or referenced in the assessment, despite this individual having a Restrictive Plan in place.
The Program Specialist was not aware that the psychological evaluation required being attached to the assessment or referenced in the assessment.
The organization keeps a social service summary as part of the annual assessment, which includes information pertaining to the psychological evaluation. The Program Specialist did not include a Social Service Summary with the annual assessment. An addendum will be completed by March 8, 2024. |
03/04/2024
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's most recent assessment does not document their progress in communication. It is marked as "N/A." | 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. | This regulation is important because assessments are essential to maximizing personal growth and development, the person's ability to self-direct through choice and control over decisions affecting them directly while protecting the health and safety of the individual. It is important they are based off of most recent and accurate information.
At the time of inspection, it was discovered that the most recent assessment completed on 6/26/23 did not document their progress in communication and marked it as "N/A".
It was determined that the program specialist failed to explain that the person supported made no progress in this area.
The Program Specialist was informed immediately following the recognition of the violation that N/A is not an appropriate assessment of motor and communication skills. An addendum will be completed by March 8, 2024. |
03/04/2024
| Implemented |
| 6400.18(b)(2) | Individual #1 did not receive their Vitamin D on 04/02/24, because there was no pill in the blister pack. This medication error was not reported to EIM. The medication errors documented in 167a1 regarding the Omeprazole were not reported to EIM. The medication error with the Metoprolol documented in 167a4 was not reported to EIM. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | This regulation is important because it ensures that people supported are receiving medications as prescribed and incidents are being reported accordingly in the EIM system.
This medication errors were not reported because they were not recognized as errors.
Over the last 10 months, the organization has reassigned the review of Medication Administration Records to the quality team. This has resulted in a more detailed review of MARs, including a review to ensure that PRNs and protocols are being followed. Since reassigning this task, the organization has seen an increase in identifying errors and providing immediate feedback to the team upon discovery. The quality team will continue to monitor MARs and ensure protocols are being followed. If there is an error discovered, this will be reported as a medication error and the team member(s) responsible for the error will receive immediate feedback and retraining if necessary.
In addition, the program staff received retraining on 2/28/2024 regarding the expectation of calling a medication monitor when they recognize a medication error and ensuring medications are ordered as needed to prevent further errors.
The Program Specialist filed these medication errors in the system. Incident # 9369123 and 9369087. |
03/04/2024
| Implemented |
| 6400.34(a) | Individual #1's rights were reviewed and signed on 01/05/23 and not again until 01/10/24, outside of the annual timeframe. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | This regulation is important because it ensures that people supported understand their rights annually.
This violation occurred because the individual's rights were not reviewed with the person within 365 days of the previous time the individual rights were reviewed with the individual. Penn-Mar had a process to review individual rights with people supported in residential programs in January of each year.
Since January 2024 has already happened and individual rights have been reviewed with individuals and persons designated by the individual, the new process to ensure compliance will go into effect in December 2024. |
03/04/2024
| Implemented |
| 6400.165(c) | (Repeat from Inspection from 3/14/23) Individual #1 was administered Colace on 12/14/23 even though they did not go two days with no bowel movement | A prescription medication shall be administered as prescribed. | It is important to accurately follow protocols and plans to promote the health and safety of people supported. When there is an error, it is important to file the error appropriately to ensure accurate tracking and response to errors.
During the inspection, it was found that Individual #1 was administered Colace on 12/14/2023 even though they did not go two days with no bowel movement. Feedback was provided to the team member who did not accurately follow the protocol, immediately upon discovery of the error.
The medication error was reported in the system on 2/27/2024. See incident #9369123. |
03/04/2024
| Implemented |
| 6400.165(g) | (Repeat from Inspection from 3/14/23) The quarterly psych med review conducted on 12/12/23 did not include the list of psychiatric medications, their dosages, or the reason for being prescribed. | 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 to ensure medications for psychiatric illnesses are solely used for psychiatric illnesses, being given correctly, and more.
During the inspection, it was found that an Individual's psych med review, dated 12/12/2023, did not have medications, dosages, and/or reason for med of the form.
The Program Supervisor failed to attach a medication list to the appointment record. The Program Specialist and Agency Nurse failed to recognize this and send it back to the Supervisor during review to ensure proper documentation was included to support the review of medications.
The Program Specialist gave feedback to the Program Supervisor surrounding expectations with medical appointment paperwork on 2/6/2024. A group of Program Specialists completed an audit on psych medication review appointments and determined that the organization is collectively in compliance with this regulation. |
03/04/2024
| Implemented |
| 6400.166(a)(2) | Individual #1's MARs for January 2024 did not include the prescriber information for Individual #1's PRN Acetaminophen, Alprazolam .25 mg, or Alprazolam 1 mg. The prescriber for Individual #1's Cetirizine 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 the home's staff persons will be able to track all medications an individual receives and to ensure all medications are administered as prescribed.
While reviewing MARs, the inspector noticed the prescriber information was not included and/or omitted for multiple medications.
When performing routine MAR reviews, the team was made aware that no prescribing physician was notated but did not address the issue on the electronic MAR, only the paper MAR which resulted in the error occurring multiple months. The Program Manager and Residential Supervisor failed to ensure the corrections were completed.
The Residential Supervisor was instructed to update Carasolva to reflect the prescribing physician for each medication. The prescribing physician was added into Carasolva for the missing medications on 2/16/2024. See attachment #11. |
03/04/2024
| Implemented |
| 6400.166(b) | Individual #1 did not receive their Vitamin D 3 on 04/02/24 because "there was no pill in the blister pack." Individual #1 has a bowel protocol that they are to receive Colace if the Individual goes two days with no bowel movement. Individual #1 did not have a bowel movement on 12/28/23 or 12/29/23. No Colace was administered to Individual #1. | 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 to ensure that medication errors are reported within 72 hours and follow up with providers and monitoring side effects, as needed.
The Program Staff and Specialist failed to report these medication errors. In addition, the program staff did not re-order a Vitamin D3 pill when they noticed it was not in the blister pack. The bowel protocol was not followed accurately, and it was not caught during the MAR review or site monitoring.
Over the last 10 months, the organization has reassigned the review of Medication Administration Records to the quality team. This has resulted in a more detailed review of MARs, including a review to ensure that PRNs and protocols are being followed. Since reassigning this task, the organization has seen an increase in identifying errors and providing immediate feedback to the team upon discovery. The quality team will continue to monitor MARs and ensure protocols are being followed. If there is an error discovered, this will be reported as a medication error and the team member(s) responsible for the error will receive immediate feedback and retraining if necessary.
In addition, the program staff received retraining on 2/28/2024 regarding the expectation of calling a medication monitor when they recognize a medication error and ensuring medications are ordered as needed to prevent further errors.
The Program Specialist filed these medication errors in the system. Incident # 9369087 and 9369123. |
03/04/2024
| Implemented |
| 6400.182(c) | Individual #1 has a restrictive procedure regarding food being locked up. The most recent ISP completed 09/29/23 does not document that Individual #1 has this restrictive procedure. Individual #1's ISP lacks information regarding a preference of being naked, the fact that the home is completely barren, and that there are areas of the home that the Individual does not have access to. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | This regulation is important to ensure that all team members are trained in restrictive plans when providing person specific support at Penn-Mar Human Services. This regulation also ensures that all areas are captured in the ISP document.
Individual #1 has a restrictive procedure regarding food being locked up. The most recent ISP completed 9/29/23 does not document that Individual #1 has this restrictive procedure. Individual #1's ISP lacks information regarding their preference of being naked, the fact that the home is completely bare, and that there are areas of the home that the individual does not have access to. The restrictive plan was given to the SC on 7/29/23 at the ISP meeting but never put into the ISP. When the ISP was finalized no one reviewed to ensure that the restrictive plan was included in the ISP document.
Program Manager did not ensure the restrictive plan was added to the ISP.
In general, the ISP does not capture adequate information for Individual #1. Therefore, the Program Specialist received immediate feedback regarding the expectation of ensuring ISP's contain adequate and detailed information about the person. The Program Specialist has been working on reviewing the individual's plan and ensuring all information is accurate.
On 3/6/2024, the Program Specialist will meet with the Assistant Director and review the necessary changes that need to be made to the ISP. The Assistant Director will ensure that the Program Specialist understands what is expected and demonstrates this understanding.
The Program Specialist will send an email asking the Support Coordinator to make specific updates to the ISP by March 8, 2023. |
03/04/2024
| Implemented |
| 6400.183(a)(1) | Individual #1 did not attend the ISP team meeting held on 07/22/23 | The individual plan shall be developed by an interdisciplinary team, including the following: The individual. | This regulation is important to ensure that individuals have input in and are attending their ISP meetings. Allowing them to use self-determination to be an active member of their own team.
Individual #1 did not attend the ISP team meeting held on 7/22/23.
This occurred because the individual did not want to attend the ISP meeting, but there was no documentation to support that they were asked and declined.
Program Managers were retrained on regulation 6400.183a1 and the need to document if someone chooses not to attend their ISP meeting.
Program Managers were also retrained in the importance of reviewing the attendance sheet from the Support Coordinator to ensure the information is accurate and complete. |
03/04/2024
| Implemented |
| 6400.210(b)(1) | Numerous times, Individual #1's funds were used to purchase bath towels because the individual destroys their bath towels. There was no written consent that is required for restitution of damages. On 09/05/23, Individual #1's money was used to purchase a 40-quart trash can. | An individual's personal funds or property may not be used as payment for damages unless the individual consents to make restitution for the damages. The following consent provisions apply unless there is a court-ordered restitution: A separate written consent is required for each incidence of restitution. | This regulation is important because it prevents exploitation and misuse of funds.
Individual #1 used their funds to purchase bath towels and a trash can. The individual destroys bath towels frequently, which is what prompted the team to believe it was reasonable for the individual to purchase these items.
Individual #1 damaged the trash can, which is what prompted the team to believe it was reasonable and acceptable for the individual to purchase a new trash can.
An audit will be completed for Individual #1 to ensure that they did not pay for items that are to be provided as part of room and board, even if the restitution process was followed.
Individual #1 will be reimbursed for anything they spent on these items in the April 2024 Room & Board Statement.
In addition, Program Specialist will complete an audit to ensure that other people supported are not paying for items that are part of room and board, unless the team determines it is important to and for them, and this is documented in their ISP.
Anyone who has paid for items through the restitution process will be reimbursed.
The audit will be completed by March 31st, and reimbursements will occur on the April room and boards for people supported. |
03/04/2024
| Implemented |