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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.80(a) | At the time of the 01/30/24 inspection, there was a section of broken sidewalk to the left of the garage and a rusty garden rake along the front pathway to the home. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | This regulation is important to minimize the risk of injury or death to individuals when they are outdoors or escaping in the event of an emergency.
At the time of inspection on 1/30/2024, there was a section of broken sidewalk to the left of the garage and a rusty garden rake along the front pathway to the home.
The garden rake was removed immediately following the inspection and put in a safe area of the home.
The Program Specialists completed an audit of all programs to ensure that regulation 6400.80(a) was being met.
Through the audit, it was determined that 4 programs had concrete that needed to be fixed.
On 2/23/2024, the maintenance team was informed of all programs that need to have the concrete fixed in order to comply with regulation 6400.80(a). See attachment #1.
The maintenance lead informed the Assistant Director that each program will be fixed by March 6, 2024. |
03/04/2024
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(6) | Individual #1's physical examinations document that the individual received a negative result on their Tuberculin skin testing by Mantoux method on 6/7/17 and not again until 7/15/19, outside the regulatory time frame requirement of completion 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. | Staff did not ensure the Tuberculin skin test by Mantoux method was completed within the required time frame of two years.
It is important to ensure individuals are tested for Tuberculous every two years to ensure they do not have this communicable disease that could jeopardize their health and people they are in contact with if precautions are not taken.
There are no individuals in this program that were due to be screened for Tuberculosis since this licensing period. Attached is a copy of a physical for another individual that was completed and shows the Tuberculous screening occurred in the required time frame. See attachment # 1 -physicals showing 2-years of TB tests.
Program managers have had training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They will continue to monitor health screening needs to ensure they are completed in the required time frames when they complete monthly site monitorings at each group home. Site monitorings completed by Program Managers are monitored monthly for completion by the Community Living Administrator and the Director of PA Program. All residential supervisors and program managers have been retrained on this regulation via email. see attachment #2 - email sent to all residential team members. A review of this regulation will also be completed with the Residential Supervisors again at their next team meeting on April 14, 2021. |
04/01/2021
| Implemented |
| 6400.167(a)(4) | Some of Individual #1's medications throughout the year were to be administered at 7AM, 8AM, and 8PM. There were many occasions from February 2020 to December 2020, where the individual's specific medications were not administered within an hour before or after their scheduled administration times of 7AM, 8AM, or 8PM. There were no records maintained of why the medications weren't administered at their scheduled times. The following are examples of the medications that were not administered correctly and the times of when this occurred:
· Levothyroxine .075mg is to be administered at 7AM but was not administered until 5:42PM on 2/10/20.
· Aspirin 81mg, Loratadine 10mg, and Sertraline 25mg are to be administered at 8AM but were not administered until 5:42PM on 2/10/20.
· Vitamin D-50,000 units are to be administered at 8PM but were not administered until 9:26PM on 2/14/20, 9:25Pm on 12/11/20, and 10:29PM on 12/25/20.
· Aspirin 81mg is to be administered at 8AM but was not administered until 12:26PM on 7/8/20. | 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. | There are times when the internet connection in the program does not work well due to the location of the home being in a rural area. Our IT team is working on a solution for this and is currently piloting a new internet connection in our rural programs. During the times that staff are unable to connect to the internet, they administered the medications and signed off on the electronic MAR later in the day. When they did this, they failed to enter a note on the electronic MAR explaining that the medication was administered on time and the reason for signing the MAR late.
It is important to ensure documentation of the medication administration is completed at the time the medication is administered to prevent potential medication errors.
All staff will be retrained on the expectation to utilize the paper MAR when they do not have internet access. In addition, all staff will be retrained on how to properly document on the electronic MAR when documentation of a medication administration is written on the paper MAR. This training has occurred via email. see attachment # 3 - medication administration documentation. All team members administering medication are also required to take a video training created by an agency nurse regarding medication administration documentation by 4/16/2021. See attachment #4 - medication documentation training.
Program managers and nurses have had training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. Program managers will continue to monitor MARs during monthly site monitorings at each group home. Site monitorings completed by Program Managers are monitored monthly for completion by the Community Living Administrator, Director of PA Program. Effective 3/22/2021, the nurses will start to complete weekly audits of MARs to ensure medications are being administered as ordered. |
04/16/2021
| Implemented |
| 6400.167(b) | The documentation of the medication errors described in 6400.167(a)(4) of this report were not documented in the individual's record, follow up action wasn't taken, and the prescriber's response was not kept in the individual's record. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | The errors described in 6400.167(a)(4) of this report were documentation errors, not medication errors. However, there is no documentation noted to indicate this and the programs supervisor, nurse and program manager did not take appropriate action.
It is important to ensure documentation of the medication administration is completed at the time the medication is administered to prevent potential medication errors. If there is a medication error, it is important to follow up with the prescribing physician regarding the error. It is also important for that medication errors are filed in EIM and that the team member with the error receives feedback and retraining on medication administration.
Program managers and nurses have had training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. Program managers will continue to monitor MARs during monthly site monitorings at each group home. Site monitorings completed by Program Managers are monitored monthly for completion by the Community Living Administrator and the Director of PA Program. Effective 3/22/2021, the nurses will start to complete weekly audits of MARs to ensure medications are being administered as ordered. |
04/01/2021
| Implemented |
| 6400.169(a) | The agency documented that Staff person #4 completed the annual medication administration training and was certified to administer medications to individuals on 10/12/19 and again on 10/12/20. However, according to the information documented by the agency's (Penn-Mar Human Services) medication administration trainer, Staff person #1 never completed the Department's approved medication administration course correctly in 2020 in order to be certified to administer medications.
In order to correctly pass the Department's annual medication administration training course, staff must complete 2 medication administration record (mar) reviews and 2 observations within 365 days of the previous year's certification date, and certified medication trainer must review the training documents and recertify the staff's training annually.
Staff person #1's 10/12/20 annual medication administration training practicum summary form states she completed all requirements and was recertified to administer medications on 10/12/20. However at that time, she had only 1 out of the 2 required observations completed. Her second observation was not completed and reviewed by a medication trainer until 10/30/20, outside the annual time frame requirements.
There were no records maintained that Staff person #1 completed the Department's modified medication administration training course and it's requirements during the COVID-19 pandemic in leu of the complete medication administration training course. | 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). | The medication trainer responsible for ensuring the medication observations were completed in the required time frame did not follow the medication administration guidelines.
It is important for medication administration trainers ensure that staff completed their medication administration observations on time to keep their medication certification current. Its also important for medication administration trainers to observe medication administrations to ensure staff are properly trained to administer medications in an effort to prevent medication errors.
Following the licensing exit on January 11, 2021, the agency nurses completed an audit to ensure all medication administration certifications are in compliance.
Program managers and nurses have had training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. Effective 3/22/2021, the Community Living Administrator will begin to conduct monthly audits of medication administration certifications. |
04/01/2021
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.181(e)(4) | The assessment for Individual #1 states that they use the church bus to attend church but it does not say that this is done independently or unsupervised. This needs to be reflected in the assessment | The assessment must include the following information: The individual's need for supervision.
| This individual had an updated assessment since licensing on 12/3/2014. The information concerning the church bus has been clarified in this updated Assessment. See attachment E.
All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014
See attachment A
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12/03/2014
| Implemented |
| 6400.181(e)(13)(viii) | The assessment dated 12/5/13 for Individual #1 did not include the ability to manage 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. | This individual had an updated assessment since licensing on 12/3/2014. The information concerning her ability to manage personal property has been clarified in this updated Assessment. See attachment E.
All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014
See attachment A
all records were reviewed for compliance. |
12/03/2014
| Implemented |
| 6400.183(5) | There was no SEEN plan in place for Individual #1 until 2/13/14. Individual #1 has had a psychiatric diagnosis and has taken medication for this for years. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | This was corrected for this individual on 2/13/14, when the new Program Manager noticed that a SEEN plan was not in place. Since licensing however, we had the opportunity to do this right within an acceptable time frame. An individual entered our program on July 14, 2014 and a SEEN Plan was written an in place on Aug 6, 2014.
See attachment H
All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014
See attachment A
All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014
All records reviewed for compliance. |
08/13/2014
| Implemented |
| 6400.186(a) | There was no ISP review in the record for Individual #1 completed in the month of December 2013. This would have been ISP review #3. | 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. | Since licensing, this individual had a quarterly report completed on 9/15/2014 and reviewed on 9/18/2014. See attachment G.
All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014
See attachment A
All records were reviewed for compliance. |
09/18/2014
| Implemented |
| 6400.186(c)(2) | The ISP review dated 3/15/14 for Individual #1 does not include a review of the behavioral plan. It indicated NA. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | Since the licensing inspection Individual #1 had an ISP review on 9/15/2014. This ISP review does include a review of the behavioral plan.
See attachment G
All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014
See attachment A
All records were reviewed for compliance. |
09/18/2014
| Implemented |
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