Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00237562 Renewal 01/29/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)At the time of the 01/30/24 inspection, there was no method to dry one's hands in the basement bathroom.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. This regulation is important because it ensures that individuals, staff, and visitors have basic hygiene items for safety and comfort. At the time of the 01/30/24 inspection, there were no towels to dry one's hands in the basement bathroom. It was determined that the paper towels were not replaced in the basement bathroom after running out at the time of inspection. There was also no extra supply immediately available. This is monitored on a monthly basis and has been compliant for the last 3 months leading up to inspection and the walkthrough following the inspection. Program Specialists completed an audit on 2/15/24 of all houses to ensure that all bathrooms were equipped with paper towels or an air dryer. All houses were in compliance at the time of the audit. 03/04/2024 Implemented
SIN-00236651 Unannounced Monitoring 12/04/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(13)The allergies and contraindicated medications section of Individual #1's 6/14/23 annual physical examination was left blank.The physical examination shall include: Allergies or contraindicated medications.Regulation 6400.14(c)(13) is important because it provides support staff with information regarding what the person supported is allergic to, so the person can be protected from harm. When the residential supervisor, agency nurse, and program specialist reviewed the annual physical, they failed to ensure that the allergies or contraindicated medications section was completed. Therefore, this section was left blank. The PCP was sent a message on 12/22/2023 to get clarification on individual #1's allergies. See attachment #5 for clarification. In addition, the Assistant Director will complete an audit to ensure all current annual physicals have the allergy section filled out. If it is not completed, the Program Specialist will ensure the PCP is consulted to provide information pertaining to someone's allergies. The audit and corrections will be completed by January 31st, 2024. 01/08/2024 Implemented
6400.144At Individual #1's 6/14/23 annual physical examination, the doctor recommended that the individual begin ear flushes for cerumen build-up. There is no documentation that this recommendation was followed, and no PRN was given for any build-up until 8/20/23. On 10/27/23, Individual #1's physician was contacted because of a suspected shingles rash. Individual #1's physician prescribed Valtrex. This medication was not picked up or received in the home, and no follow up action was taken until 10/30/23 when staff person #7 contacted the physician to indicate that the home never picked up the prescription and inquiring whether or not it should be picked up because the rash resolved.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. Regulation 6400.144 is important because it protects the person's health and safety by ensuring provision of appropriate medical services. When reviewing the annual physical from 6/14/2023, the residential supervisor, agency nurse, and program specialist did not ensure that the ear flushes began for individual #1. On 12/22/2023, Individual #1's PCP was contacted to gain clarification on what beginning ear flushes should look like. Attachment #5 is the direction provided from the PCP. See attachment #6 for the Medication Administration Record as proof of the ear drops beginning as ordered. The Valtrex medication was never picked up from the pharmacy and no follow up action was taken until 10/30/2023. The residential supervisor and program manager met with the Assistant Director on 12/28/2023 to discuss the importance of fulfilling medications as soon as possible. The residential supervisor was informed that the entire team needs to know the process for picking up medications and participate in ensuring people receive medications as soon as possible. 01/08/2024 Implemented
6400.18(a)(3)Penn Mar Human Services was informed of Individual #1's hospitalization on 11/25/23. The hospitalization was not reported through the department's incident management system until 12/4/23, when it was entered by the county's Supports Coordinator Supervisor.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 24 hours of discovery by a staff person: Inpatient admission to a hospital. Regulation 6400.18(a)(3) is important because it supports the reporting expectations of the ODP Incident Management Bulletin. Reporting incidents of hospitalizations requires the organization to review the incident thoroughly and ensure proper risk mitigation strategies are in place to prevent future incidents. Individual #1 went on a visit with their sister on 11/22/2023. On 11/25/2023, they were hospitalized. They were not receiving services from Penn-Mar at the time of the hospitalization. The hospitalization was not reported in EIM because Penn-Mar interpreted pages 13 and 14 of the Incident Management Bulletin to mean that incidents occurring when services were not being rendered by the provider are to be reported to the Supports Coordinator for filing. Penn-Mar contacted the Supports Coordinator the next business day following the hospitalization requesting that the Supports Coordinator file the incident as this was our interpretation of the bulletin. Through the inspection process, Penn-Mar was informed by ODP that it is the responsibility of the provider to report incidents when services are not being rendered because Penn-Mar is authorized to provide services 365 (or 366) days a year. Additionally, Penn-Mar would be able analyze the care and supports that were provided by Penn-Mar prior to the hospitalization. Following the hospitalization, it is Penn-Mar's responsibility to follow discharge instructions, manage any follow up care needed, and ensure staff are trained accordingly. Incident # 9333941 was filed, per a directive from ODP's Incident Management Specialist-Central Region on 12/22/2023. A meeting was requested with the Incident Management Specialist to further discuss and understand the direction that was provided during the inspection. On 1/9/2024, the Incident Management Specialist responded to the email with detailed information pertaining to the provider's responsibility to file and investigate incidents. 01/26/2024 Implemented
6400.18(g)Penn Mar Human Services was informed of Individual #1's hospitalization on 11/25/23. When admitted to the hospital, it was discovered that Individual #1 had pressure injuries, which was reported to the provider agency on 11/29/23. A certified investigation was not initiated within 24 hours of discovery.The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person.Regulation 6400.18(g) is important because it supports the reporting expectations of the ODP Incident Management Bulletin. Reporting incidents of pressure injuries requires the organization to review the incident thoroughly and ensure proper risk mitigation strategies are in place to prevent future incidents. Individual #1 went on a visit with their sister on 11/22/2023. On 11/25/2023, they were hospitalized. They were not receiving services from Penn-Mar at the time of the hospitalization. Penn-Mar staff reviewed clinical notes on 11/29/2023 and discovered there was indication of a pressure injury upon admission to the hospital. The pressure injury was not reported in EIM because Penn-Mar misunderstood the Incident Management Bulletin and believed that incidents occurring when services were not being rendered were to be reported to the Supports Coordinator. Through the inspection process, Penn-Mar was informed by ODP that it is the responsibility of the provider to report incidents when services are not being rendered because Penn-Mar is authorized to provide services 365 (or 366) days a year. Additionally, Penn-Mar would be able analyze the care and supports that were provided by Penn-Mar prior to the hospitalization. Following the hospitalization, it is Penn-Mars responsibility to follow discharge instructions, manage any follow up care needed, and ensure staff are trained accordingly. Incident # 9333941 was filed, per a directive from ODP's Incident Management Specialist-Central Region on 12/22/2023. A meeting was requested with the Incident Management Specialist to further discuss and understand the direction that was provided during the inspection. On 1/9/2024, the Incident Management Specialist responded to the email with detailed information pertaining to the provider's responsibility to file and investigate incidents. 01/26/2024 Implemented
6400.32(c)Individual #1 had a swallow study completed on 3/27/23, which changed their diet from level 6 soft and bite-sized and thin liquids to level 5 minced and moist foods and nectar thick liquids. Staff persons #1 -- 13 have worked at Individual #1's home since 9/1/23 and have not received any training on how to properly prepare Individual #1's diet according to IDDSI standards since the change in 3/2023. Individual #1 has a diagnosis of dysphagia, and this failure to train staff puts Individual #1 at risk of serious harm.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Regulation 6400.32(c) is important because it protects the person supported from harm. On 3/27/2023, Individual #1 had a swallow study completed and their diet changed from level 6 soft and bite-sized and thin liquids to level 5 minced and moist foods and nectar thick liquids. Staff did not receive updated training following his diet change. The agency nurse and program specialist did not ensure that proper training was completed and recorded. Individual #1 was discharged from rehab on 12/20/2023 with mechanically soft diet and thin liquids. The protocol was updated, and all staff were trained on the protocol and the dysphagia checklist. See attachment #1 for the updated protocol and training. Following the discharge, Individual #1 had a follow up appointment with their PCP on 12/26/2023. At this appointment, individual #1's diet was changed back to mechanical soft and nectar thick liquids. The protocol was updated, and all staff were trained on the protocol and the dysphagia checklist. See attachment #2 for the after-visit summary, updated protocol and training. 01/08/2024 Implemented
6400.52(c)(6)Individual #1 has multiple plans and protocols in place in addition to their Individual Support Plan, including a special diet, blood sugar protocol, bowel protocol, sleep and fluid tracking protocol, choking protocol, fall protocol, and CPAP protocol. Staff persons #1 -- 13 have never been trained to properly prepare Individual #1's food and drinks. Staff persons #2, 4, 10, and 11 have never been trained in Individual #1's CPAP protocol.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Regulation 6400.52(c)(6) is important because it ensures staff have the necessary information and knowledge to support the person safely and according to their needs. During the inspection, it was determined that 13 staff were not trained on Individual #1's diet and 4 staff were not trained on the individual's CPAP protocol. The lack of training for individual #1's diet and food occurred because Penn-Mar failed to establish a training plan for when diets change throughout the year. Staff person #11 never completed the training when it was assigned. Staff person #2, 4, and 10 were not assigned the CPAP protocol. The program manager failed to ensure that staff person 2, 4, and 10 were assigned. The residential supervisor and program manager failed to ensure that staff person #11 completed the training when it was assigned. To immediately fix the problem, staff were trained in Individual #1's CPAP protocol. See attachment #4. Staff were also trained on individual #1's diet. See attachment #1 and attachment #2. 01/08/2024 Implemented
6400.181(b)Individual #1's 1/3/23 assessment indicates that Individual #1 is on a level 6 soft and bite-sized diet and thin liquids. Individual #1 had a swallow study completed on 3/27/23 that changed their diet to level 5 minced and moist foods and nectar thickened liquids. Individual #1's assessment was not updated after this change.If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have an assessment completed as required under this section.Regulation 6400.181(b) is important because it ensures that team members are being trained properly according to someone's support needs. When the individual had a change in his diet, the program specialist did not ensure there was an addendum to his assessment. The immediate plan of correction was to complete an addendum for the annual assessment upon their discharge on 12/20/2023. See attachment # 7. When the diet changed again on 12/26/2023, another addendum was created and sent to the ISP team. See attachment #8. 01/08/2024 Implemented
6400.186Individual #1's Individual Support Plan (ISP) dated 6/30/23 indicates that Individual #1 is to be checked every hour while awake and asleep. Until 7/31/23, these hourly checks were completed and tracked during the overnight hours. Beginning 8/1/23, staff only tracked the time that Individual #1 went to sleep and the time the individual awoke. There was no tracking completed to confirm that these hourly checks were completed.The home shall implement the individual plan, including revisions.Regulation 6400.186 is important because it ensures that the organization and team members working in the organization are implementing the individual's plan. On August 1, 2023, Individual #1's hourly checks were not being recorded because organization switched tracking platforms and at the time, did not believe there was a medical reason to track hourly checks. Throughout this inspection process, the organization learned that if there is a specified supervision time in someone's plan, there must be documentation to support that it was being implemented. The immediate fix was to start recording hourly checks for the individual when they returned from rehab on 12/20/2023. See attachment #9. 01/08/2024 Implemented
SIN-00220315 Renewal 03/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)During the 3/16/23 onsite inspection, there was an envelope for Individual #1 titled, "Birthday money $100". In the envelope was a receipt for items purchased and a receipt that the remaining funds were transferred to another cash account at the home for Individual #1. The home reports that $100 was brought to the home for the Individual. The date the home received the $100 in the home for Individual #1 is not documented.(2) Disbursements made to or for the individual. This regulation is important because it ensures accountability of individual's resources. During the inspection, there was $100 that was not accounted for on Individual #1's money transaction sheet. On March 1, 2023, there was $170 for Individual #1 picked up from the Administrative Assistant. There was $70 deposited into Individual #1's money transaction sheet. See attachment #1. There was $100 put aside in an envelope for Individual #1 to spend for their birthday. The birthday money was being tracked on a separate money transaction sheet. The separate money transaction sheet did not deposit the $100 that was being used. Since the inspection, the two money transaction sheets have been combined. The money transfer verification document was referenced to determine if $170 was picked up from staff on 3/1/2023. See attachment #2, which indicates that $170 was picked up for Individual #1 on 3/1/2023. It has been determined that this occurred because staff did not follow the Management of Individual Funds-Pennsylvania procedures. Staff received immediate feedback regarding the importance of accurately tracking all deposits of individual's funds on the money transaction sheet. The Program Specialist immediately verified that $170 was picked up from the Administrative Assistant on 3/1/2023. Individual #1's program staff received formal retraining on the Management of Individual Funds-Pennsylvania procedures on 03/16/2023 by the Program Specialist. A follow up email was sent on 3/29/2023 to the entire team. See attachment #3. 03/29/2023 Implemented
6400.141(c)(1)Individual #1's current, 5/5/22 physical examination record did not include their previous medical history or current list of any diagnoses. The physical examination record indicated the individual had severe intellectual disabilities and slow gait. However, according to their record and other medical documents, the individual has dysfunction of both eustachian tubes, bilateral hearing loss, high cholesterol, psychosis, depression, hears voices, and has poor vision.The physical examination shall include: A review of previous medical history. This regulation is important because accurate medical information is essential to ensure an individual's medical needs are met and proper care is provided in the event of an emergency. Individual #1's 5/5/2022 physical examination did not include a previous medical history or current list of diagnoses. In addition, the physical examination and other individual records had different information regarding Individual #1's medical diagnoses. This occurred because the 5/5/2022 physical examination was completed prior to Individual #1's admission into the home. The Program Specialist and Agency Nurse failed to ensure that the annual physical included a review of medical history. In addition, the Program Specialist and Agency Nurse failed to cross reference all records for Individual #1 to ensure the medical diagnoses were clear and consistent across documents. On 6/2/2022, the Agency Nurse developed a medical history for Individual #1. The medical history was then updated on 1/5/2023. See Attachment #18 for proof of Medical Histories. The Program Supervisor, Agency Nurse, and Program Specialist are cross referencing all of Individual #1's records to compile a list of diagnoses. This list will be completed by April 6, 2023. Once the list is developed, the Program Supervisor will contact the Primary Care Physician to receive confirmation regarding Individual #1's medical diagnoses. Individual #1 will have their annual physical completed on 5/10/2023. At this appointment, the PCP will review the list of diagnoses and medical history. On 3/20/2023, the Program Specialists and Agency Nurse were retrained on the expectation of medical histories being reviewed during physical examinations and ensuring diagnoses are consistently listed throughout the individual's record. See Attachment #4 for proof of training. Program Specialists are completing an audit on all individuals to ensure medical histories are reviewed at annual physicals and diagnoses are consistent throughout individual records. This audit will be completed by March 31, 2023, and corrections will be made by 4/6/2023. 03/29/2023 Implemented
6400.141(c)(13)REPEAT FROM 3/29/22 ANNUAL INSPECTION: Individual #1's current, 5/5/22 physical examination record doesn't answer the question if the individual has any allergies to medications or contraindicated medications; the field was left blank. The record indicated that the individual had no seasonal allergies. However, the agency reported the individual did have seasonal allergies, via documentation on the individual's face sheet.The physical examination shall include: Allergies or contraindicated medications.This regulation is important because it is essential to have accurate medical information to ensure that individual's medical needs are met, and the proper care is provided in the event of an emergency. During the inspection, the 5/5/2022 physical examination did not indicate if Individual #1 had allergies to medications. The physical examination also indicated that Individual #1 had no seasonal allergies. However, there was documentation on the individual's face sheet that indicated Individual #1 has seasonal allergies. This occurred because the physical was not thoroughly reviewed during the admission process to ensure it included information pertaining to allergies. Seasonal allergies were added to Individual #1's face sheet when it was not an actual diagnosis. Immediately following the inspection, the Program Specialist and Residential Supervisor reviewed medical paperwork to determine if there was any diagnosis of seasonal allergies. During this review, it was determined that Seasonal Allergies were listed as a diagnosis because Individual #1 was prescribed Flonase. However, the Flonase was prescribed for Dysfunction of both Eustachian Tubes. The diagnosis of seasonal allergies has been removed from Individual #1's face sheet. See Attachment #6. In addition, Attachment #7 is demonstrated proof of an Annual Physical that was completed on 3/17/2023 that clearly indicates the person's allergies. 03/29/2023 Implemented
6400.144On 1/23/23 Individual #1's audiologist recommended hearing aids for the individual's diagnosed hearing loss and recommended a hearing aid evaluation be completed. At the time of the 3/14/22 inspection, there are no records that the individual has had a hearing aid evaluation, or a hearing aid was ordered or reviewed with the individual. On 6/14/22 Individual #1's podiatrist indicated they were to return in 9 weeks, on 8/16/22. Individual #1 did not return to the podiatrist until 9/16/22. On 9/16/22 Individual #1's podiatrist indicated they were to return in 3 months on 12/19/22. Individual #1 did not return until 2/2/23.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 violation is important because it protects the individual's health and safety by ensuring the provision of appropriate medical and psychological services. At the time of the inspection, Individual #1 did not receive adequate support regarding the recommendation for hearing aids at the 1/23/2023 audiologist appointment. In addition, Individual #1 had a podiatrist appointment on 6/14/2022 and they were scheduled to return on 8/16/2022. Individual #1 did not return until 9/16/2022 and there was no documentation to support why this appointment did not occur on 8/16/2022. Individual #1 was to return in 3-months for another podiatry appointment after the 9/16/2022 appointment. This was scheduled for 12/19/2022. Individual #1 did not return until 2/2/2023 and there was no documentation to support why the appointment did not occur on 12/19/2022. This occurred because the Residential Supervisor, Program Specialist, and Agency Nurse failed to follow up on the recommendation of hearing aids. It has been determined that Individual #1 does not want to use hearing aids. However, there has not been adequate documentation regarding the education that was provided to Individual #1, along with a continuous plan to reeducate and revisit the decision. The podiatry appointments were rescheduled. However, there was not appropriate documentation to support the rescheduling of appointments. On 3/21/2023, the ISP team met to review the ongoing challenges with Individual #1 complying with medical recommendations. It was determined that a general health refusal plan will be created. This plan will be created by March 31, 2023, and all team members responsible for implementing the plan will be trained by April 6, 2023. 03/29/2023 Implemented
6400.181(e)(13)(vii)Individual #1's 7/1/22 initial and updated, 1/26/23 assessments do not include the amount of money that the individual can handle independently. Currently the home reports that Individual #1 carries gift cards with balances and money in their wallet on their person. There is no record how much they carry or is carrying in their wallet.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. This regulation is important because it ensures that providers fully understand individual's needs and preferences to provide appropriate services and supports, balances self-direction, choice, and control with health and safety protection. During the inspection, it was noticed that Individual #1's assessment did not indicate their financial independence. It was reported that Individual #1 carries money and gift cards in his wallet, but the assessment doesn't indicate how much. This violation occurred because the Program Specialist failed to include specific information regarding Indvidual #1's financial independence. During the team meeting on 3/21/2023, the ISP team discussed the current level of financial independence for Individual #1. Following the meeting, an assessment addendum was completed to include information pertaining to the individual's financial independence. See Attachment #8. All staff supporting Individual #1 will be retrained by 4/6/2023. 03/29/2023 Implemented
6400.165(c)REPEAT FROM 3/29/22 ANNUAL INSPECTION: Individual #1 is ordered Isopto Tears for dry eyes. Staff administered this medication 14 times from August 2022 to March 2023. The reason for administering the medication was recorded by staff in comments as, eye irritation, a request for eye drops, eyes watery, dryness, burning eyes, red eyes, eyes bothering him. Individual #1 is ordered acetaminophen 2 tablet every 6 hours for fever over 38 degrees Celsius. Staff administered the medication for sore throat pain on 9/5/22, 9/6/22, 9/7/22. Individual #1 was not administered their medications 24 times in December 2022 and 36 times in November 2022 within an hour of their 10:30am medication administration time. Staff administered the medication late, when Individual #1 woke up, even though the individual's 5/10/22 physician's orders for missed medication are to wait and administer mediations at their next scheduled time.A prescription medication shall be administered as prescribed.This regulation is important because it prevents medication errors that could result in injury. During the review of medication administration records, it was determined that Individual #1 received their PRN medication for reasons that the medication was not prescribed for. In addition, Individual #1 was administered the medication late 24 times in December 2022 and 36 times in November 2022. The doctors order indicates that if the ordered dose is missed, staff are to wait until the next scheduled time to administer the medication. This violation occurred because team members were not following the medication administration procedures. In addition, when the agency nurse and program supervisor were reviewing the medication administration logs, this errors were not identified which resulted in unfiled medication errors and failure to provide feedback to staff to prevent this from reoccurring. Immediately following the inspection, the Program Specialist and Agency Nurse conducted a full review of Individual #1's medication administration record since last inspection. On March 28, 2023, a medication error incident was filed in EIM. The incident number is 9189713. On March 22, 2023, the program team members responsible for administering Individual #1's medications received retraining. A follow up email was sent on 3/29/2023 to summarize the information that was reviewed. See Attachment #3. The Agency Nurse received retraining on 3/22/2023 regarding the expectations of reviewing medication logs and providing feedback to appropriate team members when errors are found. On 3/29/2022, the violations will be thoroughly reviewed with the Agency Nurse by the PA Assistant Director and Quality and Compliance Administrator. It was identified through the inspection that Individual #1 was choosing to not take their medication at the identified times because they were sleeping. There was a team meeting on March 21, 2023, to address this. A general health refusal plan will be created to further address Individual #1's refusals around taking medications at prescribed times. The general health refusal plan will be completed by March 31, 2023. All team members supporting Individual #1 will be trained on the implementation of the plan by April 6, 2023. 03/29/2023 Implemented
6400.166(a)(7)Individual #1 was administered Isopto eye drops twice on 8/5/22, once on 8/6/22, once on 8/8/22, 9/29/23, 11/17/22, 12/11/22, and 12/13/22. For all administrations, the records do not indicate the dose administered to the individual or which eye/eyes the medication was administered in.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.This regulation is important because staff will be able to track all medications an individual receives and to ensure all medications are administered as prescribed. During the inspection, it was determined that Individual #1 received eye drops on 7 occasions and the record did not indicate the dose that was administered. This violation occurred because team members were not following the medication administration procedures. In addition, when the agency nurse and program supervisor were reviewing the medication administration logs, the errors were not identified which resulted in unfiled medication errors and failure to provide feedback to staff to prevent this from reoccurring. Immediately following the inspection, the Program Specialist and Agency Nurse conducted a full review of Individual #1's medication administration record since last inspection. On March 28, 2023, a medication error incident was filed in EIM. The incident number is 9189713. On March 22, 2023, the program team members responsible for administering Individual #1's medications received retraining. A follow up email was sent on 3/29/2023 to summarize the information that was reviewed. See Attachment #3. The Agency Nurse received retraining on 3/22/2023 regarding the expectations of reviewing medication logs and providing feedback to appropriate team members when errors are found. On 3/29/2022, the violations will be thoroughly reviewed with the Agency Nurse by the PA Assistant Director and Quality and Compliance Administrator. 03/29/2023 Implemented
6400.166(b)REPEAT FROM 3/29/22 ANNUAL INSPECTION: Staff person #1 reported on 5/15/22 and 5/29/22 that Individual #1 took their Bupropion and Rosuvastatin medications on time; on 5/15/22 Bupropion and Rosuvastatin scheduled for 9am, and on 5/29/22 both were scheduled for 10am. However, staff did not initial and date the medication administration record until 10:30am and 12:27am respectively. Staff person #1 reported in June 2022, that Individual #1 took their 10am medications Bupropion and Rosuvastatin on time. However, staff did not include their initials and time of administration until after the fact on some of the occasions. For example, on 6/13/22 staff didn't initial as administering the medication until 11:08am and 11:09am, on 6/19/22 until 11:07am, 6/29/22 until 1:39pm and 1:40pm and 6/30/22 until 11:25am. Staff #1 and #2 recorded on 9/20/22 and 9/28/22 that individual's 10:30am Bupropion, Rosuvastatin, and Fluticasone prop nasal spray were administered on time, but were not initialed as administered until later; 9/20/22 wasn't initialed until 10:20pm, and 9/28/22 wasn't initialed until 11:40am. Staff person #1 wrote in pen their initials and 10/12/22 for administration of individual #1's Bupropion, Fluticasone, and Rosuvastatin at 10:30am on the individual's mars. However, this mar was printed on 11/1/22 so the documentation of administration of the 10/12/22 medications weren't documented until sometime after 11/1/22. Staff #1 documented that on 3/16/23, they administered Individual #1's Bupropion, Fluticasone, and Rosuvastatin 11:30am medication on time, but didn't record the administration until 3:05pm. In December 2022, staff didn't initial immediately after administration of medications to Individual #1 46 times. In November 2022, staff didn't initial immediately after administration of medications to individual #1 15 times.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 because the staff will be able to track all medications an individual receives and to ensure all medications are administered as prescribed. During the inspection, there were 79 times that the licenser identified that Individual #1's medication was not recorded at the time the medication was administered. This violation occurred because team members were not following the medication administration procedures. In addition, when the agency nurse and program supervisor were reviewing the medication administration logs, the errors were not identified which resulted in unfiled medication errors and failure to provide feedback to staff to prevent this from reoccurring. Immediately following the inspection, the Program Specialist and Agency Nurse conducted a full review of Individual #1's medication administration record since last inspection. On March 28, 2023, a medication error incident was filed in EIM. The incident number is 9189713. On March 22, 2023, the program team members responsible for administering Individual #1's medications received retraining. A follow up email was sent on 3/29/2023 to summarize the information that was reviewed. See Attachment #3. The Agency Nurse received retraining on 3/22/2023 regarding the expectations of reviewing medication logs and providing feedback to appropriate team members when errors are found. On 3/29/2023, the violations will be thoroughly reviewed with the Agency Nurse by the PA Assistant Director and Quality and Compliance Administrator. 03/29/2023 Implemented
6400.167(b)The following medication errors were not documented, reported, and followed up on by the agency: · Staff did not administer Individual #1's 10:30am Bupropion and Rosuvastatin on 9/19/23; the medication administration record was left blank. · There are numerous times throughout the year when staff document Individual #1 was sleeping and didn't get their medications on time. There are no records that the individual was attempted to be woken up or if the individual refused, just that they were sleeping and missed their medication administration time. This occurred 3 times in October 2022, twice in September 2022, and multiple times as referenced in 165(c) of this report. · Individual #1 is ordered acetaminophen 2 tablets every 6 hours for fever. Staff recorded that one tablet was administered on 9/6/22 for sore throat pain. · Individual #1 was not administered their medications 24 times in December 2022 and 36 times in November 2022 within an hour of their 10:30am medication administration time. Staff administered the medication late, when Individual #1 woke up, even though the individual's 5/10/22 physician's orders for missed medication are to wait and administer med3ications at their next scheduled time.Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record.This regulation is important because it ensures that medication errors are handled appropriately to avoid individual injury as a result of the error. During the inspection, there were medication errors identified for Individual #1 that did not have a medication error report filed. Therefore, there was not documentation that follow-up action was taken and feedback was provided to team members. This happened because during the review of medication administration records, the Agency Nurse failed to identify medication errors and ensure they were documented appropriately. Aside from filing the errors, this was a missed opportunity to provide feedback to team members to prevent recurrence. Immediately following the inspection, the Program Specialist and Agency Nurse conducted a full review of Individual #1's medication administration record since last inspection. On March 28, 2023, a medication error incident was filed in EIM. The incident number is 9189713. On March 22, 2023, the program team members responsible for administering Individual #1's medications received retraining. A follow up email was sent on 3/29/2023 to summarize the information that was reviewed. See Attachment #3. The Agency Nurse received retraining on 3/22/2023 regarding the expectations of reviewing medication logs and providing feedback to appropriate team members when errors are found. On 3/29/2022, the violations will be thoroughly reviewed with the Agency Nurse by the PA Assistant Director and Quality and Compliance Administrator. 03/29/2023 Implemented
SIN-00181131 Renewal 01/04/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)Individual #1's bedroom was not equipped with a mirror. There are no records that the individual chose not to have a mirror in his bedroom.In bedrooms, each individual shall have the following: A mirror. This citation was received because an individual did not have a mirror in his bedroom. It is important for an individual to recognize their appearance. During the licensing walk through on 1/5/2021, it was noted that individual #1 did not have a mirror in his room. On 1/5/2021, staff bought the individual a mirror for his room. See attachment # 33of the mirror hung in the bedroom. 04/01/2021 Implemented
6400.110(f)Individual #2 is hearing impaired and can not hear the smoke detectors or fire alarm system in his home. He does have hearing aides but refuses to wear them as well. The living room and two bathrooms in his home that are accessible to Individual #2 are not equipped with strobe lights or other devices to alert him in the event of a fire. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. This citation was received because there was not an adequate number of strobe lights throughout the house for the individual to be alerted to an emergency situation from any location of the home. It is important for everyone to be alerted immediately to emergency situations. The individual that needed the additional strobes no longer resides in the home. In the event that another person moves to the home and has a hearing impairment, additional strobes will be installed. Supervisors and Program Managers are to monitor homes for safety and request modifications as needed. During monthly site monitoring in the home, managers are expected to inspect the home for safety concerns. All residential supervisors and program managers have been retrained on this regulation and the importance of safety concerns being addressed via email. see attachment #2 of the 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. 04/14/2021 Implemented
6400.50(a)At the time of the 1/4/2021 inspection, Staff person #1's training record did not include documentation of the training content, the trainer, the training source and occasionally the length of time the training took to complete.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.Penn-Mar failed to keep on file the content of trainings along with the signature sheets that show the source, dates, and length of training. This regulation is important to ensure team members are properly trained to support the individuals they are working with and are able to meet their needs. Program Managers and Supervisors were retrained on the need to ensure all team members review ISPs, protocols, support plans, behavior plans, and assessments prior to working with individuals. A new process was put in place in November 2020 to have Program Managers review weekly training reports for team members that have worked in each program to ensure all team members have completed the training requirements for each program. Weekly audits are also conducted by the Director and Administrator to provide another level of oversight to ensure that staff working have completed all required individual specific training prior to working with individuals. A new process was put into place in November requiring Managers and Nurses to meet with teams to review protocols together. These meetings are held virtually and recorded. The protocol videos along with a Microsoft Word document of the protocol will then be uploaded into UltiPro (training platform). This will show the content of each protocol training. Protocol trainings include content, dates, length of training and staff persons attending. If team members are unable to attend the team meeting, they are required to review the recorded training at the start of their next shift. New protocols or updated protocols are immediately written and reviewed with team members. See attachment # 11 Protocol Training Guide. For staff training on things such as hospitalization discharge documents, the Learning and Development department will save staff signature sheets with the content they reviewed so they we are able to provide training information when required. See attachment # 12 - in-person training guide. 04/01/2021 Implemented
6400.51(b)(5)Staff person #1 started working independently with Individuals #1-#4 within a week or two after her date of hire on 11/30/2020 per agency report. There are no records maintained that Staff person #1 received orientation specific to Individuals #1-#4, their specific plans, protocols, or health and safety needs prior to working with them. Individuals #1-#4's specific plans and protocols provide staff with the knowledge and job skills needed to ensure the individual's health and safety is properly managed while living at the residence. Failing to orient staff to the specific job skills and knowledge needed prior to working with individuals creates an environment conducive to negligence. Staff person #1 didn't receive training on any of the individual's specific protocols until 12/31/2020, Individual #1's social, emotional, and environmental needs plan until 12/20/20, Individual #2's social, emotional, and environmental needs plan until 12/31/20, Individual #1-#4's individual support plans until 12/20/20, or training on Individuals #1, #2, and #4's agency assessments until 12/20/20.The orientation must encompass the following areas: Job-related knowledge and skills.This citation was received because the program manager failed to ensure the staff was properly trained to support the individual prior to working with him. It is important to ensure staff are thoroughly trained on plans and protocols for an individual prior to working with them to ensure they have the knowledge and job skills needed to ensure the individuals health and safety is properly managed. Program Managers and Supervisors were retrained on the need to ensure all team members review ISPs, protocols, support plans, behavior plans, and assessments prior to working with individuals. Supervisors have been retrained on the need to email their Program Manager to let them know when new substitute team members are scheduled to work at a group home. The Program Manager will then ensure that team members are assigned all trainings that team member is required to complete prior to working with individuals. A new process was put in place in November 2020 to have Program Managers review weekly training reports for team members that have worked in each program to ensure all team members have completed the training requirements for each program. Previously, the training system used did not allow managers to see the training records of the people who did not directly report to them. We have since discovered a work around to this and these reports are now sent weekly via email from the Director of PA programs to the Program Managers. Weekly audits are also conducted by the Director and Administrator to provide another level of oversight to ensure that staff working have completed all required individual specific training prior to working with individuals. 04/01/2021 Implemented
Article X.1007Penn-Mar Human Services (the agency) is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff person #1 was hired by the agency on 11/30/2020. An application for a Pennsylvania criminal history record check was never submitted to the Pennsylvania State Police. At the time of the 1/4/2021 inspection, the agency only had records of a third-party background check, that did not meet the regulatory requirements of submitting an application to the Pennsylvania State Police, was completed.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.This citation was received because Penn-Mar had records of a third-party background check instead of a physical copy of the Pennsylvania criminal history check that was submitted to the Pennsylvania State Police on file. Penn-Mar understands the importance of completing criminal record checks on staff. The vendor that we used HireRight, did submit background checks to PA State Police and would indicate on the report that they sent us the outcome of the PATCH report, however they did not send us a copy of the actual PATCH document. Since this was brought to our attention during our licensing, Penn-Mars Director of HR has been working closely with our vendor to change the terms of our agreement so that we will not only receive their comprehensive report but also a copy of the PA PATCH report. He has talked to numerous people at this company in an attempt to get copies from previously submitted staff but has not been successful. We have been successful at changing our agreement moving forward and have started to receive the PA PATCH document for all staff who have been extended offers of employment. Please see attachment #10 which is the actual PA PATCH document for a new staff recently hired. Moving forward we will receive the PA PATCH report from HireRight for all new staff. We are also in the process of submitting for a PA background check (PATCH) through the PSP system for any staff previously hired that we only have the comprehensive report for, given our previous arrangement with HireRight. We anticipate this to be completed by May 15th at the very latest. 05/15/2021 Implemented
SIN-00120670 Renewal 11/07/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.21(a)Penn Mar Organization, Inc. is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 ¿ 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff #2 was hired on 5/30/17 and required an FBI check. The FBI check was not requested until 5/31/17. The legal entity responsible for a facility or agency subject to approval under Article IX of the Public Welfare Code (62 P. S. § § 901¿922) shall submit an application for a certificate of compliance prior to the inspection and issuance of a certificate of compliance by the Department.Penn-Mar was previously working under the guidelines of the state, which require any staff to start the FBI criminal background check within 5 days of hire. During the Residential Licensing process, Penn-Mar was provided clarification that indicates that the FBI background checks needs to be started on or before the date of hire. This requirement has been reviewed with Program Specialists and the Human Resources Department. Since this has been brought to our attention, we have pushed back orientation for several staff due to the PA FBI background check system being down for the last two weeks. See attachment # 42, which shows the updated checklist that the Human Resource Department follows when hiring new employees. 12/13/2017 Implemented
6400.46(i)Staff #1 had CPR and first aid training on 11/3/15 and not again until 11/7/17.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 trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Despite several reminders from her Program Manager and the training department regarding the need for Staff # 1 to complete the CPR training by 11/3/7, she failed to attend a training. She did receive corrective action for not obtaining continued certification as required by regulations. As a result of this citation, the Program Specialist will review staff training expirations with the Residential Supervisors during their weekly meetings. The Community Living Administrator will review staff training expirations with the Program Specialists during bi-weekly meetings. Program Managers were trained on this requirement. See attachment #2. Supervisors will be trained on this requirement on 12/13/17. see attachment #3. 12/13/2017 Implemented
6400.62(a)Repeat 10/05/16: Spectracide weed stop was left unlocked and accessible to individuals on the porch of the home.Poisonous materials shall be kept locked or made inaccessible to individuals.The Spectracide weed stop was removed from the porch. The Program Manager has sent an email to the Facilities Director to request that he remind his employees to remove all poisonous substance when they leave the premises, which has been forwarded to his staff (Attachment # 23). Staff at the home have been re-trained and understand the need for poisonous substances to be locked on the premise (attachment # 24). All Residential Program Managers have reviewed and understand this regulation and will continue to be mindful of the need for poisonous substances to be locked at the group homes where folks do not have adequate awareness of such substances (attachment #2). Residential Supervisors will review this regulation at the upcoming Residential Supervisor meeting on 12/13/17 (attachment #3). 12/13/2017 Implemented
6400.67(a)Individual #1's bedroom carpet had numerous stains on it. There was a large stain on the carpet by his/her bed measuring 12 inches.Floors, walls, ceilings and other surfaces shall be in good repair. The carpet in the bedroom has been spot cleaned. Unfortunately, the stain was unable to be removed from the carpet. This individual will be moving from this home to another Penn-Mar home in mid-January 2018. At that time, the carpet will be replaced. See Attachment #25 All Program Managers have been re-trained on this regulation and will monitor the repair of homes during their monthly monitoring. Program Manager understand the expectation to notify our maintenance department when the home needs repair (attachment # 2). Residential Supervisors will be retrained on this regulation during the Residential Supervisor meeting on 12/13/17 (attachment #3). 12/13/2017 Implemented
6400.112(a)Repeat 10/05/16: There was no fire drill conducted in the months of August and September of 2017. An unannounced fire drill shall be held at least once a month. Penn-Mar has evaluated and made changes to the process. Fire drills will now be submitted to the Operations Support Specialist, whom we feel has the skills to monitor and ensure that fire drills are completed for every home each month and that the form is completed in its entirety and complies with state regulations. In addition, Program Managers have completed an audit of drills for November 2017, which have been completed for each home. Program Managers have been re-trained on this regulation (attachment #2). Residential Supervisors will be trained re-trained on this regulation at the Residential Supervisor meeting on 12/13/17 (attachment #3). 12/13/2017 Implemented
6400.112(h)Repeat 10/05/16: The fire drill conducted on 12/24/2016 did not indicate that all individuals evacuated to the designated meeting place. This section of the fire drill form was left blank. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Penn-Mar has evaluated and made changes to the process. Fire drills will now be submitted to the Operations Support Specialist, whom we feel has the skills to monitor and ensure that fire drills are completed for every home each month and that the form is completed and comply with regulations. In addition, Program Managers have completed an audit of drills for November 2017, which have been completed and comply for each home. Program Managers have been re-trained on this regulation (attachment #2). Residential Supervisors will be re-trained on this regulation at the Residential Supervisor meeting on 12/13/17 (attachment #3). See Attachment # 29, which indicates the meeting place was found by all individuals. 12/13/2017 Implemented
6400.144Individual #2 is recommended to have dental care completed every three months with a Periodontist. Individual #2 had a dental appointment on 3/30/17 and not again until 7/31/17. Staff noted in the recored that they arrived at the dentist office on 5/17/17 for an appointment but no appointment was scheduled. Individual #2 was prescribed Tamsulosin .4 mg on 3/21/17. This medication was not acquired or given until 5/26/17.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. Program Specialists and agency nurses have reviewed and understand this regulation and the importance of following recommendations regarding follow-up appointments and to ensure medications recommended by a physician are ordered and started as recommended (attachment #2). As a result of this citation, when reviewing medical appointment records, the agency nurse will ensure that medications ordered have been started or medications discontinued have been discontinued by monitoring the electronic MAR to ensure compliance. Residential Supervisors will be retrained on this regulation and the need to ensure follow through with medication orders at the Residential Supervisors meeting scheduled for 12/13/17 (attachment #3). Attachment # 27 shows his follow up appointments are scheduled for 2/7/18 for a cleaning at the Dentist¿s office and 4/11/18 at the Periodontist¿s office. See attachment # 28 showing a dental appointment following the Dentist¿s recommendations and compliance with the regulation. 12/13/2017 Implemented
6400.151(a)Staff #1 had a physical completed on 10/30/15 and not again. One was due on 10/30/17. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Despite several reminders from her Program Manager regarding the need for the employee to obtain a physical by 10/30/17, she failed to have her physical completed. She did receive corrective action for not having a physical within two years as required by regulations. She did have her physical on 11/10/17. See attachment # 43 Attachment # 44 shows a staff physical completed in compliance with this regulation. As a result of this citation, the Program Specialist will review staff physical expirations with the Residential Supervisors during their weekly meetings (attachment #2 & 3). The Community Living Administrator will review staff physical expirations with the Program Specialists during bi-weekly meetings. 12/13/2017 Implemented
6400.151(c)(2)Staff #1 had a Tuberculin skin test completed on 10/30/15 and not again. One was due 10/30/17. 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. Despite several reminders from her Program Manager regarding the need for the staff to obtain a PPD by 10/30/17, she failed to have her PPD completed. She did receive corrective action for not having a physical/PPD within two years as required by regulations. She did have her PPD on 11/8/17. See attachment #43 Attachment #44 shows a staff physical/PPD completed in compliance with this regulation. As a result of this citation, the Program Specialist will review staff physical/PPD expirations with the Residential Supervisors during their weekly meetings (attachment #3). The Community Living Administrator will review staff physical/PPD expirations with the Program Specialists during bi-weekly meetings (attachment #2). 12/13/2017 Implemented
6400.186(a)Repeat 10/05/16: Individual #2 did not have an ISP review completed every 3 months. Individual #2's ISP review period covering from 10/14/16 to 1/13/17 was not completed until 6/9/17. Individual #2's ISP review covering 1/14/17 to 4/13/17 was not completed until 6/9/17.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. Program Specialists have been retrained and understand that the ISP review is to be completed quarterly based on the ISP date (Attachment #2). As a result of this citation, the Community Living Administrator will review upcoming quarterly review dates with the Program Specialist during their bi-weekly meetings to ensure quarterly reviews are completed in accordance to the state regulation. See Attachment # 26, which shows a quarterly completed in compliance with the regulation. 12/13/2017 Implemented
6400.186(c)(2)Repeat 10/05/16: Individual #2's ISP review completed on 10/27/17 did not review his/her blood sugar protocol recommended by the doctor on 8/30/17 and his/her fall protocol. It is documented that Individual #2 had a fall on 7/17/17.Individual #2's ISP reviews dated 10/27/17, 7/27/17 and both dated 6/9/17 did not review his/her social, emotional, environmental plan. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. Program Specialists have been re-trained on this regulation and understand that the ISP review is to include all plans of care and any changes that are made to the individual¿s plan of care during each quarter (attachment #2). The Program Specialists has submitted an addendum to the last quarterly review dated 10/27/17 to the individual¿s team (attachment # 30). See Attachment # 26, which shows a quarterly completed in compliance with the regulation. 12/13/2017 Implemented
SIN-00089974 Unannounced Monitoring 11/04/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual#1 is prescribed the medication Vimpat for a seizure disorder. On 9/25/15, 10/15/15, 10/24/15 & 10/24/15 Individual #1 was not administered the Vimpat per the Medication logs. On 9/26/15 Individual #1 had to be taken to the Emergency Room due to seizures lasting more than 5 minutes. This followed the missing dosage of Vimpat on 9/25/15. On 10/25/15 Individual #1 had to be taken to the Emergency Room due to seizures lasting more than 5 minutes. This followed the missing dosage of Vimpat on 10/24/15. On 10/31/15 Individual #1 had to be taken to the Emergency Room due to seizures lasting more than 5 minutes. This followed the missing dosage of Vimpat on 10/31/15. On 8/10/15 Individual #1 was not administered Levitracetra( Keppra) 250mg at 7am for seizures per the Medication log. 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. When these medication errors occurred, staff were coached regarding how to avoid the errors in the future, but there was not a good documentation trail of this. Staff did receive corrective action in accordance with out medication error policy. After this licensing, the decision was made to retrain all staff on the steps of medication administration, including new staff who were being trained to work at the house but had previously not had any medication errors. Attachment G & H All Supervisors and Program Managers were re-trained on November 11, 2015 on the ramifications of medication errors. Supervisors engaged in conversation regarding the medication errors that happen at Penn-Mar and how as an organization we could work to improve this. Supervisors and Managers were encouraged to advocate for documented re-training for staff struggling with medication administration so as to try to be proactive and not simply reactive with staff in the form of disciplinary action. 11/19/2015 Implemented
6400.185(b)The ISP for Individual #1 states that all knives are to be locked due to the past history of Individual #1 threatening to harm staff with them. On 11.4.15 when completing a walk thru of the kitchen area the knives where found unlocked in a kitchen drawer near the kitchen sink. Individual #1 had access to this area without staff supervision. The ISP shall be implemented as written.This individuals safety regarding knives was documented in the assessment and ISP, since this is such an important matter it was decided to have a specific safety protocol for knives completed for this individual. The creation of this safety protocol should ensure that all staff who work at the home review this information prior to working at the home and annual. Although all staff do review the ISP, there is a great deal of information in this document. Seperate protocols for health and safety allow the information to be more easily accessed for staff. All staff who work at the home or sub at the home have were re-trained on the Safety Protocol for Knives in November after this licensing inspection. Attachment F In addition, there have been Staff who were trained to sub at this program since the training that occurred in November. In addition to reading the ISP, these staff also reviewed this protocol and other protocols pertinent to this home/individuals at this home. that may have subbed at the home since this protocol was implemented completed training prior to being able to work alone in the home. Attachment G All Supervisors and Program Managers were re-trained on November 11, 2015 on the need to ensure that all staff and sub staff are aware of safety issues regarding knives and individuals safety with chemicals. Discussion regarding creating separate protocols outside of simply having sub staff read ISP's occurred and was agreed upon for all homes. 12/17/2015 Implemented
6400.186(c)(2)The ISP reviews for Individual #1 dated 8/27/15 & 5/27/15 did not review each section of the ISP. The ISP reviews did not review the outcome Home- daily hygiene. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. Although the ISP reviews for this individual on 8/24/2015 & 5/27/2015 did highlight the outcome of Home-Daily hygiene, there was not enough specific information regarding how the individual was progressing with the outcome. General statements such as "has shown progress" and "will not complete the outcome this ISP year", were all that was mentioned. This was corrected with the individuals 11/16/2015 quarterly. This quarterly includes more detailed information regarding the individuals progress with this outcome. Attachment E All Supervisors and Program Managers were re-trained on November 11, 2015 on the need for the quarterly ISP review to contain specific detail regrading the individuals progress. In many cases this information was being highlighted on the Monthly Progress Report, and staff were not ensuring that the same level of detail was contained on the Quarterly. 11/24/2015 Implemented
6400.213(9)Individual #1's record did not contain the current ISP. There was an ISP dated 8/21/15, but the most current one was dated 10/29/15 which was not printed and in the record. Each individual's record must include the following information: A copy of the current ISP. The ISP from 10/29/2015 was immediately printed and placed in the individuals record. Since this licensing inspection, the plan was again updated on 3/1/2016 and it was placed in the record. Attached you will find the 3/1/2016 ISP that is now in the record. Attachment A In addition, all Supervisors and Program Managers were re-trained on November 11, 2015 on the need to ensure that ISP's are printed and placed in the record. It is not always easy to know when ISP's are updated, as we are not always alerted by Supports Coordinators. Penn-Mar staff were encouraged to ensure that they check for updated ISP's after each annual meeting and critical revision. 11/11/2015 Implemented
6400.213(11)REPEAT Violation from Annual Inspection completed 8/15/15 Content discrepancy- Individual #1's ISP has unsupervised time for 2 hours while staff on premise, the annual assessment has 3 hours of alone time while staff are on premise. The ISP has Individual is not safe around poisons except hand/dish soaps, but the annual assessment has the Individual #1 is Independent and has adequate awareness around poisons. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. Following this licensing inspection an addendum to the individuals Assessment was completed to ensure that the information regarding supervision and awareness of poisons materials was updated. This addendum was sent to the team on 11/17/2015 Attachment B An entire new assessment was completed for Aaron on 12/3/2015 due to Penn-Mar staff wanting to ensure that all information in his assessment was accurate and most up to date given the numerous changes in this individuals life. Attachment C It appears that several of the changes were made in the 3/1/2016 ISP update, however not all needed changes were made. Melissa Williams, Program Manager sent an email to the Supports coordinator on 3/3/2016 outlining the changes that still need to be made to the ISP so that it matches the assessment. Attachment D All Supervisors and Program Managers were retrained on the need for Assessments and ISP's to match on November 11, 2015. All staff were also trained on the need to thoroughly read all ISP's to ensure that changes suggested at the ISP meeting and information from the assessment make it into the ISP and that there is not conflicting information. 03/03/2016 Implemented
SIN-00083010 Renewal 08/12/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)The closet by the front door unlocked contained cleaning supplies. The cabinet underneath the sink in the downstairs bathroom by staff office had clorox clean up unlocked. Poisonous materials shall be kept locked or made inaccessible to individuals. Violation ¿ 6400.62(a) Violation Description: The closet by the front door unlocked contained cleaning supplies. The cabinet underneath the sink in the downstairs bathroom by staff office had Clorox clean up unlocked. Plan of Correction: The front door is always to remained locked. All staff who directly work in this home have been retrained on the need to know each individuals cognizance of danger related to poisonous materials and the need for this door to remain locked. The Clorox that was in the downstairs bathroom has been removed. All cleaning supplies are to be kept in this locked closet by the front door. Attachment L All Penn-Mar Program staff responsible for this requirement, were re-trained on the regulation and execution of this regulation. Attachment B Correction Date: 8/19/2015 Implemented
SIN-00177819 Renewal 05/07/2021 Compliant - Finalized
SIN-00070784 Initial review 10/30/2014 Compliant - Finalized