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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.51(a)(3) | Staff person #10 transferred from Penn Mar Human Services' Maryland programs on 6/3/23. However, this staff person was "subbing" in homes before this time. This staff person did not receive training in the areas required by 6400.51b1 -- 6400.51b5 within 30 days of transfer and before working alone with individuals. This staff member received a Maryland Abuse Recognition training on 8/25/23, Person Centered Practices training on 10/5/23, and Incident Management training on 11/16/23. Additionally, all individual plans and protocols were trained as a "self-read." Regulation 6400.51b5 requires an in-person training with the individual physically present; "self-read" is not considered sufficient training. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons. | Regulation 6400.51(a)(3) is important because it ensures that all staff understand the laws and best practices relating to supporting individuals with an intellectual disability or autism and has the knowledge and skills necessary to assure the health and welfare of the individual(s) served.
Staff person #10 did not have the training required by 6400.51b1-6400.51b5 within 30 days of transfer and before working alone with individuals.
Prior to the inspection, Penn-Mar identified that we were not in compliance with people transferring or subbing in programs in accordance with 6400 regulations. This occurred mostly when team members assigned in Maryland Programs would choose to sub in Pennsylvania Programs.
In August 2023, the organization implemented a Compliance and Training Process for New Team Members to ensure that New Hires, Subs, and Transfers met the requirements of 6400 regulations. Unfortunately, Staff Person #10 started subbing in programs prior to the implementation of the process. See attachment #3 for the process.
The requirement under 6400.51b5 for training to include the individual physically being present was also not met as indicated in this violation.
The organization did not acknowledge this addition to the RCG and therefore did not have a process in place to ensure that training with the individual physically present was happening and there was document to support it. However, part of the initial training for team members involved an in-person component where the supervisor would sit down with the team member and review the individual specific training. This would include a demonstration of skills and the person supported was present for a portion of this training.
In order to ensure compliance with regulation 6400.51b5, the PA Individual Specific Training Checklist was updated to include the following statement: The training in this checklist includes the person(s) supported being present and team members demonstrating the skills and knowledge necessary per regulations.
On March 5, 2024, an email will be sent to Program Specialists and Residential Supervisors reinforcing that the initial training of team members must include an in-person component where the person(s) supported are present. Effective March 6, 2024, the new training checklist will be implemented. See attachment #4 for the training checklist. |
03/04/2024
| Implemented |
| 6400.52(c)(6) | Staff persons #2, 3, 4, 6, 7, and 9 did not receive training in implementing the individual plans and protocols for the individuals they work with in training year 2022-2023. Many of the plans and protocols on the training record indicate that the training was "self-read;" however, regulation requires that this training occur in person with the individual physically present. This cannot be a "self-read" or web-based training. | 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 6400.51(c)(6) is important because it ensures that all staff understand the laws and best practices relating to supporting individuals with an intellectual disability or autism and has the knowledge and skills necessary to assure the health and welfare of the individual(s) served.
At the time of the inspection, many staff did not receive training in implementing the individuals plan and protocols according to the regulation requirements because the training was self-read.
Penn-Mar did not ensure that annual training encompassed implementation of the individual plan through live training and with the individual(s) physically present.
In order to ensure compliance with regulation 6400.52(c)(6), the process for annual training and updated training throughout the year needs to be modified.
On 2/7/2024, Penn-Mar met with licensing to ensure there was a clear understanding of the expectation to meet this regulation. Since then, there have been several conversations to determine the best way to meet this regulation.
The operations team will meet with the learning and development team on 3/20/2024 to solidify how this regulation will be met and captured for annual training, as well as updates to individual specific training throughout the year.
Once a plan is established, the Program Specialists, Supervisors, Nurses, and Behavior Support Specialist will be trained on the new method of training and process to capture compliance.
The new training method and process will be implemented by April 1, 2024. |
03/04/2024
| Implemented |
| 6400.166(a)(7) | At the time of the 01/31/24 inspection, the Calcium 600mg medication dosage was listed as 800mg on Individual #1 January 2024 Medication Administration Record. | 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 to ensure all medications are administered as prescribed.
During the inspection, it was noted that the Calcium 600mg medication dosage was listed as 800mg on the January 2024 Medication Administration Record (MAR).
The medications on the Medication Administration Record were discontinued and re-posted due to the labels needing to include to put in soft foods. When the Residential Supervisor reposted Calcium, it was written as 800mg rather than 600mg. The paper MAR was not used to administer medications after the labels were changed, so no team member would have caught the error as part of their 15 steps of medication administration.
On 1/31/2024 following the inspection, the Residential Supervisor corrected the error from 800mg to 600mg on the medication administration record. |
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)(13) | Individual #1's individual plan states that Individual #1 is allergic to Depakote and Prozac. This information is not included on the most recent annual physical dated 7/14/20. | The physical examination shall include: Allergies or contraindicated medications. | Staff did not ensure Depakote and Prozac were noted on the annual physical as allergies or contraindicated medications.
It is important for allergies or contraindicated medications to be documented on annual physicals in order for this to be reviewed with the physician and to prevent the physician from ordering a medication that may cause harm to the person.
On June 9, 2021, the physician added Depakote and Prozac to list of allergies. This individual¿s next physical is scheduled for 7/15/21. The allergy information will be documented on the annual physical. See attachments- 5740 Liggitt Lane Primary Care Drug Allergy Correspondence and 540 Liggit Ln 07.15.2021 annual physical with allergy information included on the document to be reviewed with the PCP
Program Managers have had training regarding this regulation during the exit conference with the state licensing team on June 9, 2021.
All residential staff have been retrained on this regulation via email. See attachment- citation review. This regulation has been reviewed with Residential Supervisors on June 23, 2021 during their team meeting. See attachment RS meeting agenda
Each supervisor is required to review allergies noted in each individuals record and ensure they are listed on the annual physical. If they are not listed on the current physical, the supervisor is responsible for rectifying the record of the missing information by Friday, 7/2/21. |
07/02/2021
| Implemented |
| 6400.166(a)(2) | There is no prescriber name listed for the medications on the Medication Administration Records for Individual #1. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | Staff did not ensure all prescribing physicians were included on the medication administration record.
It is important to note the physician that prescribes each medication so that staff know which physician to contact in the event there are questions surrounding the medication.
The prescribing physician has been added to the medication administration record for every medication prescribed. See attachment- 5740 Liggitt Lane MAR with prescribing physicians and allergies
Program Managers have had training regarding this regulation during the exit conference with the state licensing team on June 9, 2021.
All residential staff have been retrained on this regulation via email. See attachment- citation review. This regulation has been reviewed with Residential Supervisors on June 23, 2021 during their team meeting. See attachment ¿ RS meeting agenda
An audit of medication records for all individuals residing in a Penn-Mar CLA has been completed and records have been updated to include the prescribing physician for each medication prescribed.
When staff enter medications onto the electronic MAR, they will include the prescribing physician. When nurses review MARs they will ensure the prescriber is listed. Program Managers will review MARs during site monitoring's and ensure prescribing physicians are listed for each medication prescribed. |
06/29/2021
| Implemented |
| 6400.166(a)(3) | Individual #1's individual plan states that Individual #1 is allergic to Depakote and Prozac. This is not included on Individual #1's Medication Administration Records. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies. | Staff did not ensure Depakote and Prozac were documented on the individuals medication record as an allergy.
It is important for allergies or contraindicated medications to be documented on medication administration record in order for anyone that is reviewing the medication administration record to be aware of the medication allergies.
The allergies have been added to the medication administration record. See attachment- 5740 Liggitt Lane MAR with prescribing physicians and allergies
Program Managers have had training regarding this regulation during the exit conference with the state licensing team on June 9, 2021.
All residential staff have been retrained on this regulation via email. see attachment citation review. This regulation has been reviewed with Residential Supervisors on June 23, 2021 during their team meeting. See attachment RS meeting agenda
Each supervisor was required to review allergies noted in each individuals records and ensure they are listed on MAR. Medication records for each person supported in a CLA has been audited and allergy information has been entered onto the persons medication administration record if applicable. |
06/29/2021
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.76(a) | Individual #1 drywall is damaged in multiple of location from hanging objects. | Furniture and equipment shall be nonhazardous, clean and sturdy. | It is important for the drywall to be sealed with paint so that it does not retain moisture.
The individual often tapes items such as posters to her walls and then takes them down. While doing so, the tape pulls the paint off the drywall.
The drywall was repaired and painted on 11/2/18. See attachment of the repaired and painted drywall.
All residential team members have been trained that as situations like this occur with the normal wear and tear of a home, they are to continue to submit a maintenance request form. Maintenance should be able to respond in a timely manner. If they do not, staff are to make the Program Manager aware.
Program Managers have had training regarding this regulation during the exit conference with state licensures on 10/17/2018. They will continue to monitor and ensure furniture and equipment is not hazardous and in good repair 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, Director of PA Program, and the PA Chief Operations Officer. A review of this regulation will also be completed with the Residential Supervisors again at their next team meeting on 12/12/2018. See attachment of the email sent to all residential team members on 10/31/18. |
11/02/2018
| Implemented |
| 6400.81(k)(6) | Individual #1's apartment in the basement there was no mirror in the bedroom. | In bedrooms, each individual shall have the following: A mirror. | The individual resides in an apartment-like setting and has her own bathroom where she has utilized a mirror.
A mirror was purchased and placed in the individual¿s bedroom to meet the regulation. See attachment of mirror hung on the back of the bedroom door on 11/2/18.
All residential team members have reviewed this regulation and are aware that when something happens to the mirror that is in the individual¿s bedroom they are to have it replaced. If the individual prefers to not have a mirror, the team will need to ensure that this is clearly documented in their ISP. Program Managers have had training regarding this regulation during the exit conference with state licensures on 10/17/2018. They will continue to monitor for mirrors in the bedroom of each individual 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, Director of PA Program, and the PA Chief Operations Officer. A review of this regulation will also be completed with the Residential Supervisors again at their next team meeting on 12/12/2018. See attachment of the email that was sent to all residential team members on 10/31/18. |
11/02/2018
| Implemented |
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