Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00202405 Renewal 03/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(4)(REPEAT VIOLATION FROM 1/4/21) -- Individual #1 was admitted to Penn-Mar Human Services on 12/22/21. As of the 3/29/22 inspection, there has been no vision or hearing exam completed for Individual #1. Individual #1's 12/3/21 physical examination reviewed their eyes and ears but not vision or hearing.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. This regulation is important because accurate medical information is essential to develop accurate assessments and individual plans. Knowing accurate information would ensure that Individual #1 is receiving proper medical support and that their needs are being met. During the physical examination on 12/3/2021, a thorough vision and hearing screening was not completed. The team member who supported Individual #1 at the physical examination appointment did not ensure the physician completed a thorough vision or hearing screening. Additionally, the Agency Nurse and Program Specialist did not thoroughly review the medical paperwork for Individual #1's physical examination. Individual #1 has a PCP appointment scheduled on 4/13/2022 for a vision and hearing exam. . Additionally, Program Specialists will do an audit of all annual physicals to ensure a vision and hearing screening is completed as recommended by the physician. 04/29/2022 Implemented
6400.211(b)(2)Individual #1's emergency information does not include the address and telephone number of their primary care physician. Emergency information for each individual shall include the following: The name, address and telephone number of the individual's physician or source of health care.This regulation is important because having the address and phone number of Individual #1's primary care physician will ensure critical health information is available in the event of a medical emergency. Individual #1's emergency information did not include the address and telephone number of their primary care physician. The Residential Supervisor, Direct Support Professionals, and Program Specialist that support Individual #1 did not ensure the emergency information was completed in its entirety. Individual #1's emergency information has been updated to include the address and telephone number of her primary care physician. See Attachment #5. Additionally, Program Specialists will be completing an audit of all individual's emergency information to ensure it includes the address and telephone number of their primary care physician. The Program Specialist will make changes as needed to ensure this information is listed. This audit will be completed by April 22, 2022. 04/29/2022 Implemented
6400.211(b)(3)Staff person #1 is to be contacted in case of an emergency where medical consent is needed for Individual #1. Staff person # 1's address and telephone number are not included with Individual #1's emergency information.Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. This regulation is important because having the address and phone number of Individual #1's emergency contact and emergency consent will ensure critical health information is available in the event of a medical emergency. Individual #1's emergency information did not include the address and telephone number of the emergency contact or emergency consent person. The Residential Supervisor, Direct Support Professionals, and Program Specialist that support Individual #1 did not ensure the emergency information was completed in its entirety. Individual #1's emergency information has been updated to include the address and telephone number of their emergency contact and emergency consent person. See Attachment #5. Additionally, Program Specialists will be completing an audit of all individual's emergency information to ensure it includes the address and telephone number of their primary care physician. The Program Specialist will make changes as needed to ensure this information is listed. This audit will be completed by April 22, 2022. 04/29/2022 Implemented
6400.166(a)(11)(REPEAT VIOLATION FROM 1/4/21) -- Individual #1's Medication Administration Record does not include the diagnosis or purpose for Junel.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.This regulation is important because the same medications may be used to treat different conditions and the certified medication administrator needs to know what medications they are given to the individual, as well as the diagnosis associated with the medication. Knowing this information supports the 15 steps of medication administration and ensures medications are administered as prescribed. Individual #1 is prescribed Junel 1/20 Tab once a day. The Medication Administration Record did not include the diagnosis or purpose for the medication. When reviewing April medications and comparing MARs to medication labels, the Residential Team Member did not ensure the Medication Record included diagnosis or purpose for the medication. Additionally, the team members who administered Individual #1's Junel did not notice or communicate that the diagnosis or purpose for medication was not listed on the MAR. On April 5, 2022, Individual #1's Medication Administration Record was updated to include the diagnosis or purpose for the medication. See Attachment #4. The Program Specialist will complete an audit of all individual's MAR's to ensure the diagnosis or purpose for the medication is listed on the Medication Administration Record. In the event it is not listed, the Program Specialist will update the MAR. The audit will be completed by April 22, 2022. 04/29/2022 Implemented
SIN-00188624 Unannounced Monitoring 06/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(a)The walkway leading to the back of the house has two sections that are trip hazards. One area of the sidewalk has a crack that runs across the sidewalk about three inches wide. The other section of the walkway, dips down unexpectedly and drops about an inch and a half. Outside walkways shall be free from ice, snow, obstructions and other hazards. The maintenance department now recognizes that the yellow paint indicating the trip hazard is not acceptable and that moving forward, such hazards must be repaired immediately. The maintenance department is working to replace the sidewalk. This project will be completed by July 30, 2021. Program Managers have had training regarding this regulation during the exit conference with the state licensing team on June 9, 2021 All staff have been retrained on this regulation via email sent to all residential team members. See attachment- citations review. This regulation has been reviewed with Residential Supervisors on June 23, 2021 during their team meeting. See attachment RS meeting agenda 07/30/2021 Implemented
SIN-00102848 Renewal 10/05/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The top left cabinet under the kitchen sink was missing a knob. Individual #1's dresser on the right wall was missing a knob on the first and third drawers.Floors, walls, ceilings and other surfaces shall be in good repair. The knob was replaced on the kitchen cabinet and individual #1¿s dresser See Attachment O All Residential Supervisors and Program Specialists were re-trained on this regulation. All Residential Supervisors and Program Specialist level staff were trained on the need to be more mindful of knobs in general, as there were several citations for missing furniture knobs as well. Program Specialists now look for this during their monthly site visits. See Attachment A 10/12/2016 Implemented
6400.110(a)There was no smoke detector in the attic. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. The attic entrance was sealed off, as there is no need for staff to be in this area and nothing is stored there. As a result, a smoke detector is not needed. See Attachment B All Supervisors and Program Managers were re-trained on the need to ensure that attic spaces remained closed off should maintenance ever need to unseal it to get to the attic space. Should this happen, residential staff will contact maintenance and remind them to re-seal off the space. See Attachment A 10/12/2016 Implemented
6400.111(a)There was no fire extinguisher in the attic.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. The attic entrance was sealed off, as there is no need for staff to be in this area and nothing is stored there. As a result a fire extinguisher is not needed. See Attachment B All Supervisors and Program Managers were re-trained on the need to ensure that attic spaces remained closed off should maintenance ever need to unseal it to get to the attic space. Should this happen, residential staff will contact maintenance and remind them to re-seal off the space. See Attachment A 10/12/2016 Implemented
6400.112(h)The 8/25/16 fire drill log did not indicate if all individuals met at the meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Attached you will see that Woodland¿s fire drills for September, October, and November show that the form is documented thoroughly to include the fact that all individuals met at the meeting place. See attachment N Penn-Mar¿s previous expectation was that Residential staff turn in fire drills on the first of the month for drills completed the prior month. This policy did not allow for enough oversight to ensure that drills were completed thoroughly. Therefore, all Residential Supervisors are now required to turn in fire drills by the 20th of each month. This will allow for a 10 day review so that Program Specialist can ensure that the form is completed thoroughly and if there are issues associated with the drill another drill can be completed within that month. All Supervisors and Program Managers were re-trained on the need to ensure that fire drill forms are thoroughly filled out. See attachment A 11/14/2016 Implemented
SIN-00083013 Renewal 08/12/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There was hand sanitizer left unlocked in the room of the kitchen on top of the desk.The individual in the home needs all posions locked. Poisonous materials shall be kept locked or made inaccessible to individuals. The hand sanitizer is now kept in a locked medication cabinet. 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. They were retrained to ensure that all poisonous substances are kept locked. Attachment I All Penn-Mar Program staff responsible for this requirement, were re-trained on the regulation and execution of this regulation. Attachment B 08/19/2015 Implemented
6400.141(c)(6)Individual #1's tuberculin skin testing was completed on 2/23/13 and then again on 4/3/15. 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. Since this licensing inspection another individual was due for a TB skin test. Their last testing was done on 8/19/13. They returned within the 2 year window for another TB skin test on 8/19/15. Attachment H All Penn-Mar Program staff responsible for this requirement, were re-trained on the regulation and execution of this regulation. Attachment B 08/19/2015 Implemented
6400.181(e)(13)(vi)Individual #1's assessment did not include progress over the last 365 calendar days and current level in recreation. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. Penn-Mar's Program Manager completed an addendum to this assessment that will document the individuals progress and growth in the area of recreation. Attachment D All Penn-Mar Program staff responsible for this requirement, were re-trained on the regulation and execution of this regulation. Attachment B 08/31/2015 Implemented
6400.186(e)Individual #1's record did not include the option to decline the ISP review documentation. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. Individual#1's team was contacted about their option to decline the ISP review after licensing. Attachment F All Penn-Mar Program staff responsible for this requirement, were re-trained on the regulation and execution of this regulation. Attachment B 08/31/2015 Implemented
6400.213(11)Individual #1's assessment 2/24/15 states 1:1 supervision at home and ISP states 1:4 or 2:4 at home. ISP states there is a seizure protocol in place but it not documented in the assessment. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. Program Manager revised the individual's assessment (addendum), as this individual does not require 1:1 supervision at home and the assessment will now include information on the seizure protocol. Attachment D Program Manager sent this addendum to the assessment to the Supports Coordinator and requested that the ISP be revised to reflect the accurate information. Attachment E Since this licensing inspection another staff person was due for their bi-annual physical exam. This person's last physical was done on ? Their next physical was completed on ?? Attachment C All Penn-Mar Program staff responsible for this requirement, were re-trained on the regulation and execution of this regulation. Attachment B 09/21/2015 Implemented
SIN-00070900 Renewal 07/28/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The bathroom on the lower floor had feces on the toilet seat.Clean and sanitary conditions shall be maintained in the home. The toilet was immediately cleaned upon knowledge of the feces. Residential Supervisor of the home revised the staff cleaning chart to specifically indicate bathroom and toilets being cleaned and has assigned specific shifts to complete this. See attachment J Physical site inspections is part of the monthly site mountings completed by Program Managers monthly. All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014 See attachment A 08/13/2014 Implemented
6400.67(a)The mirror in the main floor bathroom is broken in the right corner. Floors, walls, ceilings and other surfaces shall be in good repair. The mirror was replaced. See attachment I. Physical site inspections is part of the monthly site mountings completed by Program Managers monthly. All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014 See attachment A 08/13/2014 Implemented
SIN-00177824 Renewal 05/07/2021 Compliant - Finalized
SIN-00143492 Renewal 10/15/2018 Compliant - Finalized
SIN-00070886 Initial review 10/31/2014 Compliant - Finalized