Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.44(b)(1) | The program specialists were not completing the assessments; house managers were. | The program specialist shall be responsible for the following: Coordinating and completing assessments. | The process for completing assessments at Penn-Mar has changed as a result of this clarification. House supervisors had previously completed the assessment and Program Specialists reviewed and made changes as needed. Program Specialists now complete the assessment; however, they still rely on information obtained from the house supervisor as the house supervisor has the best first-hand knowledge about the individual. Attached is a completed assessment that was completed with this new process.
See attachment X |
12/16/2016
| Implemented |
6400.103 | The written evaucation procedure plan did not include individual and staff responsibilities and means of transportation. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| As a result of this citation an audit of all homes written evacuation procedure plan was completed and it was determined that as Penn-Mar has grown, an issue has also grown that too many Supervisors were creating their own written evacuation procedure plan and it was becoming too easy for the information that is required to get missed. Therefore, a master template was created to address the written evacuation procedure plan. This template was given to all Supervisors of all Penn-Mar residential homes. All homes have now completed this updated standardized form. Attached you will find the new written evacuation procedure plan for the Stewartstown home. |
11/01/2016
| Implemented |
6400.106 | The furnace has not been cleaned and inspected since the opening of the home on 9/20/15. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The furnace at Stewartstown Road was cleaned on 10/27/2016. Stewartstown Road has been added to the cleaning schedule for future annual cleanings.
See Attachment V
Director of Facilities for Penn-Mar Human Services has been retrained on the need to ensure that any new home that is opened is added to the furnace cleaning list provided to the vendor. |
10/27/2016
| Implemented |
6400.141(c)(14) | Individual #1's 8/31/16 physical examination did not include information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The annual physical exam form has been adjusted/revised as this required section was previously at the very bottom of the physical. This required section has been moved to the section that is filled out by the doctor during the exam. Attached you will find a completed physical for an individual that was completed with this revised form.
See Attachment U |
10/18/2016
| Implemented |
6400.145(3) | The emergency medical plan did not include an emergency staffing plan. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | As a result of this citation an audit of all homes emergency medical plan was completed and it was determined that as Penn-Mar has grown, an issue has also grown that too many Supervisors were creating their own emergency medical plan and it was becoming too easy for the information that is required to get missed. Therefore, a master template was created to address the emergency medical plan. This template was given to all Supervisors of all Penn-Mar residential homes. All homes have now completed this updated standardized form. Attached you will find the new emergency medical plan for the Stewartstown home.
See Attachment T |
10/12/2016
| Implemented |
6400.163(c) | Individual #1's 4/13/16 and 9/21/16 psychiatric medication reviews did not include the medications or necessary dosages. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Attached you will find a psychiatric medication review for individual #1 that was completed in November. All medications/dosages are documented on this form.
See Attachment S
All Supervisors were retrained on the need for medications/dosages to be attached to the psychiatric medication review form. Staff have been discouraged from printing this on a separate piece of paper and attaching it to the review as it is easy for the separate piece of paper to become detached.
See attachment A |
11/30/2016
| Implemented |
6400.181(e)(8) | Individual #1's 6/7/16 assessment did not include his/her ability to evacuate in the event of a fire. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | Attached you will find an addendum to Individual #1¿s assessment that more clearly defines the individual¿s ability to evacuate in the event of a fire.
See Attachment R
All Program Specialists were trained on the need to be more thorough in their descriptions in assessments. Although we have previously used the word independent and assumed that this was descriptive enough, all Program Specialists were trained on the fact that they need to be more descriptive rather than just assuming that everyone has the same definition for independent.
See Attachment A |
12/21/2016
| Implemented |
6400.185(b) | Individual #'1s Individual Support Plan (ISP) included a social activities outcome. This outcome was not implemented. | The ISP shall be implemented as written. | Program Specialist contacted the Supports Coordinator to ask for the outcome in the ISP to be revised slightly so that the outcomes/goals that were agreed to at Individual's ISP meeting (learning address/phone number) are more clearly defined in the Social/Recreation outcome. Program Specialist states that Supports Coordinators want the outcome in the ISP to be a broad over-arching outcome, however Program Specialist has requested that the details within the broad outcome better match the specific outcome/goal that is being worked on. Attached you will find the email to the Supports Coordinator AND September-November data/monthly report on this outcome.
See Attachment G
All Program Specialists have been re-trained to ensure that they are reading ALL sections of the ISP when sent to them by Supports Coordinators to ensure that the information discussed at the ISP meeting is accurate in the ISP. Although, Supports Coordinators make broad outcome phrases, the details within that outcome need to match the work that is happening each day within the outcome in the home.
See Attachment A |
12/21/2016
| Implemented |
6400.186(a) | Individual #1 was admitted to the program on 10/6/15. An Individual Support Plan (ISP) review was not completed until 3/28/16. The program specialist was not completing the ISP reviews. | 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 required additional training on this matter. They now understand that the ISP review is to be completed quarterly based on the ISP date NOT the date the individual moved into the home.
See Attachment A
Penn-Mar has not had an individual move into residential services since this licensing inspection, therefore we have not yet been able to show compliance. However, an individual is moving into the Jeffrey Lane home on 12/20/2016. His ISP date is 11/1/16. The Program Specialist is now aware that the quarterly will be due on 2/1/17. Attached you will see a screen shot of the Program Specialists calendar reminding him of the quarterly being due on 2/1/17.
See Attachment P |
02/01/2017
| Implemented |
6400.186(d) | Individual #1's 3/28/16, 6/67/16, and 9/26/16 Individual Support Plan (ISP) reviews were not sent to his/her behavior specialist. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | Individual #1¿s next quarterly is due 12/27/2016. Program Specialist will ensure that it is sent to the appropriate Behavioral Specialists for this individual. See attached screen shot of the Program Specialists calendar that has the quarterly due and reminds him to send to the Behavioral Specialist.
See Attachment Q
All Program Specialists were re-trained on the need to ensure they know who to send ISP reviews to. Although many behavioral specialist decline to receive this, Program Specialists need to be checking to ensure that is on file for each individual.
See Attachment A |
12/27/2016
| Implemented |