| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00297008
|
Unannounced Monitoring
|
05/11/2026
|
Needs Verification
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1 began receiving residential habilitation services from Penn Mar Human Services on 2/6/93. The individual had a diagnosis of ambulatory dysfunction, anemia, cholestasis, constipation, dysphagia, depression, sleep apnea, and profound ID. Individual #1 was non-verbal, communicating through vocalizations and gestures. Individual #1 required physical assistance with ambulating and transfers due to balance issues, as well as physical assistance from staff with all ADL's.
Individual #1's daily service notes indicate that on 5/8/26, Individual #1 began making noises after going to bed. Making noises overnight was unusual for the individual. On the overnight shift of 5/8/26, staff noted in daily service notes that the individual continued to be "very noisy," making loud moaning and groaning noises, not falling asleep until after 1am. Staff noted the individual threw up sometime during the day on 5/9/26, however, it was not noted how often or what time this occurred.
On 5/10/26 between 12am and 8am, Staff Person #9 noted that the individual continued to make noises all night. Staff frequently checked the individual to ensure they had not thrown up. Individual #1 woke up at 5am, and Staff Person #9 helped the individual to the bathroom. The staff noted that the individual struggled to transfer and was unable to use their legs and feet to help with the transfer. Staff utilized the individual's pants and underwear to help transfer the individual back to their wheelchair, then to their recliner. At 5:18am, Staff person #9 then sent video messages to fellow staff via Snapchat indicating that Individual #1 had fallen multiple times. Individual #1 could be heard in distress in the background of the video message. Staff person #9 then left Individual #1 in their recliner, not checking on the individual again until at least 7:53am, when the staff person attempted to call Staff Person #25 because Individual #1 was unresponsive. These calls and texts continued until at least 7:57am. Staff person #9 then called 911. Individual #1 was pronounced dead at the scene at 8:28am.
Individual #1's death certificate lists cause of death of "Probable Acute Necrotizing Pancreatitis in the Setting of Cholestasis." Cleveland Clinic indicates that symptoms include nausea/vomiting and severe upper abdominal pain. Staff noted unusual moaning and groaning, loud noises, and vomiting in the days leading to Individual #1's passing. No medical care was sought. Failure to seek timely medical care created conditions conducive to Individual #1's death. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | This regulation is important because it protects individuals from abuse, neglect, and exploitation.
During the inspection, it was noted that Individual #1 displayed increased noises and vomiting the days leading to death. Staff had to provide increased support, such as frequently checking on Individual #1 overnight. When Individual #1 woke up on 5/10/2026, the staff had to utilize the individual's pants and underwear to help transfer, which was not Individual #1's baseline supports. The team member did not call for medical assistance when they were providing the additional support during the morning routine. While it is unknown if emergency medical services could have fixed the necrotizing pancreatitis between 5a and 8a on 5/10/2026, Staff Person #9 neglected to act immediately to protect the health and safety of Individual #1 which violated this regulation. The immediate plan of correction was reporting this incident to law enforcement, licensing entities, and initiating an investigation of Neglect. Penn-Mar Human Services also spoke with the family to request an Autopsy Report. The team member was placed on administrative leave during the investigation. The administrative review team determined this incident to be confirmed, and the team member is no longer employed with Penn-Mar Human Services. |
10/16/2026
| Accepted |
| 6400.64(a) | At the time of the 5/14/26 inspection, there was a mold-like substance in the freezer located in the basement of the home. | Clean and sanitary conditions shall be maintained in the home. | This regulation is important because it minimizes the risk of illness, infection, or injury and provides for a dignified living environment.
During the inspection, the inspector found a mold-like substance in the freezer. On June 20, 2026, a maintenance request was submitted to remove the freezer, as seen in Attachment #4. The request was completed on June 23, 2026. Physical site monitoring is completed monthly by trained team members. The monthly site monitoring was not happening at the time of the site inspection by the Program Specialist. The Program Specialist was held accountable and is no longer employed with Penn-Mar Human Services. A re-training for supervisors on the monthly site monitoring process and the importance of the site monitoring will be completed at the next Residential Supervisor Meeting scheduled on November 18, 2026.
After further reviewing the number of physical site violations specific to this inspection, the Residential Administrator and Director of Operations believe there is an opportunity to further educate our Direct Support Professionals on physical site regulations. Therefore, a training plan will be created and introduced by 11/2/2026 with a projected completion of 12/31/2026 for the training to be completed. The training plan will include examples cited in this inspection, as well as examples that were discovered during the annual self-assessment completion. |
10/16/2026
| Accepted |
| 6400.64(f) | At the time of the 05/14/26 inspection, there was trash strewn on the lawn outside of the garage side exit door and under the patio. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | This regulation is important it minimizes the risk of illness, infection, or injury and provides for a dignified living environment.
During the inspection, trash was found on the lawn and under the patio that did not have lattice. While the trash was collected to be discarded, the date it was completed is unknown since it happened under the guidance of the Program Specialist who is no longer employed at Penn-Mar Human Services. See Attachment #12. As a part of monthly site monitorings, the home is reviewed to ensure there is compliance with regulations regarding physical site. At the time of the inspection, the walk throughs of the program to check for compliance were not occurring. A re-training for supervisors on the monthly site monitoring process and the importance of the site monitoring will be completed at the next Residential Supervisor Meeting scheduled on November 18, 2026.
After further reviewing the number of physical site violations specific to this inspection, the Residential Administrator and Director of Operations believes there is an opportunity to further educate our Direct Support Professionals on physical site regulations. Therefore, a training plan will be created and introduced by 11/2/2026 with a projected completion of 12/31/2026 for the training to be completed. The training plan will include examples cited in this inspection, as well as examples that were discovered during the annual self-assessment completion. |
10/16/2026
| Accepted |
| 6400.67(b) | At the time of the 05/14/26 inspection, there were trash, leaves, and a small white trash can on and around the stairs leading from the garage to the basement. | Floors, walls, ceilings and other surfaces shall be free of hazards. | This regulation is important because it monitors safe surfaces which helps to maintain sanitary conditions in the home, minimize the risk that individuals will suffer an injury while ambulating, and provide dignified living conditions.
During the inspection, the inspector found trash, leaves, and a trash can on the stairs leading from the garage to the basement which can affect someone's safety regarding the usage of the steps. While the trash and leaves were collected to be discarded and the trash can removed, the date it was completed it is unknown since it happened under the guidance of the Program Specialist who is no longer employed at Penn-Mar Human Services. See Attachment #13. As a part of monthly site monitorings, the home is reviewed to ensure there is compliance with regulations regarding physical site. At the time of the inspection, the walk throughs of the program to check for compliance were not occurring. A re-training for supervisors on the monthly site monitoring process and the importance of the site monitoring will be completed at the next Residential Supervisor Meeting scheduled on November 18, 2026.
After further reviewing the number of physical site violations specific to this inspection, the Residential Administrator and Director of Operations believes there is an opportunity to further educate our Direct Support Professionals on physical site regulations. Therefore, a training plan will be created and introduced by 11/2/2026 with a projected completion of 12/31/2026 for the training to be completed. The training plan will include examples cited in this inspection, as well as examples that were discovered during the annual self-assessment completion. |
10/16/2026
| Accepted |
| 6400.72(b) | At the time of the 05/14/26 inspection, the side exit door from the garage to the back yard was rusted and pitted at the bottom corner. | Screens, windows and doors shall be in good repair. | This regulation is important because it monitors that windows are in good repair to prevent injury to individuals.
During the time of inspection, the side exit door from the garage was found to not be in good repair. On 6/23/2026, Penn-Mar's maintenance team fixed the side exit door by adding a kick plate. The maintenance request submission and completion date can be found in Attachment #4.
During a review of doors in the program, it was found that the office exterior door could use a kick plate that was installed as a part of the plan of correction. A site inspection helped to find an issue, and a maintenance request was submitted on 10/15/2026 that can be seen in Attachment #4 for the Maintenance Team to fix the office external door as well. In Attachment #7, pictures of both doors can be reviewed.
After further reviewing the number of physical site violations specific to this inspection, the Residential Administrator and Director of Operations believes there is an opportunity to further educate our Direct Support Professionals on physical site regulations. Therefore, a training plan will be created and introduced by 11/2/2026 with a projected completion of 12/31/2026 for the training to be completed. The training plan will include examples cited in this inspection, as well as examples that were discovered during the annual self-assessment completion. |
10/16/2026
| Accepted |
| 6400.80(a) | At the time of the 05/14/26 inspection, there were two door mats on the front porch that were rolled and in the walking path. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | This regulation is important because it minimizes the risk of injury or death to individuals when they are outdoors.
During the inspection, there were two door mats on the front porch that could have affected someone safely walking on the porch. While the mats were removed, the date it was completed it is unknown since it happened under the guidance of the Program Specialist who is no longer employed at Penn-Mar Human Services. See Attachment #14. As a part of monthly site monitoring's, the home is reviewed to ensure there is compliance with regulations regarding physical site. At the time of the inspection, the walk throughs of the program to check for compliance were not occurring. A re-training for supervisors on the monthly site monitoring process and the importance of the site monitoring will be completed at the next Residential Supervisor Meeting scheduled on November 18, 2026.
After further reviewing the number of physical site violations specific to this inspection, the Residential Administrator and Director of Operations believe there is an opportunity to further educate our Direct Support Professionals on physical site regulations. Therefore, a training plan will be created and introduced by 11/2/2026 with a projected completion of 12/31/2026 for the training to be completed. The training plan will include examples cited in this inspection, as well as examples that were discovered during the annual self-assessment completion. |
10/16/2026
| Accepted |
| 6400.80(b) | At the time of the 5/14/26 inspection, there was a large collection of leaves in the outside window wells of the egress windows leading from the basement to the yard. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | This regulation is important because it minimizes the risk of injury or death to individuals when they are outdoors.
This was reviewed to ensure it was corrected during the walk through on 9/30/2026 when the Program Manager completed a walk through for the Self-Assessment. The date that it was initially addressed is unknown due to the task being under the guidance of a Program Specialist who is no longer at Penn-Mar. As a part of monthly site monitorings, the home is reviewed to ensure there is compliance with regulations regarding physical site. At the time of the inspection, the walk throughs of the program to check for compliance were not occurring. A re-training for supervisors on the monthly site monitoring process and the importance of the site monitoring will be completed at the next Residential Supervisor Meeting scheduled on November 18, 2026.
After further reviewing the number of physical site violations specific to this inspection, the Residential Administrator and Director of Operations believe there is an opportunity to further educate our Direct Support Professionals on physical site regulations. Therefore, a training plan will be created and introduced by 11/2/2026 with a projected completion of 12/31/2026 for the training to be completed. The training plan will include examples cited in this inspection, as well as examples that were discovered during the annual self-assessment completion. |
10/16/2026
| Accepted |
| 6400.144 | Individual #1 was to have their weight checked monthly to ensure their weight did not fall below 80 pounds. Individual #1's weight was not checked in July 2025 or November 2025. | 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 regulation is important because it protects an individual's health and safety by ensuring the provision of appropriate medical and psychological services.
At the time of inspection, it was discovered that Individual #1 did not have their weight checked in July 2025 or November 2025. The Administrator completed an audit on 10/14/2026 that showed another discrepancy in the weights of those who reside at the home. Due to the discrepancy, the person supported will be weighed weekly for one month to ensure their weight continues to be consistent. The weight task has been changed to the morning to reflect an accurate weight for the person. The Residential Supervisor was trained on 10/15/2026 so that when a task is completed by team members, such as the weight, it documents automatically on the MAR and Health Record in CIMS to prevent missing documentation. |
10/16/2026
| Accepted |
| 6400.171 | At the time of the 05/14/26 inspection, there was a bottle of "Lite House Chunky Blue Cheese" with a "best by" date of 09/01/25. | Food shall be protected from contamination while being stored, prepared, transported and served.
| This regulation is important because it prevents illnesses associated with contaminated food.
At the time of the inspection, a bottle of expired blue cheese dressing was found. The bottle was discarded on 5/14/2026 after the inspection. All food was reviewed in the program to check for quality and expiration dates on 5/14/2026.
After further reviewing the number of physical site violations specific to this inspection, the Residential Administrator and Director of Operations believe there is an opportunity to further educate our Direct Support Professionals on physical site regulations. Therefore, a training plan will be created and introduced by 11/2/2026 with a projected completion of 12/31/2026 for the training to be completed. The training plan will include examples cited in this inspection, as well as examples that were discovered during the annual self-assessment completion. |
10/16/2026
| Accepted |
| 6400.32(d) | Individual #1 was unable to help with transferring from the toilet to their wheelchair, then into their recliner at 5am on 5/10/26. Once the individual was in their recliner, at approximately 5:18am, Staff Person #9 sent a Snapchat video message to fellow Penn Mar Human Services staff. This video message included calling Individual #1 a "bitch" and indicating that Staff Person #9 was not going to move the individual again until Staff person #25 arrived at the home a couple hours later for their shift. Individual #1 could be heard in distress in the background of the message. This is undignified and disrespectful. | An individual shall be treated with dignity and respect. | This regulation is important because it ensures that individuals are not subject to emotional harm.
During the inspection, it was noted that Staff Person #9 sent a Snapchat message that called Individual #1 a "bitch" and indicated that staff Person #9 was not going to support Individual #1 until Staff Person #25 arrived. Individual #1 was present and could be heard in the background when Staff Person #9 was creating and sending the video. Staff Person #9 violated Penn-Mar's policy on Social Media which is on page 70-71 of the Team Member Handbook, and it can be viewed in Attachment #2.
The immediate plan of correction was reporting this incident to law enforcement, licensing entities, and initiating an investigation of Neglect. The team member was placed on administrative leave during the investigation. The administrative review team determined this incident to be confirmed, and the team member is no longer employed with Penn-Mar Human Services. This type of behavior is unacceptable, undignified, and disrespectful, and the organization does not condone the actions by the team member. |
10/16/2026
| Accepted |
| 6400.52(c)(6) | Individual #1 had multiple plans and protocols that staff were to be trained in before working with the individual. These plans included: Individual Support Plan (ISP), SEEN plan, Refusals protocol, Fall protocol, Seizure protocol, Choking Protocol, and a bowel protocol. Only 3 of the 28 staff who worked in Individual #1's home from 5/1/25 through 5/10/26 were fully trained in the Individual's plans and protocols.
· Staff person #1 was only trained in Individual #1's SEEN plan.
· Staff persons #2, 3, and 9 were not trained in the individual's refusal protocol.
· Staff persons #6, 7, 16, 23, and 28 were not trained in any of the individual's plans and protocols.
· Staff person #10 was not trained in the individual's seizure protocol.
· Staff persons #11 and #14 were not trained in the individual's ISP, SEEN plan, or refusal protocol.
· Staff person #12 was not trained in the individual's ISP or refusal protocol.
· Staff person #13 was not trained in the individual's SEEN plan.
· Staff person #15 was only trained in the individual's ISP and fall protocol.
· Staff persons #17 and #18 were only trained in the individual's fall protocol.
· Staff person #19 was only trained in the individual's ISP, fall protocol, and refusal protocol.
· Staff persons #20, 21, and 25 were only trained in the individual's ISP and refusal protocol.
· Staff person #22 and #24 were only trained in the individual's ISP.
· Staff persons #26 and #27 were only trained in the individual's refusal 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. | This regulation is important because it ensures that staff who work directly with individuals receive the training necessary to safely support them; ensures that all staff understand the laws and best practices relating to supporting individuals with an intellectual disability or autism and that staff working with individuals are knowledgeable about the needs of the person; the practices to assure the person's health, safety and welfare of the individual(s) served.
During the inspection, it was found that not all team members were fully trained on protocols and plans related to Individual #1. Through further investigation, it was determined that this occurred because their was a failure on the Program Specialists behalf to ensure that the training was fully completed. Team members received a portion of training, but it was not fully completed.
A report was pulled on 10/15/2026 and all team members who were not fully trained have all completed the Individual Specific Training Checklist, see Attachment #10. To demonstrate compliance for new team members, in Attachment #8, a new team member was trained in-person on 9/4/2026, had their first shift on 9/5/2026, and they were not left alone with people supported until 9/21/2026 showing that this team member was fully trained before supporting the individuals. |
10/16/2026
| Accepted |
| 6400.165(g) | Individual #1 was prescribed sertraline for depression. Medication reviews were only conducted on 5/15/25, 10/22/25, and 3/2/26. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | This regulation is important because it ensures that medications prescribed for treatment of a psychiatric illness are used exclusively for the treatment of the illness.
At the time of the inspection, it was noted that Individual #1 had medication reviews on 5/15/2025 and then not again until 10/22/2025 which was outside of the 5-day grace period. Individual #1 did have their medications reviewed at their Annual Physical on 12/15/2025, so the 10/22/2025 review is the only one out of compliance. The Annual Physical can be reviewed in Attachment #6, with the physician checking off on the first page that medications were reviewed.
This issue has historically been cited through self-assessments and inspections. We have since implemented additional training. Currently, self-assessments are being completed which will serve as an audit, which will be completed 10/26/2026. Retraining will occur where this violation is noted to the specific team members involved.
Penn-Mar is also piloting a program to have a virtual calendar that can be viewed by the Residential Supervisor, Program Specialist, Program Nurse, and DSPs within the program. This will allow for medical appointments to be viewed on the calendar to ensure they are scheduled within regulatory timeframes. |
10/16/2026
| Accepted |
| 6400.166(a)(5) | Individual #1's May 2026 Medication Administration Record did not include the strength of medication for the following medications: Vitafusion Omega 3 Gummy, Culturelle Chewable Tab, Chlorhexidine Oral Rinse, Benefiber Powder. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | 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.
At the time of the inspection, the strength of the medication was not listed for 4 medications for Individual #1. Due to the passing of Individual #1, the medications were not able to be fixed specifically for Individual #1. A spreadsheet was created for each program to document the audit of their program. During this audit, each program is to review that each medication label has a strength for each medication. The audit will conclude on 10/28/2026. The Residential Administrator will review the spreadsheet for completion and thoroughness. |
10/16/2026
| Accepted |
| 6400.167(a)(1) | Individual #1 did not receive their 8am dose of Valproic Acid on 7/7/25. | Medication errors include the following: Failure to administer a medication. | 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, the documentation did not show that the Valproic Acid was administered by the staff on duty at the time. It is believed that the medication was administered as prescribed. When the MAR was reviewed for July 2025, the team member on duty at the time was no longer employed at Penn-Mar. After reviewing documentation, the medication error was filed on 10/16/2026 EIM #9948854. |
10/16/2026
| Accepted |
| 6400.169(a) | Staff person #3 began their initial Medication Administration Training in January 2025. Per policy, this training was to be conducted online, with the completion of the online user transcript as verification of the staff person's training completion and qualification. The initial online training transcript for Staff Person #3 does not include observations or the completed Trainer Attestation of Qualification, meaning that this staff person is not qualified to administer medications. Staff person #3 has administered medications to Individual #1. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | This regulation is important because it ensures that medications are administered properly by trained personnel to avoid medication errors.
During the inspection, it was discovered that Penn-Mar did not have all observations and attestations documented online in the user transcript. This was found with Staff Person #3 and their documentation for their initial Medication Administration Training in January 2025. On 3/11/2026, the Quality Administrator met with med observers to review the new process of having all documentation related to observations and attestations online. With it being a new process, a re-training was completed on 8/21/2026 for all med trainers and observers to be aware of the process for consistency of documentation. |
10/16/2026
| Accepted |
|
|
|
SIN-00286683
|
Unannounced Monitoring
|
03/30/2026
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1 does not understand the value of money and needs full assistance managing their money. Individual #1's parents are Individual #1's Social Security representative payee and are responsible for providing spending money to the individual out of the individual's SSI payments. Penn Mar Human Services maintains the individual's spending money that is provided by the individual's parents. When advised by Penn Mar Human Services that Individual #1's funds were low, Individual #1's father reported on 3/3/26 that many checks written for the care of Individual #1 in 2023 and 2024 were not applied to the individual's account. In total, there was $4500 in checks written to Staff Person #1. These checks were cashed by staff person #1 but never added to the Individual's account. The last check was sent by the individual's family on 8/28/24. Upon reviewing Individual #1's financial records from 1/1/23 to 2/28/26, Individual #1 only had 3 deposits to their account in 2023. No other deposits have been made to date, leaving the house account very low. Subsequently, Individual #1 was unable to enjoy community outings and shopping because of the low funds. Penn Mar Human Services did not question the lack of funds and deposits. They did not ensure that Individual #1 had access to their finances until after 3/3/26, when Individual #1's father reported the missing money. Additionally, as of 4/9/26, this stolen money has not been reimbursed to the individual. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | This regulation is important because it protects individuals from abuse, neglect, and exploitation.
During the inspection, it was found that Individual #1's family had written $4,500 in checks to Staff Person #1, but the $4050 of the money was not accounted for on Penn-Mar's money transaction forms for Individual #1. A $4050 credit was placed on Individual #1's account for reimbursement. Staff person #1 did not communicate with Penn-Mar management that they had received money from Individual #1's parents throughout the years. When a Program Manager would seek to understand why Individual #1 would continuously not have money, Staff Person #1 would state that Individual #1 did not have any spending money according to their parents. On 3/11/2026 and 3/31/2026, the Program Manager had communication with Individual #1's parents to notify them of Penn-Mar's financial policy and how spending money should be sent to Penn-Mar's finance department and the finance department would then provide spending money for the house for Individual #1. On 4/28/2026, the Program Manager confirmed that Individual #1's parents sent money for spending to Penn-Mar's finance department according to the financial policy.
An audit was completed on 4/23/2026 by the Residential Administrator to review the finances of each person supported that has a Rep-Payee that is not Penn-Mar Human Services. The audit captured how much spending money the person supported received in 2025 and how much money the person supported has received so far in 2026. Attachment #1 shows the content of the audit. |
05/01/2026
| Implemented |
| 6400.43(b)(1) | Individual #1 received a total of $4500 from their representative payee in 2023 and 2024 to be utilized for their care. These checks were written to staff person #1, cashed by staff person #1, and never added to Individual #1's account. This staff was the only one in charge of the individual's finances, and there were no checks and balances being utilized per the Agency Financial Policy. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | This regulation is important because it ensures that there is an implementation of policies and procedures.
At the time of the inspection, it was found that checks for Individual #1's spending money totaling $4,500 were written to a previous employee of Penn-Mar. Staff Person #1 did not disclose to management that they were receiving checks from Individual #1's Rep-Payee. Of the 4,500, $4,050 was unaccounted according to Penn-Mar's financial transaction forms. Penn-Mar was unaware that the Staff Person #1 was not following company policy. Individual #1's family was informed as of (date) to send spending money to Penn-Mar's finance department according to Penn-Mar's financial policy. This will provide additional oversight to money being sent to Penn-Mar for Individual #1.
An audit was completed on 4/28/2026 to ensure all twenty-six Rep-Payees outside of Penn-Mar are sending funds in the appropriate manner to the finance department to then be disbursed for spending money. Attachment #1 shows the content of the audit. Individual #1 went several years with Penn-Mar assuming that she did not have any spending money. An audit was completed on 4/23/2026 to review how much money each person supported has received in 2025 and 2026 that has a Rep-Payee outside of Penn-Mar. This audit was to ensure people supported have necessary funds for spending money.
Individual #1's Rep-Payee has sent spending money to Penn-Mar through the finance department per the financial policy. Two hundred dollars was deposited into Individual #1's cash account to be used for spending money. The cash account balance can be seen on Attachment #5.
Program Manager attempted to call Individual #1's parents on 4/24/2026 and 4/30/2026 regarding the reimbursement but was unable to reach her parents. Program Manager spoke to Individual #1's parents on 4/28/2026 regarding how they would like to receive the reimbursement, and they had not decided how to receive the reimbursement. Penn-Mar offered to do one payment for reimbursement or smaller reimbursement payments to ensure Individual #1 remains within her resource limit. Since Penn-Mar has not received an answer as to how to process the reimbursement, Individual #1 will be receiving a credit to her account in the whole amount of $4,050. An email was sent by the Residential Administrator on 5/1/2026 to Penn-Mar's finance department requesting that Individual #1 receive a credit of $4,050 since Individual #1's Rep-Payee has not decided how they want the reimbursement. If they contact Penn-Mar to have a lump sum, Penn-Mar will reimburse in that manner. The email requesting the reimbursement is Attachment #3. A $4050 credit was made to Individual #1's account. |
05/01/2026
| Implemented |
| 6400.18(c) | An exploitation incident involving stolen funds from Individual #1 was discovered on 3/3/26. The incident was not reported to the individual because, "[Individual #1] would not understand if it was explained to [them]." | The individual and persons designated by the individual shall be notified within 24 hours of discovery of an incident relating to the individual. | This regulation is intended for individuals designated by the individual are notified of significant events. In addition, individuals that have a circle of support extending beyond the paid provider service system experience a greater quality of life and an increase in health and safety protections.
The incident was not reviewed with Individual #1 because it was believed that the individual would not understand the complexities of theft and amounts of money, given that they have a Rep-Payee that oversee their finances. The incident has since been reviewed with Individual #1 by the Program Manager on 4/27/2026.
Program Managers and Residential Supervisors will be re-trained on the importance of communication with people supported regarding information pertaining to them, even if it is unsure how much they understand. Penn-Mar has a communication policy that will be reviewed during the re-training to ensure that team members are communicating in a way that each person supported understands to the best of their ability. The re-training will occur on May 13, 2026. |
05/01/2026
| Implemented |
| 6400.18(f) | An exploitation incident involving stolen funds from Individual #1 was discovered on 3/3/26. As of 4/9/26, law enforcement has not been contacted. | The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident. | This regulation is important because it increases health and safety protections for all individuals at an organization via the implementation of policies and procedures that allow for immediate actions to protect health, safety rights, and well-being.
When Penn-Mar reported the incident in EIM, law enforcement was not initially contacted. It was unclear at the time who would be responsible for contacting law enforcement, given that Penn-Mar is not the Rep-Payee for Individual #1. It was misunderstood that the Rep-Payee would be responsible for contacting law enforcement. When Penn-Mar notified Individual #1's parents, who are also the Rep-Payee, they noted that they did not want law enforcement to be contacted.
Law enforcement was notified by Program Manager on 4/13/2026. An officer took the report for stolen funds and requested the contact information for Individual #1's parents and the contact information for Staff Person #1. |
05/01/2026
| Implemented |
| 6400.32(d) | On 10/8/25, Penn Mar Human Services explained to Individual #1 that they had the choice who their SNAP benefits were utilized for within the home. This document indicates that Individual #1 was ok with their SNAP benefits being utilized for themselves, other individuals in the home, Penn Mar staff, and visitors, with Individual #1's mark as a signature. On 3/3/26, an exploitation incident involving stolen funds from Individual #1 was discovered, however, the incident was not reported to the individual because, "[Individual #1] would not understand if it was explained to [them]." Assuming the inability to understand what is happening with the individual's finances, even when previous financial decisions have been made by the individual, is undignified and disrespectful. | An individual shall be treated with dignity and respect. | This regulation is intended for individuals designated by the individual are notified of significant events. In addition, individuals that have a circle of support extending beyond the paid provider service system experience a greater quality of life and an increase in health and safety protections.
The incident was not reviewed with Individual #1 because it was believed that the individual would not understand the complexities of theft and amounts of money, given that they have a Rep-Payee that oversee their finances. The incident has since been reviewed with Individual #1 by the Program Manager on 4/27/2026.
Program Managers and Residential Supervisors will be re-trained on the importance of communication with people supported regarding information pertaining to them, even if it is unsure how much they understand. Penn-Mar has a communication policy that will be reviewed during the re-training to ensure that team members are communicating in a way that each person supported understands to the best of their ability. The re-training will occur on May 13, 2026. |
05/01/2026
| Implemented |
| 6400.32(g) | Individual #1's Individual Support Plan indicates that they have a community life plan that includes expanding the individual's exposure to the community. Community outings are to last under 2 hours, and the individual especially likes outings involving food. Individual #1 has also enjoyed quiet parks, the mall, the Amish market, and going to the movies, among other activities. Individual #1's 9/8/25 annual assessment reinforces this idea, saying, "[Individual #1] enjoys outings and responds positively to familiar community settings." Upon reviewing Individual #1's financial records from 1/1/23 to present, Individual #1 is only recorded as spending money in the community 13 times since 1/1/23. Most of these expenses were in 2023. Service notes reviewed from 11/1/25 through 4/8/26 reveal that Individual #1 has only been on 4 outings in the last 6 months. There are 4 occasions in this 6-month period where Individual #1 left the home for doctor appointments, but there was no additional community time added to the trip. On all special outings listed above and at least 1 doctor's appointment, Individual #1 was very upset when they got home because they enjoyed being out of the home. | An individual has the right to control the individual's own schedule and activities. | This regulation is important because it protects self-direction, choice, and control.
Records have shown that Individual #1 has not experienced time in the community as much as what they may want to. Individual #1 is on the wait list to attend Penn-Mar's Day Program. Expectations were reviewed with Residential Program Managers on 4/22/2026 to check in with all people supported on their caseload to ensure they are living the lives they want to, including additional time in the community if desired. Each person supported was reviewed on 4/28/2026 and 4/29/2026 to review each person's desired schedule. Program Managers and Residential Supervisors will be retrained on 5/13/2026 to assess and reflect current supports during quarterly progress reports to ensure each person supported is living the life they intend to. |
05/01/2026
| Implemented |
|
|
|
SIN-00257872
|
Renewal
|
01/27/2025
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | (repeat from inspection 1/29/24)For individual #1, there was a purchase on 11/13/24 from Kohl's in the amount of $79.99 for bedding and this item was not listed on the individual's Property Record. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | This regulation is important to keep track of and protect the people supported personal items that cost more than $50.
During the inspection, it was determined that a purchase that was over $50 was not tracked in Individual #1's property record.
This occurred because the organization did not have a process in place to ensure property records were being kept up to date.
Immediately following the inspection, all team members in the program received feedback to document all purchases of at least $50 or of sentimental value on the property records. The property record for Individual #1 was updated. See Attachment #11. |
02/21/2025
| Implemented |
| 6400.68(b) | At the time of the inspection on 1/29/25, the water temperature in the bathroom with the washer and dryer was 123.2 degrees and the water temperature in the smaller bathroom was 123.4. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | This regulation is important because it protects the people supported from scalding and injuring their skin, which could lead to serious injury or death.
During the inspection, the water temp was 123.4 at two bathroom sinks during the time of physical walkthrough.
When completing monthly monitorings of the water temperatures, staff were taking the temperature from a cup of water rather than directly from the faucet. Therefore, they were not obtaining accurate water temperatures.
On 1/30/2025, the water temperature was adjusted by the maintenance team. An audit was completed and all water sources were 120 degrees or lower. All water sources were tested, and temperatures were below 120 degrees. See Attachment #13. |
02/21/2025
| Implemented |
|
|
|
SIN-00202398
|
Renewal
|
03/29/2022
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(d) | Staff person #11 resided out of state prior to their 2/14/22 date of hire with Penn-Mar Human Services. While an FBI background check was completed on 2/2/22, there is no record on file of the results of the background check. | A copy of the final reports received from the State Police and the FBI, if applicable, shall be kept.
| The team member started the FBI background check, but Penn-Mar did not ensure a copy of the background check was on file.
For the safety of the people we support and our team members, it is important to ensure the organization receives a copy of the FBI background check in a timely manner.
Penn-Mar has obtained a copy of the team member's FBI background check. See attachment #7 of the background check.
The Human Resource department completed an audit by April 30th to ensure there is follow up with any outstanding background checks. |
04/30/2022
| Implemented |
| 6400.112(e) | There was only one sleep drill that took place from March 2021 to the present and that was on 10/13/21. | A fire drill shall be held during sleeping hours at least every 6 months. | This regulation is important because it provides an opportunity to practice fire safety and evacuation while individuals are sleeping. It is important that all individuals respond to the fire alarm and that staff are prepared to assist where needed. There was a sleep drill completed on 4/9/2021. However, because the time of the drill was not documented, the drill does not count. The team member responsible for the drill, the residential supervisor, and the quality supports specialist who reviews the documentation for completion did not ensure the time was included. The team member responsible for the drill, the residential supervisor, and the quality supports specialist who reviews the documentation for completion did not ensure the time was included. A sleep drill was completed on April 7, 2022, at Hain Road. The Fire Drill Form was completed in its entirety, including the evacuation time. See Attachment #14.
The Program Managers and Residential Supervisors were retrained on 4/13/2022 on regulation 6400.112(e). |
04/29/2022
| Implemented |
| 6400.112(g) | The fire drill completed on 4/9/21 did not have the time of the drill documented. | Fire drills shall be held on different days of the week and at different times of the day and night. | This regulation is important because completing fire drills will prepare individuals and staff to evacuate quickly, safely, and efficiently in the event of a real fire. Timing a fire drill can help determine if the individuals and staff are prepared to exit as soon as possible in the event of a fire. Extended period of time to evacuate would prompt the program specialist to assess, evaluate, and provide resources where possible to increase the speed in which individuals and staff exit the home. There was a sleep drill completed on 4/9/2021. However, because the time of the drill was not documented, the drill does not count. The team member responsible for the drill, the residential supervisor, and the quality supports specialist who reviews the documentation for completion did not ensure the time was included. The team member responsible for the drill, the residential supervisor, and the quality supports specialist who reviews the documentation for completion did not ensure the time was included.A sleep drill was completed on April 7, 2022, at Hain Road. The Fire Drill Form was completed in its entirety, including the evacuation time. See Attachment #14.
The Program Managers and Residential Supervisors were retrained on 4/13/2022 on regulation 6400.112(g). |
04/29/2022
| Implemented |
| 6400.141(c)(13) | The allergies and contraindicated medications section on Individual #1's most recent annual physical examination completed on 11/1/21 was left blank. | The physical examination shall include: Allergies or contraindicated medications. | 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. The allergy and contraindicated medication section was left blank on Individual #1's annual physical examination. Individual #1's family has full involvement with the Individual's medical care. The family is very private and reserved and does not want support from Penn-Mar with Individual #1's medical appointments. Therefore, the family took Individual #1 to the physical appointment and the paperwork was not completed in its entirety. When the Residential Supervisor informed the family that the allergy section needed to be completed, they were not responsive with getting this information added to the physical. Additionally, the family did not want the Residential Supervisor to contact the PCP directly.
Feedback was received in the exit conference regarding how Penn-Mar can approach the situation. Given that Individual #1 is their own legal guardian and Penn-Mar is responsible for the Individual's care and implementing recommendations, a meeting will be held with the family to help them understand why Penn-Mar needs to be involved in the medical care moving forward. This meeting is scheduled for 4/29/2022.
Additionally, in the meantime, the Residential Supervisor will continue to ask the family to get the annual physical updated to include allergies and contraindicated medications.
Program Specialists will be completing an audit by 4/22/2022 to ensure all annual physicals include allergies and contraindicated medications.
Since this inspection, an Annual Physical was completed on 4/5/2022 and includes the allergies and contraindicated medications. See attachment #6. |
04/29/2022
| Implemented |
| 6400.141(c)(14) | (REPEAT VIOLATION FROM 1/4/21) -- The medical information pertinent to diagnosis or treatment in the event of an emergency section on Individual #1's most recent annual physical examination completed on 11/1/21 was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | 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. The information pertinent to diagnosis or treatment in the event of an emergency section was left blank on Individual #1's annual physical examination. Individual #1's family has full involvement with the Individual's medical care. The family is very private and reserved and does not want support from Penn-Mar with Individual #1's medical appointments. Therefore, the family took Individual #1 to the physical appointment and the paperwork was not completed in its entirety. When the Residential Supervisor informed the family that the information pertinent to diagnosis or treatment in the event of an emergency section needed to be completed, they were not responsive with getting this information added to the physical. Additionally, the family did not want the Residential Supervisor to contact the PCP directly.
Feedback was received in the exit conference regarding how Penn-Mar can approach the situation. Given that Individual #1 is their own legal guardian and Penn-Mar is responsible for their care and implementing recommendations, a meeting will be held with the family to help them understand why Penn-Mar needs to be involved in her medical care moving forward. This meeting is scheduled for 4/29/2022.
Additionally, in the meantime, the Residential Supervisor will continue to ask the family to get the annual physical updated to include medical information pertinent to diagnosis or treatment in the event of an emergency.
Program Specialists will be completing an audit by 4/22/2022 to ensure all annual physicals include medical information pertinent to diagnosis or treatment in the event of an emergency.
Since this inspection, an Annual Physical was completed on 4/5/2022 and includes medical information pertinent to diagnosis or treatment in the event of an emergency section is completed. See attachment #6. |
04/29/2022
| Implemented |
| 6400.142(a) | Individual #1's dentist indicates that they need exams every 6 months. As of the 3/29/22 inspection, Individual #1 has not had a dental examination since 8/19/21. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | This regulation is important because it ensures individuals receive necessary dental care to prevent illness and serious health conditions. Individual #1 had a dental examination on 8/19/2021 and the recommendation was to follow up in 6 months. The 6-month appointment was cancelled because Individual #1's family thought the staff sounded like they had a cold. The dental appointment was rescheduled for 3/30/2022. However, the medical appointment record has not been received because Individual #1 has not returned home and the family took the Individual to the appointment.
Individual #1's family is very private with the Individual's medical care and does not want Penn-Mar staff taking the Individual to appointments. This is another citation which is a result of the family taking ownership of the Individual's medical care. Feedback was received in the exit conference regarding how Penn-Mar can approach the situation. Given that Individual #1 is their own legal guardian and Penn-Mar is responsible for the Individual's care and implementing recommendations, a meeting will be held with the family to help them understand why Penn-Mar needs to be involved in her medical care moving forward. This meeting is scheduled for 4/29/2022.
Program Specialists will be completing an audit by 4/22/2022 to ensure all dental exams are scheduled as recommended. |
04/29/2022
| Implemented |
| 6400.151(c)(2) | Staff person #1's tuberculin test dated 1/20/21 was not read by a registered nurse, licensed practical nurse, licensed physician, licensed physician's assistant or certified nurse practitioner.
Staff person #4's tuberculin test dated 6/26/21 was read by a medical assistant.
Staff person #8's had a tuberculin test on 4/2/19 and not again until 9/3/21. This test was also read by a medical assistant. | 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. | This citation was received because Penn-Mar failed to ensure that when team members received their TB test, it was completed by a registered nurse, licensed practical nurse, physician, licensed physician's assistant or certified nurse practitioner. In addition, a team member failed to complete their bi-annual physical within the required timeframe.
It is important to ensure that the appropriate medical professionals complete the TB test as required by this regulation. In addition, for the safety of team members and the people we support, It is important to ensure team members complete their bi-annual physical in the required timeframe. |
04/11/2022
| Implemented |
| 6400.151(c)(3) | Staff person #3's most recent physical examination completed on 2/25/22 did not address if staff person #3 has a communicable disease.
Staff person #5's most recent physical examination completed on 10/1/20 did not address if staff person #5 has a communicable disease. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | This citation was received because on two occasions Penn-Mar failed to ensure staff physicals addressed if staff were free from a communicable disease, or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that prevent the spread of the disease to individuals.
For the safety of the people supported by Penn-Mar, it is important to know if team members have a communicable disease to ensure proper precautions are taken to prevent the spread of a disease.The Human Resources Manager contacted the medical provider who failed to document if the staff has a communicable disease. The provider was asked on 4/18/2022 to include this information on the physical examination for staff person #3 and staff person #5. In the event they are unwilling to update the documentation without seeing the team members, the team members will receive a new physical examination and be assessed for communicable diseases. |
04/11/2022
| Implemented |
| 6400.211(b)(1) | There is not an address listed for Individual #1's emergency contact. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| 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 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 of their emergency contact and emergency consent person. See Attachment 10.
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 |
| 6400.46(b) | Staff person #1 was trained in fire safety on 2/1/21 and not again until 3/4/22. Staff person #2 was trained in fire safety on 2/1/21 and not again until 3/7/22. Staff person #3 was trained in fire safety on 2/2/21 and not again until 3/4/21. Staff person #4 was trained in fire safety on 2/10/21 and not again until 3/15/22. Staff person #5 on 2/2/21 and not again until 3/8/22. Staff person #6 was trained in fire safety on 2/11/21 and not again until 3/11/22. Staff person #7 was trained in fire safety on 2/11/21 and not again until 3/7/22. Staff person #8 was trained in fire safety on 2/1/21 and not again until 3/7/22. Staff person #9 was trained in fire safety on 2/3/21 and not again until 3/7/22. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Penn-Mar failed to ensure that team members completed fire safety training within one year of their previous training. In 2021, team all team members received annual fire safety training in February 2021. This year, team members received fire safety training in March 2022.
It is important for team members to be trained annually on fire safety training to ensure they understand evaluation procedures of the program. |
04/12/2022
| Implemented |
| 6400.46(d) | Staff person # 10's CPR and First Aid certification expired on 4/30/21. They did not complete recertification until 2/25/22. | 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 training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Penn-Mar failed to ensure that a team member completed their CPR and First Aid recertification within the required timeframe.
For the safety of the people we support, it is important for program specialists, direct service workers and drivers of and aides in vehicles to receive CPR and First Aid recertification as required by regulation.
After receiving this citation, Penn-Mar realized that we did not have a tracking system in place to monitor CPR/First Aid trainers certification expirations |
04/11/2022
| Implemented |
| 6400.166(a)(11) | (REPEAT VIOLATION FROM 1/4/21)-- Individual #1's Medication Administration Records do not list the diagnosis/purpose for the following medications: famotidine, fluticasone, levothyroxine, prebiotin, and Preparation H Cream Max. | 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. The Medication Administration Record did not include the diagnosis or purpose for famotidine, fluticasone, levothyroxine, prebiotin, and Preparation H Cream Max.
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 medications did not notice or communicate that the diagnosis or purpose for medication was not listed on the MAR.
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.
Unfortunately, Individual #1 has not been in program since the inspection. Therefore, their MAR has not been updated because the labels are not at the program to ensure they match. However, another individual was cited for the diagnosis/purpose not being listed and her log has been updated. See attachment #4. |
04/29/2022
| Implemented |
| 6400.167(a)(4) | (REPEAT VIOLATION FROM 1/4/21)-- Individual #1's Levothyroxine, which is to be administered at 6am, was administered more than an hour late on the following dates: 2/25/21, 3/2/21, 6/21/21, 12/9/21, 2/1/22, 2/7/22. | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | This regulation is important because administering medication at the right time ensures that medications are being administered as prescribed. Medications have a time to be administered to ensure effectiveness and limit unintended interactions with other prescribed medications. Individual #1's Levothyroxine was administered late on 2/25/21, 3/2/21, 6/21/2, 12/9/21, 2/1/22, and 2/7/22. After review of the instances in which Levothyroxine was delivered late, it is unknown as to why this happened. Unfortunately, there was not a note on the Medication Administration Record that states why the medication was late. It is believed by the team members that the medication was given on time but the Medication Administration process was not followed correctly by clicking off the medication as administered.
Residential Supervisors and Program Specialists will be retrained on 4/13/2022 regarding the 15 steps of medication administration.
All residential team members will be retrained by April 29, 2022 regarding the 15 steps of medication administration. |
04/29/2022
| Implemented |
| 6400.169(a) | (REPEAT VIOLATION FROM 1/4/21)-- At the time of the 3/29/22 inspection, staff person #7's Medication Administration Training recertification was signed as complete and pre-dated with the date 4/17/22. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | This citation was received because the medication trainer pre-dated and signed a team member's medication recertification packet with the date by which the team member needed to complete the recertification.
It is important to ensure documentation is not pre-dated to prevent falsifying records.
To prevent this error from occurring in the future, all medication administration trainers have been retrained on this regulation. Following the licensing exit on March 31, 2022, the agency nurses completed an audit to ensure all medication administration certifications are in compliance. |
04/11/2022
| Implemented |
|
|
|
SIN-00161729
|
Renewal
|
09/24/2019
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(2) | On 8/28/19 Individual # 1's balance ledger documented $35.89, then on 8/29/19 $10.05 was spent at Infinito's pizza and then new balance recorded was $25.85 when it should have read $25.84. The ending balance for the month should have been $218.04 but the ledger documented $218.05. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: For a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. | It is important to keep an accurate record of funds to ensure the funds of the individuals we support are spent appropriately.
The Program Manager trained the staff on the need to ensure they are counting funds accurately and accurately documenting deposits and withdrawals onto the money transaction form for each transaction. The Program Manager re-programmed the calculation on the form to automatically calculate changes. The $0.01 that was found was added to the ledger and the balance has been corrected. See attachment of the corrected money transaction forms for August and September.
All residential team members have reviewed this regulation and understand the need to ensure money is counted and recorded accurately. See attached email sent to all team members on 10/11/19. Program managers have had training regarding this regulation during the exit conference with state licensing staff on 9/25/19. They will continue to monitor funds for each individual when they complete monthly site monitoring at each group home. Site monitoring 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 was also completed with the Residential Supervisors at their team meeting on 10/9/19. |
10/15/2019
| Implemented |
|
|
|
SIN-00102845
|
Renewal
|
10/05/2016
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(b)(1) | The program specialist did not complete Individual #1's assessment; the house manager did. | 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 |
| 6400.67(a) | Individual #2's third dresser drawer is missing a handle. The second drawer had two detached handles. | Floors, walls, ceilings and other surfaces shall be in good repair. | Handles were replaced on the dresser.
See attachment AH
All Residential Supervisors and Program Specialist level staff were trained on the need to be more mindful of furniture knobs/handles. Program Specialists now look for this during their monthly site visits.
See attachment A |
10/12/2016
| Implemented |
| 6400.77(b) | The first aid kit did not include tape. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The first aid kit does now include tape.
See Attachment AG
All Residential Supervisors and Program Specialists were re-trained on the need to ensure that the first aid kit is stocked with the items required by regulations. Supervisors are to inform all their staff that if they use a required item they must inform the supervisor so that a replacement can be purchased. This is to be checked on a monthly basis by the Program Specialist during their site inspection.
See Attachment A |
10/12/2016
| Implemented |
| 6400.103 | The written evacuation 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.
See Attachment AF |
11/01/2016
| Implemented |
| 6400.141(c)(9) | Individual #1's 2/29/16 prostate exam was completed. The previous exam was completed on 10/29/14. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Attached are the past two year annual physicals for an individual which shows that the prostate exam was completed on time.
See Attachment AE
All Residential Supervisors and Program Specialists were retrained on this regulation and received specific guidance on how to proceed if a prostate exam should fall off the annual physical cycle. The issue with this situation is that the doctor deferred a prostate at the individuals annual physical because a colonoscopy had been done 4 months prior. In the future if this happens, Staff will need to keep track of the prostate exam date separately from the physical.
See Attachment A |
11/25/2016
| Implemented |
| 6400.141(c)(11) | Individual #1's 2/29/16 physical exam did not include health maintenance needs. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Attached is a physical exam that was completed since licensing that includes the health maintenance needs section being completed.
See Attachment AE
All Residential Supervisors and Program Specialists were re-trained on the need for all sections of the physical to be completed.
See Attachment A & U |
11/25/2016
| Implemented |
| 6400.141(c)(14) | Individual #1's 2/29/16 physical exam did not include information pertinent to diagnosis and treament in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Attached is a physical exam that was completed since licensing that includes the information pertinent to diagnosis and treatment in case of emergency section being completed.
See Attachment AE
All Residential Supervisors and Program Specialists were re-trained on the need for all sections of the physical to be completed.
See Attachment A & U |
11/25/2016
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's 2/29/16 assessment did not include progerss over the past year in health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| Attached you will find an addendum to Individual #1¿s assessment that includes his progress over the past year in health.
See Attachment AD
In addition, there is an attachment from an assessment that was completed since our licensing inspection, for a different individual, that documents this information as part of the assessment.
See Attachment X
All Program Specialists were re-trained on the need to ensure that assessments document specific progress over the past year rather than simply reiterating information from last year. Even if the individual has not made any significant improvement or regression, Program Specialists are being tasked with ensuring that a thorough assessment is completed.
See Attachment A |
12/16/2016
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's 2/29/16 assessment did not include progerss over the past year in motor and communication skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | Attached you will find an addendum to Individual #1¿s assessment that includes his progress over the past year in motor and communication skills.
See Attachment AD
In addition, there is an attachment from an assessment that was completed since our licensing inspection, for a different individual, that documents this information as part of the assessment.
See Attachment X
All Program Specialists were re-trained on the need to ensure that assessments document specific progress over the past year rather than simply reiterating information from last year. Even if the individual has not made any significant improvement or regression, Program Specialists are being tasked with ensuring that a thorough assessment is completed.
See Attachment A |
12/16/2016
| Implemented |
| 6400.181(e)(13)(iii) | Individual #1's 2/29/16 assessment did not include progerss over the past year in residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | Attached you will find an addendum to Individual #1¿s assessment that includes his progress over the past year in residential living
See Attachment AD
In addition, there is an attachment from an assessment that was completed since our licensing inspection, for a different individual, that documents this information as part of the assessment.
See Attachment X
All Program Specialists were re-trained on the need to ensure that assessments document specific progress over the past year rather than simply reiterating information from last year. Even if the individual has not made any significant improvement or regression, Program Specialists are being tasked with ensuring that a thorough assessment is completed.
See Attachment A |
12/16/2016
| Implemented |
| 6400.181(e)(13)(iv) | Individual #1's 2/29/16 assessment did not include progerss over the past year in personal adjustment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | Attached you will find an addendum to Individual #1¿s assessment that includes his progress over the past year in personal adjustment.
See Attachment AD
In addition, there is an attachment from an assessment that was completed since our licensing inspection, for a different individual, that documents this information as part of the assessment.
See Attachment X
All Program Specialists were re-trained on the need to ensure that assessments document specific progress over the past year rather than simply reiterating information from last year. Even if the individual has not made any significant improvement or regression, Program Specialists are being tasked with ensuring that a thorough assessment is completed.
See Attachment A |
12/16/2016
| Implemented |
| 6400.181(e)(13)(v) | Individual #1's 2/29/16 assessment did not include progerss over the past year in socialization. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | Attached you will find an addendum to Individual #1¿s assessment that includes his progress over the past year in socialization.
See Attachment AD
In addition, there is an attachment from an assessment that was completed since our licensing inspection, for a different individual, that documents this information as part of the assessment.
See Attachment X
All Program Specialists were re-trained on the need to ensure that assessments document specific progress over the past year rather than simply reiterating information from last year. Even if the individual has not made any significant improvement or regression, Program Specialists are being tasked with ensuring that a thorough assessment is completed.
See Attachment A |
12/16/2016
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's 2/29/16 assessment did not include progerss over the past year 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. | Attached you will find an addendum to Individual #1¿s assessment that includes his progress over the past year in recreation.
See Attachment AD
In addition, there is an attachment from an assessment that was completed since our licensing inspection, for a different individual, that documents this information as part of the assessment.
See Attachment X
All Program Specialists were re-trained on the need to ensure that assessments document specific progress over the past year rather than simply reiterating information from last year. Even if the individual has not made any significant improvement or regression, Program Specialists are being tasked with ensuring that a thorough assessment is completed.
See Attachment A |
12/16/2016
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's 2/29/16 assessment did not include progerss over the past year in financial independence. | 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.
| Attached you will find an addendum to Individual #1¿s assessment that includes his progress over the past year in financial independence.
See Attachment AD
In addition, there is an attachment from an assessment that was completed since our licensing inspection, for a different individual, that documents this information as part of the assessment.
See Attachment X
All Program Specialists were re-trained on the need to ensure that assessments document specific progress over the past year rather than simply reiterating information from last year. Even if the individual has not made any significant improvement or regression, Program Specialists are being tasked with ensuring that a thorough assessment is completed.
See Attachment A |
12/16/2016
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's 2/29/16 assessment did not include progerss over the past year in managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Attached you will find an addendum to Individual #1¿s assessment that includes his progress over the past year in managing personal property.
See Attachment AD
In addition, there is an attachment from an assessment that was completed since our licensing inspection, for a different individual, that documents this information as part of the assessment.
See Attachment X
All Program Specialists were re-trained on the need to ensure that assessments document specific progress over the past year rather than simply reiterating information from last year. Even if the individual has not made any significant improvement or regression, Program Specialists are being tasked with ensuring that a thorough assessment is completed.
See Attachment A |
12/16/2016
| Implemented |
| 6400.181(f) | Individual #1's 9/26/16 assessment was sent to plan team members on 9/26/16 for a 10/12/16 Individual Support Plan meeting. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| Since this licensing inspection another individual has an ISP meeting scheduled for 1/19/2017. This individual¿s assessment was sent to plan team members on 12/16/16, thus meeting the requirement.
See Attachment X
All Program Specialists were re-trained that even though they may encounter an issue with a Supports Coordinator who is not responsive to emails about scheduling the ISP meeting, they should plan to have the assessment completed within one year of the last assessment and they could always send the assessment to plan team members even if the ISP meeting is not yet scheduled. In doing this they can ensure that the assessment is sent within 30 days of the ISP meeting, even if the ISP meeting is not scheduled yet. Program Specialists were also trained to reach out to an SC supervisor if the SC is not responsive to emails about the need to schedule the ISP meeting.
See Attachment A |
12/16/2016
| Implemented |
| 6400.186(a) | The program specialist did not complete Individual #1's Individual Support Plan (ISP) reviews; a direct care staff member did. | 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. | The process for completing ISP reviews at Penn-Mar has changed as a result of this clarification. House supervisors had previously completed the ISP reviews and Program Specialists reviewed and made changes as needed. Program Specialists now complete the ISP reviews; 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 new ISP review template that will be completed by Program Specialists moving forward.
See Attachment Y |
12/21/2016
| Implemented |
| 6400.186(c)(1) | Individual #1's 4/11/16 and 7/10/16 Individual Support Plan (ISP) reviews did not include progress and participation towards the independence outcome in the ISP. | The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. | Attached is the ISP review for October for Individual #1 which does include his progress and participation towards the independence outcome in the ISP.
See Attachment AB
All Program Specialists were trained on the need to ensure that ISP reviews are completed thoroughly and that all progress on outcomes is reviewed.
See Attachment A |
10/20/2016
| Implemented |
| 6400.186(c)(2) | Individual #1's social, emotional, environmental needs (SEEN) plan was not reviewed in the Individual Support Plan (ISP) reviews. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | Attached is the ISP review for October for Individual #1 which does include a review of the SEEN plan.
See Attachment AB
All Program Specialists were trained on the need to ensure that ISP reviews are completed thoroughly and include a review of the SEEN plan if the person has one.
See Attachment A |
10/20/2016
| Implemented |
| 6400.186(e) | Individual #1's plan team members were not given the option to decline the Individual Support Plan reviews. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | Individual #1¿s team members have since been sent the option to decline the ISP reviews.
See Attachment AC
All Program Specialists were trained on the need to ensure that a letter is sent to all team members giving them the option to decline the ISP review.
See Attachment A |
10/12/2016
| Implemented |
|
|
|
SIN-00177817
|
Renewal
|
05/07/2021
|
Compliant - Finalized
|
|
|
SIN-00070782
|
Initial review
|
10/30/2014
|
Compliant - Finalized
|
|