| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.58(b) | At the time of the 7/31/23 physical site inspection, there was a golf ball size amount of lint in the dryer's lint trap. | Floors, walls, ceilings and other surfaces shall be free of hazards. | This regulation is important because excessive amounts of lint build up in the dryer, causes harm to the dryers efficiency and lifespan, and increases the risk of fires. Failing to ensure that floors, walls, ceilings, and other surfaces are free from hazards puts the individuals within programming in potential harm. At the time of the physical site inspection, there was a golf ball size amount of lint in the dryer lint trap. When completing laundry, the lint was not removed immediately following the use of the dryer. |
09/01/2023
| Implemented |
| 2380.91(a) | (Repeated Violation -- 8/1/22) Individual #2's admission date is 4/4/23. Individual #2 did not receive fire safety training until 4/6/23. | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility. | Individual #2's admission date was 4/4/2023. Individual number two did not receive fire safety training until 4/6/2023. Failure to provide appropriate training within the appropriate time frame puts the individuals at risk. Upon initial admission, it is imperative that the individuals be trained on general fire safety evacuation procedures, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Penn-Mar failed to ensure that individual #1, completed fire safety training on the day of their admission, 4/4/2023. The individual did not receive training until 4/6/2023, two days past admission. Program Managers failed to ensure that the individual has appropriate training during the orientation process. The checklist for admission was not followed with resulted in the individual not receiving training. There is no immediate plan of correction that would correct this violation. |
08/10/2023
| Implemented |
| 2380.111(a) | Individual #6 had a physical examination on 10/12/21 and not again until 1/26/23, outside of the annual timeframe. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | This regulation is important because it is important to have the individuals medical information in their file in order to provide safe and healthy services. Individual #6 had an annual physical exam on 10/12/21 and not again until 1/26/2023, outside of the annual timeframe. This individual continued to receive services with an out of date physical exam on file. The Program Specialist failed to appropriately monitor the individual #6 annual physical exam dates and allowed the individual to continue to receive services during this time. |
08/15/2023
| Implemented |
| 2380.111(b) | Individual #5's 7/28/22 tuberculin test was read and signed by a Medical Assistant. | The physical examination documentation and tuberculin test shall be signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant. | This regulation is important because it ensures accurate medical information that is essential in supporting people. Individual #5's 7/28/2023 tuberculin test was read and signed by a medical assistant. When Individual #5 submitted the annual physical, the Program Specialist did not review the physical for accuracy. Individual #5 will be getting a TB test on 8/11/2023. The results will be read by a licensed physician, certified nurse practitioner, or certified physician¿s assistant. Physicals are reviewed by the Program Specialist upon receiving the documents. |
08/15/2023
| Implemented |
| 2380.111(c)(2) | The section for a general physical examination on Individual #7's 7/7/23 annual physical examination was crossed out and "attached" was written. There was no documentation attached to the physical examination confirming that a general physical examination was completed. The after-visit summary notes were requested on 7/31/23, after the commencement of the annual inspection. | The physical examination shall include: A general physical examination. | This regulation is important because having the appropriate information for the examination in pertinent to being able to provide safe supports to the individuals. The section for a general physical exam on individual #7's 7/7/2023 annual physical examination was crossed out and "attached" was written. There was no documentation attached to the physical examination confirming that a general physical examination was completed. The after-visit summary notes were requested on 7/31/2023, after the commencement of the annual inspection. Program Specialist did not thoroughly review the annual physical to ensure it met the regulations. Program Specialist did not thoroughly review the annual physical to ensure it met the regulations or ensure that all of the needed paperwork was submitted. The information was produced during the inspection, so the violation was corrected prior to this being entered. |
08/15/2023
| Implemented |
| 2380.111(c)(7) | (Repeated Violation -- 8/1/22) The need for bloodwork section on Individual #2's 10/8/22 physical, which was used for admission, is blank.
The need for bloodwork section on Individual #4's 2/28/23 annual physical examination section is blank.
The health maintenance needs section of Individual #7's 7/7/23 annual physical examination was left blank. | 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. | This regulation is important because having the appropriate information for the examination in pertinent to ensure the health and safety of the individuals supported. Individual #2 and Individual #4's bloodwork sections were left blank, incomplete. Individual #7's health maintenance needs section was left blank, incomplete. Program Specialist did not thoroughly review the annual physical to ensure it met the regulations or ensure that all of the needed paperwork was submitted. Physicals are reviewed by the Program Specialist upon receiving the documents. On 8/11/2023, the Program Specialist requested the missing information from the individual and their support team. The Program Specialist will continue to seek this information until the regulation is met. |
08/15/2023
| Implemented |
| 2380.111(c)(8) | The physical limitations section of Individual #7's 7/7/23 annual physical examination was left blank. | The physical examination shall include: Physical limitations of the individual. | This regulation is important because having the appropriate information for the examination in pertinent to being able to provide safe supports to the individuals. Individual #7's,7/7/2023 physical examination did not include physical limitations. Program Specialist did not thoroughly review the annual physical to ensure it met the regulations. Program Specialist did not thoroughly review the annual physical to ensure it met the regulations or ensure that all of the needed paperwork was submitted. The Program Specialist is requested this information for Individual #7 on 8/11/2023 from the individual and their support team. |
08/15/2023
| Implemented |
| 2380.111(c)(9) | Individual #4's 2/28/23 annual physical examination indicates that Individual #4 has no known drug allergies, however, they have a known allergy to Ativan. | The physical examination shall include: Allergies or contraindicated medication. | The regulation is important because the physician must review the allergies to ensure the health and safety of the individuals receiving services. Individual #4's 2/28/2023 physical examination indicated that they have no known drug allergies, however, they have a known allergy to Ativan. Program Specialist did not thoroughly review the annual physical to ensure the allergies were correct. Physicals are reviewed by the Program Specialist upon receiving the documents. On 8/11/2023, the Program Specialist will request the annual physical be updated for individual #4 to include accurate information. |
08/15/2023
| Implemented |
| 2380.111(c)(10) | The medical information pertinent to diagnosis and treatment in case of an emergency section of Individual #4's 2/28/23 annual physical examination is blank.
The medical information pertinent to diagnosis and treatment section of Individual #7's 7/7/23 annual physical examination was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The regulation is important because support staff need to be aware of an individual's diagnosis and how to safely support them in case of an emergency. Knowing this information will ensure that the needed care and supports are provided to the individual. Program Specialist did not thoroughly review the annual physical to ensure it met the regulations. Prior to Individual #1 and Individual #2 getting a physical, the Program Specialist reviewed the physical with the support team to inform them of what needed to be completed. When Individual #1 and Individual #2 submitted their annual physical form to the Program Specialist, the Program Specialist did not complete a thorough review to ensure the dietary needs and allergies were clearly listed. Therefore, Individual #1 and Individual #2's support team were not informed of the information being misleading or incorrect. On 8/11/2023, the Program Specialist will request the annual physical be updated to include information pertinent to diagnosis. |
08/11/2023
| Implemented |
| 2380.111(c)(11) | The diet information section on Individual #2's 10/8/22 physical, which was used for admission, is blank. | The physical examination shall include: Special instructions for an individual's diet. | The regulation is important because support staff need to be aware of an individual's dietary needs. Knowing this information will ensure that the needed care and supports are provided to the individual. Individual #2's physical didn't include the dietary information; the section was left blank. Program Specialist did not thoroughly review the annual physical to ensure it met the regulations. Physicals reviewed by the Program Specialist upon receiving the documents. On 8/11/2023, the Program Specialist requested the diet section be updated on Individual #2's physical. |
08/11/2023
| Implemented |
| 2380.173(1)(ii) | Individual #2's face sheet does not include their eye color. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | It is important to have individual's identifying information in their files, therefore the regulation is important. Individual #2's eye color was not included on their face sheet. Program Specialist did not thoroughly review the facesheet, ensuring that all regulations are met. Program Specialist did not thoroughly review the facesheet to ensure it met the regulations. Facesheets are completed by the Program Specialist upon admission and as needed thereafter. Since the inspection date, Individual #2's facesheet has been updated to include all regulatory requirements. See attachment number #10 as proof. |
08/15/2023
| Implemented |
| 2380.173(1)(iv) | (Repeated Violation -- 8/1/22) Individual #3's religious affiliation is listed as "unknown." | Each individual's record must include the following information: Personal information including: Religious affiliation. | The regulation is important because the individual's religious views are documented and respected. Individual #3's religious affiliation is listed as "unknown", thus, not specifying what their religious preference is. Program Specialist did not thoroughly review the face sheet, ensuring that all regulations are met. Program Specialist did not thoroughly review the face sheet to ensure it met the regulations. Face sheets are completed by the Program Specialist upon admission and as needed thereafter. Since the inspection date, Individual #3's face sheet has been updated to include all regulatory requirements. See attachment number #8 as proof. |
08/15/2023
| Implemented |
| 2380.36(b) | (Repeated Violation -- 8/1/22) Staff person #3 did not receive fire safety training in 2022. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | It is important for team members to be trained annually on fire safety training to ensure they understand evacuation procedures of the program. Penn-Mar failed to ensure that team member #3 received fire safety training in 2022, upon transfer into the program. The team member received annual fire safety training in 2/2023, three months after their hire date. Program Specialist failed to ensure that all required trainings were completed during the on-boarding process for team member #3. On 4/ 24/2023, Penn-Mar implemented a On-Boarding Checklist for all new and transferring team members. Penn-Mar recognized that additional processes need to be in place to ensure that team members received the appropriate training. This checklist provides team members and management with a guide to ensure that trainings are not missed. |
08/10/2023
| Implemented |
| 2380.126(a)(2) | Individual #2's Medication Administration Record does not include the name of the prescriber for their medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | This regulation is important because the prescribing doctor needs to be easily accessible if there was a need to contact the physician regarding a medication issue. Having this information accessible will allow for quick and efficient care of an individual. Individual #2's mediation administration record didn't include the name of the prescribing doctor. The Program Specialist failed to ensure that the regulatory requirements for medication administration records was fulfilled. The Program Manager failed to ensure that the regulatory requirements for medication administration records was fulfilled. Since the inspection, Individual #2's medication administration record has been updated and the prescribing doctor has been added to the MAR. See attached #6 for proof. |
08/17/2023
| Implemented |
| 2380.126(a)(3) | Individual #2's Medication Administration Record does not include drug allergies. Individual #2's Individual Support Plan indicates that they have a sensitivity to Focalin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies. | The regulation is important because support staff need to be aware of an individual's allergies. Knowing this information will ensure that the needed care and supports are provided to the individual. Individual #2's medication administration record didn't indicate that they had a sensitivity to Focalin. The Program Manager failed to ensure that the regulatory requirements for medication administration records was fulfilled. Since the inspection, Individual #2's medication administration record has been updated and medication sensitivity has been added to the MAR. See attached #6 for proof. |
08/17/2023
| Implemented |
| 2380.173(1)(i) | (Repeated Violation -- 8/1/22) Individual #3's admission date to the facility is not included on their face sheet. | The name, sex, admission date, birthdate and Social Security number. | This regulation is important because there needs to record of when the individual began 2380 service. Individual #3's admission date to the facility is not included on their face sheet. Program Specialist did not thoroughly review the facesheet, ensuring that all regulations are met. Facesheets are completed by the Program Specialist upon admission and as needed thereafter. Since the inspection date, Individual #3's facesheet has been updated to include all regulatory requirements. See attachment number #8 as proof. |
08/15/2023
| Implemented |