Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00234420 Unannounced Monitoring 11/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(b)Individual #1 is prescribed Triad Wound Dressing. The November 2023 Medication Administration Record (MAR) for Individual #1 and the pharmacy label both note that "Apply to the affected area(s) topically (ulcer of right lower extremity.)" The frequency of administration was not recorded on the November 2023 MAR for Individual #1 nor the pharmacy label on the medication. (Repeat Violation 8/31/23)The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The label from the pharmacy was corrected and now states that application is to be made 8am Mondays Wednesdays and Fridays. 11/30/2023 Implemented
SIN-00230302 Unannounced Monitoring 08/31/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Ammonium Lactate 12% lotion is prescribed for Individual #1 and is listed on the August medication administration record but was not available in the home at the time of inspection. Staff stated that they thought the medication had been discontinued but could not produce a discontinuation order from the prescriber. Individual #1 is prescribed the medication Lorazepam 1 mg. tablets, to be administered 1 tablet four times per day as needed for anxiety. The physician's order did not include written instructions by a physician or medical practitioner listing the individual's specific symptoms of the psychiatric diagnosis that would warrant the use of an as needed psychotropic medication.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. What happened and why? Ammonium Lactate 12% lotion is prescribed for Individual #1 and is listed on the August medication administration record but was not available in the home at the time of inspection. Staff stated that they thought the medication had been discontinued but could not produce a discontinuation order from the prescriber. Individual #1 is prescribed the medication Lorazepam 1 mg. tablets, to be administered 1 tablet four times per day as needed for anxiety. The physician's order did not include written instructions by a physician or medical practitioner listing the individual's specific symptoms of the psychiatric diagnosis that would warrant the use of an as needed psychotropic medication. Providence has gone through staffing changes and shortages within the homes and DSP staff have not executed all protocols and maintained compliance with regulations consistently. What are we doing right now? Immediately after the inspection, Providence Home Care implemented several correction measures right away. 1. Medical Care Coordinator contacted the physician and Hartzell¿s Pharmacy regarding the medications and missing or insufficient documents. Discontinued medications were properly discarded. A. Medical Care Coordinator developed a letter template that will be sent to the physicians for PRNs justification and symptom explanations. The letter template and direct contacts were made to the physicians and Hartzell¿s pharmacy to ensure compliance. The letter template will be used moving forward for every PRN. B. Any refusals by an individual were followed up on by Kathy with the physician and Hartzell¿s Pharmacy. Requests were made to transition frequent refusal medications to PRNs to reduce the frequency and number of formal refusals. 10/31/2023 Implemented
6400.163(h)The medication Coricidin HBP was discontinued on 8/05/2023 but was still in the medication box with the current medications.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.WHAT HAPPENED & WHY? The medication Coricidin HBP was discontinued on 8/05/2023 but was still in the medication box with the current medications.What happened and why? Providence has gone through staffing changes and shortages within the homes and DSP staff have not executed all protocols and maintained compliance with regulations consistently. What are we doing right now? Immediately after the inspection, Providence Home Care implemented several correction measures right away. 1. Medical Care Coordinator contacted the physician and Hartzell¿s Pharmacy regarding the medications and missing or insufficient documents. Discontinued medications were properly discarded. A. Medical Care Coordinator developed a letter template that will be sent to the physicians for PRNs justification and symptom explanations. The letter template and direct contacts were made to the physicians and Hartzell¿s pharmacy to ensure compliance. The letter template will be used moving forward for every PRN. B. Any refusals by an individual were followed up on by Kathy with the physician and Hartzell¿s Pharmacy. Requests were made to transition frequent refusal medications to PRNs to reduce the frequency and number of formal refusals. 10/31/2023 Implemented
6400.166(b)At the time of the inspection, there were 8 blister cards for the pro re nata (PRN) medication Ativan which is a controlled substance. Two of the blister cards were dispensed from the pharmacy on 12/21/2022 and two were dispensed on 7/18/2023. There were two pills popped out of one of the blister packs dispensed on 7/13/2023, but there was no record that the pills were administered in July or August 2023 to Individual #1.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.What happened and why? At the time of the inspection, there were 8 blister cards for the pro re nata (PRN) medication Ativan which is a controlled substance. Two of the blister cards were dispensed from the pharmacy on 12/21/2022 and two were dispensed on 7/18/2023. There were two pills popped out of one of the blister packs dispensed on 7/13/2023, but there was no record that the pills were administered in July or August 2023 to Individual #1. Providence has gone through staffing changes and shortages within the homes and DSP staff have not executed all protocols and maintained compliance with regulations consistently. What are we doing right now? Immediately after the inspection, Providence Home Care implemented several correction measures right away. 1. Medical Care Coordinator contacted the physician and Hartzell¿s Pharmacy regarding the medications and missing or insufficient documents. Discontinued medications were properly discarded. A. Medical Care Coordinator developed a letter template that will be sent to the physicians for PRNs justification and symptom explanations. The letter template and direct contacts were made to the physicians and Hartzell¿s pharmacy to ensure compliance. The letter template will be used moving forward for every PRN. B. Any refusals by an individual were followed up on by Kathy with the physician and Hartzell¿s Pharmacy. Requests were made to transition frequent refusal medications to PRNs to reduce the frequency and number of formal refusals. 10/31/2023 Implemented
SIN-00204498 Unannounced Monitoring 04/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(b)Individual #4 is prescribed "Acetaminophen Take 1 tab by mouth every 6 hrs as needed for mild pain (Pain score 1-3)." The April 2022 Medication Administration Record (MAR) for Individual #4 records that the medication was administered eight times during April 2022. Administrations are entered for 4/4, 4/7, 4/9, 4/10, 4/15, 4/19, 4/24 and 4/28. The blister pack of Acetaminophen is use was filled on 11/23/21. There were ten doses administered out of the blister pack. Date and initials on the blister pack document that the Acetaminophen was given two times on 4/9 and 4/28. The second doses given on 4/9 and 4/28 were not properly entered onto the MAR. The date and time of the administration as well as the name of the person administering the medications were not recorded at the time the medication was administered.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.1) Individual #4 is prescribed "Acetaminophen Take 1 tab by mouth every 6 hours as needed for mild pain (Pain score 1-3)." The April 2022 Medication Administration Record (MAR) for Individual #4 records that the medication was administered eight times during April 2022. Administrations are entered for 4/4, 4/7, 4/9, 4/10, 4/15, 4/19, 4/24 and 4/28. The blister pack of Acetaminophen is use was filled on 11/23/21. There were ten doses administered out of the blister pack. Date and initials on the blister pack document that the Acetaminophen was given two times on 4/9 and 4/28. The second doses given on 4/9 and 4/28 were not properly entered onto the MAR. The date and time of the administration as well as the name of the person administering the medications were not recorded at the time the medication was administered. 06/10/2022 Implemented
SIN-00200469 Unannounced Monitoring 02/17/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)There was a soap dispenser bottle with the label "Softsoap Milk and Honey" liquid hand soap in the bathroom off of Individual #4's bedroom that had been refilled with clear "Equate" brand liquid hand soap. There was a decorative soap dispenser in the 2nd bathroom that was also refilled with "Equate" brand hand soap. The label for Equate soap reads "contact poison control if ingested".Poisonous materials shall be stored in their original, labeled containers. During the inspection, it was discovered that there was a soap dispenser bottle with the label "Softsoap Milk and Honey" liquid hand soap in the bathroom off of Individual #4's bedroom that had been refilled with clear "Equate" brand liquid hand soap. There was a decorative soap dispenser in the 2nd bathroom that was also refilled with "Equate" brand hand soap. The label for Equate soap reads "contact poison control if ingested". Poisonous materials shall be stored in their original, labeled containers(62c). Providence staff use hand soap at J 9 to keep their hands clean after assisting with individual #4¿s dog (cleaning up after his incontinence), before and during cooking, before giving medications, after cleaning the apartment, after helping individual #4 with any hygiene tasks, etc. Some of the handsoaps that were used in the home a long time ago were removed (Softsoap Milk and Honey- everything except free and clear was supposed to be out of the home) However, one of the empty containers made its way into the locked closet and someone refilled it with the Equate free and clear handsoap. Also, a decorative soap container was purchased by individual #4 with staff apparently because it was more appealing for the bathroom while shopping with the individual #4, however, staff are NOT supposed to store the cleaning products in different containers- they must stay in the original labeled containers. The staff who did this clearly were unaware of the regulation. After the inspection, Providence Medical Coordinator and Program Specialist spent hours online doing research, and went to a cleaning supply company called Master Supply in Macungie, PA, and were educated by the Manager on safe, more eco-friendly cleaning products. Then, safer, less toxic, more effective and fewer cleaning and laundry products were purchased for every home on 2/25/22. 02/28/2022 Implemented
6400.165(c)Divalproex Sodium DR 500mg tablets are prescribed to be administered to Individual #4 two tablets, 3 times daily to Individual #1 at 8 AM, 4PM and 8PM. The Medication Administration Record for February 2022 was signed as though the medication was administered 3 times daily but there were extra pills remaining in the pack. Omega 3 Fish Oil capsules are to be administered 2 times daily to Individual #4 but the 8AM dose was still in the blister pack and the MAR was initialed as having been administered.A prescription medication shall be administered as prescribed.At the time of inspection, it was found that the Divalproex Sodium DR 500mg tablets are prescribed to be administered to Individual #4 two tablets, 3 times daily to Individual #1 at 8 AM, 4PM and 8PM. The Medication Administration Record for February 2022 was signed as though the medication was administered 3 times daily but there were extra pills remaining in the pack. Omega 3 Fish Oil capsules are to be administered 2 times daily to Individual #4 but the 8AM dose was still in the blister pack and the MAR was initialed as having been administered. Providence Home Care had implemented weekly medication box checklists to be completed at every home to check for compliance by Pharmaceutical Educator/RN, as well as the Director of Nursing and Group Home Medical Coordinator to alternate weeks of checking the medication boxes for compliance. These checks were being completed on a weekly basis, but the frequency of medication box inspection by the Providence team was not often enough. Since the inspection, Pharmaceutical Nurse Educator/RN created a new checklist for Daily Medication box checks, and has traveled to every Providence group home on a daily basis since 2/24/22 checking every box for every individual at every Providence group home in Lehigh County and utilizing the new Daily version of the checklist (please see new checklist in evidence email). Pharmaceutical Nurse Educator/RN also fully Medication Administration trained 2 more Providence Direct Care/CS staff since the inspection on 2/17/22 help maintain compliance (please see certificates in evidence email). 05/26/2022 Implemented
SIN-00199337 Unannounced Monitoring 01/07/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The main bathroom of the home had what appeared to be urine and hairs on the surface of the toilet and at the base of the tank. The bathroom located off of the bedroom of Individual #2 had several brown streaks of what appeared to be feces on the toilet seat near the tank. The toothbrush used by Individual #1 (confirmed by Staff #2 and #3) was found in the locked medication box. It was uncovered and laying on the bottom of the medication box, under blister packs of medication, and a ziploc bag with the Individual's money and receipts. The bottom of the medication box is not a clean and sanitary place to store an uncovered toothbrush. There were multiple quarter-size brown stains on the carpet in Individual #1's bedroom. (REPEAT VIOLATION FROM 10/26/21)Clean and sanitary conditions shall be maintained in the home. Upon arrival, the inspector observed the main bathroom of the home had what appeared to be urine and hairs on the surface of the toilet and at the base of the tank. The bathroom located off the bedroom of Individual #2 had several brown streaks of what appeared to be feces on the toilet seat near the tank. The toothbrush used by Individual #1 (confirmed by Staff #2 and #3) was found in the locked medication box. It was uncovered and laying on the bottom of the medication box, under blister packs of medication, and a Ziploc bag with the Individual's money and receipts. The bottom of the medication box is not a clean and sanitary place to store an uncovered toothbrush. There were multiple quarter-size brown stains on the carpet in Individual #1's bedroom. Clean and sanitary conditions shall be maintained in the home (64a). Individual #2 can be messy when wiping due to his very shaky hands and can leave a streak or hairs on the toilet. Staff go in and clean the toilet after, but the inspector arrived before the toilet could be addressed. The toothbrush used by individual #1 was put in his medication box by him because he doesn¿t like to brush his teeth and attempts to hide the toothbrush whenever he can. Staff should have placed his toothbrush in a sanitary container covered rather than allowing it to stay in the medication box uncovered (even if that is what individual #1 wanted). The brown stains on the carpet of individual #1¿s bedroom were from the food/beverages he eats in his bedroom. Staff did not have time to address the stain with the carpet shampooer before the inspector arrived (individual #1 struggles with maintaining cleanliness in his bedroom on a daily basis). Immediately after inspection, the toilet and the carpet were cleaned and the stains removed. The toothbrush for individual #1 was removed from his medication box and his team continues to discuss the importance of oral hygiene with him. 01/10/2022 Implemented
6400.82(f)The main bathroom did not have soap or individual paper or cloth towels. The bathroom located off the bedroom of Individual #2 did not have soap.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. During inspection, it was observed that the main bathroom did not have soap or individual paper or cloth towels. The bathroom located off the bedroom of Individual #2 did not have soap. Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle (82f). The main bathroom soap and soap in the other bathroom were locked up- staff are still getting used to the Poisonous Chemicals and Sharp Objects Policy, and in this home, locked up the hand soap as well. Immediately after inspection, Residential Coordinator spoke with staff and the free and clear Soft-soap hand soap was put back out in both bathrooms. Also, hand towels were washed and put back up on the towel rack in the main bathroom so that individuals and staff can dry their hands. 01/10/2022 Not Implemented
6400.214(b)The record in the home for Individual #1 did not contain the Individual's assessment or copy of the physical examination. The record in the home for Individual #2 did not contain a copy of a dental examination. (REPEAT VIOLATION 10/26/21) The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The record in the home for Individual #1 did not contain the Individual's assessment or copy of the physical examination. The record in the home for Individual #2 did not contain a copy of a dental examination. The most current copies of record information required in § 6400.213(2)(14) shall be kept at the residential home. Providence placed binders with documentation necessary to meet compliance immediately after inspections in November 2021. However, documents have been removed from the binder or were unable to be located at the time of inspection. Therefore, Residential Coordinator made copies at the office and placed the current records needed at the home. 02/26/2022 Implemented
6400.52(c)(6)The annual training hours must include the implementation of the individual plan if the staff works directly with an individual. Staff #1 was not trained in the Individual Support Plan (ISP) for Individual #1. While Staff #1 stated that he did read Individual #1's ISP prior to working with him, no record of training in the ISP or Behavioral Support Plan (BSP) was provided (all training records were requested on 1/12/2022 for Staff #1 for the previous year, including trainings related to Individual #1's ISP, BSP, restraints and crisis intervention, to be provided no later than the end of day on 1/13/2021). Additionally, Staff #1 stated in an interview on 1/14/2022 with this Licensing Representative om 1/14/2022 that the behavioral support training he received was the abbreviated summary that was included in the ISP and that he was not trained on nor had he read the BSP that was developed by New Leaf Supports and updated on November 1, 2021.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.During the inspection, the annual training hours must include the implementation of the individual plan if the staff works directly with an individual. Staff #1 was not trained in the Individual Support Plan (ISP) for Individual #1. While Staff #1 stated that he did read Individual #1's ISP prior to working with him, no record of training in the ISP or Behavioral Support Plan (BSP) was provided (all training records were requested on 1/12/2022 for Staff #1 for the previous year, including trainings related to Individual #1's ISP, BSP, restraints and crisis intervention, to be provided no later than the end of day on 1/13/2021). Additionally, Staff #1 stated in an interview on 1/14/2022 with this Licensing Representative om 1/14/2022 that the behavioral support training he received was the abbreviated summary that was included in the ISP and that he was not trained on nor had he read the BSP that was developed by New Leaf Supports and updated on November 1, 2021 (52C6). Staff #1 was trained on the ISP/BSP, but did not sign the Read & Sign log after completion as is the protocol. Since the inspection, staff person has been removed from the home. Residential Coordinator checked the ISP/BSP information binder for individual #1 at the home and ensured that the most current BSP created by New Leaf Supports and ISP were in the binder for all staff to read and sign off that they understand. 01/10/2022 Implemented
6400.186The home shall implement the individual plan, including revisions. The provider failed to implement the plan by not providing the required staffing for Individual #1. Individual #1's Individual Support Plan (ISP) dated 12/21/2021 states that Individual #1 requires 1:2 staffing in his home during evening hours (4 PM to 12 AM), and overnight. Individual #2, per the Autism/Acap plan dated 10/27/2021, requires 1:1 staffing in his residence with intensive supervision. One staff was working in the home on the evening of 12/23/2021, and that staff was assigned to be Individual #2's 1:1 support staff. As Individual #2's 1:1 staff, Staff #1 was not available to provide 1:2 support to Individual #1. The home shall implement the individual plan, including revisions. The provider failed to implement the plan by not following the Behavior Support Plan (BSP) developed for Individual #1. The BSP developed for Individual #1 by New Leaf Supports and was updated November 1, 2021. The plan states that Individual #1 dislikes firm instructions, being pressured to fulfill responsibilities (in this case, taking his prescribed medication) and when others are displeased with him or seem to not like him. Staff #1 questioned the Individual as to why he always gives staff a hard time taking his medication. The BSP states that staff should approach the Individual in a non-reactive way. By questioning why he always gives staff a hard time taking medication, the Staff was being reactive and confrontational, rather than following the interventions recommended in the BSP. By failing to follow the BSP, the staff likely escalated the situation with Individual #1, which culminated with the Staff applying a restraint, Individual #1 requiring police intervention, a 72-hour hospitalization, and an injury to the Staff. Additionally, Individual #1's current ISP states in the Crisis Support Section that the individual has a BSP that should be followed when the individual is having a crisis.The home shall implement the individual plan, including revisions.The home shall implement the individual plan, including revisions (186). The provider failed to implement the plan by not providing the required staffing for Individual #1. Individual #1's Individual Support Plan (ISP) dated 12/21/2021 states that Individual #1 requires 1:2 staffing in his home during evening hours (4 PM to 12 AM), and overnight. Individual #2, per the Autism/Acap plan dated 10/27/2021, requires 1:1 staffing in his residence with intensive supervision. One staff was working in the home on the evening of 12/23/2021, and that staff was assigned to be Individual #2's 1:1 support staff. As Individual #2's 1:1 staff, Staff #1 was not available to provide 1:2 support to Individual #1. Providence did not realize that the staffing ratio was incorrect/non-compliant after the day shift due to confirmation and collaboration with both teams Service Coordinators agreeing and accepting the ratios. After Providence was informed that the supervision levels were not being met, immediately after the unannounced inspection, Providence increased the ratios after the day shift for individual #1 so that individual #2¿s supervision level was not impacted or affected. Both staff receive 24 hour staffing post-inspection. 02/04/2022 Implemented
SIN-00195159 Unannounced Monitoring 10/26/2021 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There were stains on the carpet in areas throughout the unit. Individual #9's bedroom had brown smudges on his walls. There were also approximately 3 (unused) cigarettes and empty soda bottles on his floor. Loose tobacco was on his floor, window ledge and his mattress. There was a plate with two pieces of old pizza and several empty snack-sized bags of chips on his TV stand. Clothes, sheets and boxes are all over the floor in Individual #9's walk-in closet. When the door was opened, the licensing representative could not walk into it due to everything cluttered on the floor. Clean and sanitary conditions are not being maintained.Clean and sanitary conditions shall be maintained in the home. Clean and sanitary conditions must be always maintained in the home. There were several unclean and unsanitary observations at the time of the inspection. There were stains on the carpet in areas throughout the unit. Individual #9¿s bedroom had brown smudges on his walls. There were also approximately 3 (unused) cigarettes and empty soda bottles on his floor. Loose tobacco was on his floor, window ledge and his mattress. There was a plate with 2 pieces of old pizza and several empty snack-sized bags of chips on his TV stand. There were also clothes, sheets, and boxes all over the floor of individual #9¿s walk-in closet- when the door was opened the licensing representative was unable to walk in because of the clutter. Individual #9 is new to the Providence J9 group home and has not been interested in unpacking boxes or hanging up clothing even with staff encouragement and assistance-his main motivation is playing video games, finding a girlfriend, and going out into the community. 10/30/2021 Not Implemented
6400.144Individual #8 is prescribed Ativan (1mg) as needed for anxiety. There prescription does not contain specific symptoms of a mental, emotional, or behavioral condition which would indicate that the medication should be administered. Proper medical services are not being provided.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. Providence did not ensure medical services were provided for individual #8. Individual #8 is prescribed Ativan 1mg for anxiety. The prescription did not contain specific symptoms of the mental, emotional, or behavioral conditions that would indicate there is a need for the staff to administer the medication. Providence Pharmaceutical Educator (RN) Markel Dunn created a policy for PRN medications that was provided for the staff to reference as a general document for signs and symptoms to illicit utilization of PRN anxiety medication for group home individuals. Markel was unaware that this document was not sufficient for staff to utilize as a reference at the time he created and distributed it. The original policy was removed immediately after inspection. 11/05/2021 Not Implemented
6400.214(b)The following items are not kept at this home for Individual #8: Physical exam, dental exam, dental hygiene plan, assessment an Individual Support Plan (ISP). The following items are not kept at this home for Individual #9: physical exam, dental exam and dental hygiene plan. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The most current copies of record information were not at the J9 group home at the time of the inspection. For Individual #8: Physical exam, dental exam, dental hygiene plan, assessment an Individual Support Plan (ISP). For Individual #9: physical exam, dental exam, and dental hygiene plan. Providence has not had a group home manager overseeing the group homes in Breinigsville, PA including the J9 group home since May 2021. That staff person ensured that proper documentation remained at the home and was accessible for staff (especially during the COVID-19 pandemic). Providence was unaware that the dental exam and dental hygiene plan needed to be with the documents at the home. Immediately after unannounced inspection, Providence created new binders for every group home individual containing copies of all necessary documents to be at the residential site and distributed to the site (including J9 group home). 11/05/2021 Implemented
6400.166(b)The following medications were not initialed as administered for Individual #8: Allopurinol 100mg, Aripiprazole 30mg and Aspirin 81mg on 10/10/2021 (8am); Benztropine 0.5mg on 10/3/2021 (8pm), 10/9-10/10/2021 (8am); Boost on 10/10/2021 (8am); Diclofenac gel on 10/1/2021 (4pm), 10/3/2021 (12pm, 4pm, 8pm), 10/8/2021 (12pm, 4pm), 10/9-10/10/2021 (8am, 12pm, 4pm, 8pm), 10/11/2021 (12pm, 4pm, 8pm), 10/3/2021 (8pm), and 10/24/2021 (12pm. 4pm 8pm); Divalproex Sodium 1000mg on 10/3/2021 (8pm), 10/8/2021 (2pm), 10/9/2021(8pm), and 10/23-10/24/2021 (8am); Fenofibrate 134mg and Meloxicam 7.5mg on 10/10/2021 (8am); Levothyroxine 175mcg on 10/10/2021 (7am); Metamucil fiber singles on 10/2-10/3/2021 and 10/10/2021 (8am); Mirtazapine 15mg on 10/9-10/102021 and 10/23-10/24/2021 (8am); Ocuvite Adult and Pantoprazole 40mg on 10/10/2021 (8am); Fish Oil 1000mg on 10/4/2021, 10/8/2021, 10/11/2021, 10/24/2021 (8pm) and 10/10/2021 (8am & 8pm); Propranolol 20mg on 10/3/2021, 10/11/2021, 10/23-10/24/2021 (8pm), and 10/9-10/10/2021 (8am & 8pm); and Thera tablet and Vitamin E 1000 units on 10/9-10/10/2021 (8am). The following medications were not initialed as administered for Individual #9: Eliquis 2.5mg on 10/10/2021 (8am & 8pm), and 10/23-10/24/2021 (8pm); Levothyroxine 100mcg, Lisinopril 10mg and Vitamin D3 2000 units on 10/10/2021 (8am).The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Numerous medications were not recorded at the time the medications were administered at the J9 group home. Providence has recently started utilizing a new system for medication administration called QuickMar, which is an electronic medication administration record system instead of utilizing paper (which was what Providence used for the past 5 years-staff were accustomed to that system). Markel Dunn-Pharmaceutical Nurse Educator (RN) has been rolling out the new system and training the staff, and the rollout has not been as smooth as Providence hoped. Immediately after unannounced inspection, Incident reports completed in EIM, and Individual #8 and Individual #9¿s physicians were contacted and informed of the missed medications. 11/05/2021 Not Implemented
SIN-00164044 Renewal 10/08/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The license for this agency expires on 11/15/2019. A self-assessment wasn't completed until 9/26//2019 (Repeat Violation: 10/11/2018).The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The self-assessment for the residential home was not completed within the 3-6 month time period out from the license renewal date. Providence Program Specialist was under the impression that the assessment needed to be done within 3-6 months of the renewal date, but was incorrect as far as the time frame. Therefore, the Program Specialist instructed the Group Home Manager to complete the assessment in the incorrect timeframe. Now Providence Program Specialist has the correct assessment form and is aware of the correct time frame schedule. Providence will maintain a calendar that includes due dates of specific tasks, so that Program Specialist and Group Home Manager are aware of the required assessment completion time frame to ensure compliance. Regular updates and observation of the calendar will keep Providence compliant moving forward. 10/31/2019 Implemented
6400.22(d)(1)There is no up-to-date property record for Individual #4.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. There was not an up-to-date property record kept for the individual. Program Specialist was not aware that an up-to-date property record was necessary and required. Providence completes a property record upon initial move-in and for every move from one group home to another, but not an ongoing property record. Now that Program Specialist is aware of this important requirement, moving forward the property record will be updated for every individual. Providence had a staff training on October 24th, 2019, and presented the new property record form that was created after the audit and explained to staff how to complete the record for every individual. Moving forward, Providence team and staff will work together to maintain compliance utilizing the new property record. 10/31/2019 Implemented
6400.113(a)Individual #4 did not have fire safety training annually. His most current fire safety training is dated 3/29/2018. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, 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 home. The individual did not have the fire safety training annually. The most current fire safety training was done on 3/29/18 at the group home. Program Specialist was not aware that every individual needs the full fire safety training annually that the individual receives upon initially moving in and if he or she moves to any other site-the individual must be trained annually even if he or she remains at the same group home site indefinitely. Now Program Specialist is aware of the requirement, and moving forward will supervise the Group Home Manager with completing this task annually. Providence will maintain a calendar that includes due dates of specific tasks, so that Program Specialist and Group Home Manager are aware of the required annual fire safety training due dates to ensure compliance. Regular updates and observation of the calendar will keep Providence compliant moving forward. ((Fire training completed 11/15/19 -CH11/26/2019)) 10/31/2019 Implemented
6400.151(a)The most current physical exam for Staff #3 is dated 4/6/2017. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Staff person #3 did not have a physical exam done in the employee file completed at the correct, required timeframes. Due to having the previous HR person being disorganized, and the new HR person recently starting her position, this error was not recognized prior to the renewal audit at the Providence office on 10/8/19. Now Providence HR person and Program Specialist are aware that physicals for staff must be completed within 12 months of initial employment and then every 2 years thereafter. Since the audit, the new HR person was given the new 6400 regulations requirements for staff files and created a new file system to increase organization. Moving forward, the new HR person is going through every group home staff file to ensure compliance and that all documents are secure and in the proper files. ((Staff #3 no longer works for agency -CH 11/26/2019)) 10/31/2019 Implemented
6400.181(a)Individual #4 had an assessment done on 1/3/2018. He didn't have another assessment completed until 6/15/2019, which exceeds the annual requirement. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The residential assessment for the individual was not completed within the annual time frame. Providence Program Specialist was under the impression that the assessment needed to be done within the calendar year at any point but was incorrect as far as the time frame. Therefore, the Program Specialist completed the assessment on a date that was outside the requirement and past the 15 -day grace period, so it was in the incorrect timeframe. Now Providence Program Specialist is aware of the correct time frame schedule. Providence will maintain a calendar that includes due dates of specific tasks, so that Program Specialist is aware of the required assessment completion time frame to ensure compliance. Regular updates and observation of the calendar will keep Providence compliant moving forward. 10/31/2019 Implemented
6400.181(e)(9)This area wasn't assessed in Individual #4's assessment dated 6/15/2019.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. The ¿functional and medical limitations¿ was not included in the residential individual assessment. Program specialist was not aware that functional and medical limitations were required on the assessment forms (only had ¿acquisition of functional skills¿ on the assessment). Program Specialist has edited the Residential Individual Assessment forms to include the ¿functional and medical limitations¿ so that moving forward it will not be forgotten in future individual assessments. Program Specialist will make sure to utilize the updated assessment form for individuals to ensure that the section for ¿functional and medical limitations¿ is not forgotten. No staff training necessary. ((All individual assessments will be reviewed and updated to include all required information by 12/1/2019 -CH 10/30/2019)) 10/31/2019 Implemented
6400.181(e)(14)Individual #4's ability to regulate water temperature wasn't assessed in his assessment dated 6/15/2019.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. The ¿ability to regulate water temperature¿ was not included in the residential individual assessment. Program specialist was not aware that the ability to regulate water temperature was required on the assessment forms. Program Specialist has edited the Residential Individual Assessment forms to include the ¿ability to regulate water temperature¿ so that moving forward it will not be forgotten in future individual assessments. Program Specialist will make sure to utilize the updated assessment form for individuals to ensure that the section for ¿ability to regulate water temperature¿ is not forgotten. No staff training necessary. ((All individual assessments will be reviewed and updated to include all required information by 12/1/2019 -CH 10/30/2019)) 10/31/2019 Implemented
6400.15(b)The self-assessment used is not the correct form; the form utilized is for opening new houses.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.The incorrect self-assessment tool form was utilized to conduct the home assessments. Providence management was under the impression that the correct form was being used per advice in a previous licensing audit, so assessments were completed by the Group Home Manager using the advised form. Now we have the correct self-assessment tool form from licensing, so moving forward Providence Group Home Manager will conduct all assessments using this correct form. Providence will save this document and provide it for the Group Home Manager to make copies for her assessments of the homes. Program Specialist will check the Group Home Manager¿s assessments regularly to make sure that the correct tool is still being used. Program specialist will train the Group Home Manager on the new form and it will be used for the first time in November. 11/30/2019 Implemented
6400.165(g)Psych Med Reviews were not held every 3 months. Individual #3 had his Psych Med Reviews on 9/10/2018, 1/11/2019, 2/28/2019, 5/9/2019 and 9/25/2019.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.Psych medication reviews were not held every 3 months for individual #3 as required. Medical Coordinator had difficulty scheduling the psych medication reviews on time for individual #3 because of the busy, very booked psychiatrist that the individual sees. Despite immediately attempting to schedule follow up appointments with this psychiatrist and explaining the urgency and requirements, Medical Coordinator was unable to schedule them at the 3 month time frame because of the high demand and popularity of this psychiatrist. Now that the scheduling is clearly a consistent problem, a solution was decided on by the Providence team that Medical Coordinator will schedule psych medication reviews for this individual with Providence¿s Medical Director/Physician- Dr. Eric Cochran. He will have to complete the psych medication reviews for this individual moving forward to maintain compliance. No training necessary for this violation. 11/30/2019 Implemented
6400.169(d)Staff #3 had his initial Medication Administration training on 11/9/2017. His entire packet was not kept. Missing from the packet is his multiple choice examination, Script/label examination and MAR examination.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.Staff #3 had initial medication administration training on 11/9/17 and his entire packet was not in his file (multiple choice test, script/label exam, MARexam). Staff #3 had part off his initial medication administration training documents in his folders, but the rest of the documents were put elsewhere in another staff person¿s folder with a similar name. Due to having the previous HR person being disorganized, and the new HR person recently starting her position, this error was not recognized prior to the renewal audit at the Providence office on 10/8/19. Since the audit, the new HR person has located the rest of staff #3¿s medication administration documents from 2017. Since the audit, the new HR person was given the new 6400 regulations requirements for staff files and created a new file system to increase organization. Moving forward, the new HR person is going through every group home staff file to ensure compliance and that all documents are secure and in the proper files. HR also placed the remainder of staff #3¿s medication administration documents from 2017 into his proper file. Staff training of HR completed-given new regulations by Program Specialist. 10/31/2019 Implemented
6400.207(4)(I)A chemical restraint is a prohibitive procedure. Individual #4 is prescribed Lorazepam (1mg QID PRN) for Anxiety. The specific symptoms of Anxiety to be treated are not listed. Individual #3 was administered this medication on 1/4/2019 and 8/2/2019.A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition.The use of Lorazepam as a PRN medication was incorrectly documented by staff when administered and it is considered a chemical restraint. It should only be administered when 1 or more of the specific physical symptoms of Anxiety determined by the individual¿s physician and listed on the MAR are exhibited by this individual. Staff must contact the CEO¿s designee Kathy Rodriques the Medical Coordinator or Denise Yuppa the Group Home Manager (if Kathy is unavailable or unreachable) for approval of administration of the Lorazepam. Staff were not thorough in their documentation of the administration as they should have been, but the list of symptoms for the individual¿s Anxiety were also not listed for the staff to recognize and write down. Staff may or may not have contacted either Kathy or Denise, but moving forward it must be documented on the MAR which CEO designee approved the administration. The protocol will be that if staff notice this individual is experiencing any of the listed symptoms of Anxiety OR the individual states that he is feeling Anxiety and/or wants a PRN Lorazepam-then staff will go through the list of symptoms on the MAR to check for the symptoms and then will contact the CEO designee Kathy Rodriques the Providence Medical Coordinator or Denise Yuppa the Group Home Manager (if Kathy is unavailable or unreachable) for approval for administration. If the staff person receives approval, then he/she will administer the PRN Lorazepam and will fill out the MAR correctly. To ensure that that all staff are aware of the symptoms list and protocol moving forward, Medical Coordinator, Program Specialist and Group Home Manager will be holding a training to openly discuss and review the importance of thorough, detailed documentation and the proper steps for PRN medications with all group home staff. This training will be titled ¿Medication Documentation and Administration Responsibility¿ and is being held on November 19, 2019. 11/19/2019 Implemented
SIN-00143547 Renewal 10/11/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)A self-assessment was not completed by the agency within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. ((REPEAT VIOLATION 11-14-17))The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter.New Group Home Manager Jude Felix will ensure compliance moving forward with this goal. Jude will be notified by Program Specialist Sigrid Hurdle when the agency's certificate of compliance is within 3-6 months of expiring, and he will then complete the self-assessment of the site. Sigrid will ensure that this will not occur again by checking all site expiration dates and informing Jude, and then making sure Jude puts the prior to expiration 3-6 month window for each site in his calendar. Jude will correspond with Sigrid to make sure that all assessments are thoroughly completed. Sigrid will train Jude on how to complete the assessments, along with assistance from Behavioral Director Liz O'Connor. Jude will implement the new process with Sigrid and Liz's help as of January 1, 2019. 01/01/2019 Implemented
6400.112(e)The fire drills held between October 2017 through September 2018 were all held during waking hoursA fire drill shall be held during sleeping hours at least every 6 months. Group Home Manager Jude Felix will ensure that fire drills will be held at least every 6 months during sleeping hours (between 11PM-7AM). Jude Felix will accomplish this correction by training the staff at all of the 6400 group homes in the fire drill training so that whoever is on shift when he schedules a sleeping hours fire drill will be knowledgeable and trained on how to execute a surprise fire drill during sleeping hours. Jude will make sure that staff know the time to do the fire drill and will provide the proper documentation at each site so that the staff are prepared to record what occurred. The group home individuals will also sign that they participated. This new process will be implemented to begin as of January 1st, 2019. 01/01/2019 Implemented
6400.112(h)A designated meeting place is not identified nor is there indication that individuals evacuated to a designated meeting place during each fire drill. (( REPEAT VIOLATION 11-14-17))Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.A designated meeting place will be clearly defined and displayed at every group home site by Jude Felix the Group home manager. Jude will also ensure that the designated meeting place will be incorporated into the fire drill training noted in violation 6400.112(e). Jude will train the staff in every group home site regarding the locations of the designated meeting places, and will train the staff to train the individuals on the locations of the designated meeting places. Jude will ensure compliance with this by holding monthly fire drill trainings. Jude will implement the changes by January 1, 2019. 01/01/2019 Implemented
SIN-00125932 Renewal 11/14/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)At the time of inspection, self-assessments were not being done.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Self-assessments were completed on 07/10/17 for all the group homes within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. They were not available at the time of audit because it was mistakenly placed in a different file cabinet. Moving forward copies of self-assessments will be kept in a dedicated file cabinet for easy access. The Quality Assurance Manager will be responsible to ensure continuous compliance. 07/10/2017 Implemented
6400.22(d)(1)A current property record is not being kept for Individual #3.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. The Programs Specialist is responsible for monitoring and overseeing all financial activities of individuals fund and properties. The organization has set up a financial system for monitoring and documenting all individuals fund. Every home will now have a petty cash log that will be monitored and supervised by the Program Manager. The log will then be reviewed monthly by the Accounting Office and reconcile bank statements with the balance of the account of each individual. 11/20/2017 Implemented
6400.22(e)(3)There is a record of money coming into the home, but a record of all expenditures exceeding $15 is not being kept for Individual #3. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. All receipts have been accounted for and filed properly. Programs Specialist, supervised by Financial Controller will ensure all receipts and expense record, of every single purchase exceeding 15 dollars made on behalf of all individuals carried out by or in conjunction with a staff person. Financial Controller or designee will conduct monthly audits of financial records to ensure receipts are present for purchases of 15 dollars or more. 11/20/2017 Implemented
6400.31(b)Individual #3 was admitted on 12/1/2016. There is no signed copy of his Individual Rights in his record.Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. A new individual rights' has been issued and signed by individual#3. Programs Specialist is responsible for ensuring all individuals who come on board are issued; Individual Rights statements, and make sure it is signed, dated, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. Programs Specialist will conduct weekly audits to prevent future occurrences and continuous compliance. 12/18/2017 Implemented
6400.77(b)The First aid kit did not have a thermometer. 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 thermometer was replaced in this first aid kit on 11/15/2017 by the House Manager. To prevent future occurrences every week, the House Manager will check the contents of the first aid kit to ensure completeness during their site visits. Quality Assurance Manager will monitor for compliance 11/30/2017 Implemented
6400.104Notification was not made to the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Notification letters were sent to the fire department, moving forward the Programs Specialist will ensure that the Fire Department is notified of the individuals living in the home. To prevent future occurrences, The Programs Specialist will be responsible for notifying the fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. 11/30/2017 Implemented
6400.112(h)Documentation of the designated meeting place is not kept on the fire drill records. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.A designated meeting place is now available on all fire drill records. To prevent future occurrences the Programs Specialist will be responsible to ensure compliance by making sure all fire drill charts for individuals have designated meeting place indicated on the fire drill records and ensure Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. ((Fire drill logs will indicate that all individuals evacuated to the designated meeting place during each fire drill.-CH 1/24/18)) 11/15/2017 Implemented
6400.141(c)(2)This section was not on Individual #3's physical exam dated 8/4/2017.The physical examination shall include: A general physical examination. A new appointment for the individual#3 has been set on 02/05/18 at 9:00 am for a general physical exam. Programs Specialist will ensure proper documentation is easily accessible showing physical examinations 12 months prior to admission and annually thereafter. To prevent future occurrences the program specialist will review individual¿s appointments on a weekly basis and communicate to team leaders and staff all changes. 12/18/2017 Implemented
6400.141(c)(3)This section was not on Individual #3's physical exam dated 8/4/2017.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. A new appointment for the individual#3 has been set on 02/05/18 at 9:00 am for a general physical exam which will include Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. Programs Specialist will ensure proper documentation is easily accessible showing physical examinations 12 months prior to admission and annually thereafter. To prevent future occurrences the program specialist will review individual¿s appointments on a weekly basis and communicate to team leaders and staff all changes. 12/18/2017 Implemented
6400.141(c)(4)This section was not on Individual #3's physical exam dated 8/4/2017.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. A new appointment for the individual#3 has been set on 02/05/18 at 9:00 am for a general physical exam which will include Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Programs Specialist will ensure proper documentation is easily accessible showing physical examinations 12 months prior to admission and annually thereafter. To prevent future occurrences the program specialist will review individual¿s appointments on a weekly basis and communicate to team leaders and staff all changes. 12/18/2017 Implemented
6400.141(c)(6)This section was not on Individual #3's physical exam dated 8/4/2017.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. A new appointment for the individual#3 has been set on 02/05/18 at 9:00 am for a general physical exam which will include Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Programs Specialist will ensure proper documentation is easily accessible showing physical examinations 12 months prior to admission and annually thereafter. To prevent future occurrences the program specialist will review individual¿s appointments on a weekly basis and communicate to team leaders and staff all changes. 12/18/2017 Implemented
6400.141(c)(10)This section was not on Individual #3's physical exam dated 8/4/2017.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. A new appointment for the individual#3 has been set on 02/05/18 at 9:00 am for a general physical exam which will include specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. Programs Specialist will ensure proper documentation is easily accessible showing physical examinations 12 months prior to admission and annually thereafter. To prevent future occurrences the program specialist will review individual¿s appointments on a weekly basis and communicate to team leaders and staff all changes. 12/18/2017 Implemented
6400.141(c)(11)This section was not on Individual #3's physical exam dated 8/4/2017.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. A new appointment for the individual#3 has been set on 02/05/18 at 9:00 am for a general physical exam which will include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Programs Specialist will ensure proper documentation is easily accessible showing physical examinations 12 months prior to admission and annually thereafter. To prevent future occurrences the program specialist will review individual¿s appointments on a weekly basis and communicate to team leaders and staff all changes. 12/18/2017 Implemented
6400.141(c)(12)This section was not on Individual #3's physical exam dated 8/4/2017.The physical examination shall include: Physical limitations of the individual. A new appointment for the individual#3 has been set on 02/05/18 at 9:00 am for a general physical exam which will include physical limitations of the individual. Programs Specialist will ensure proper documentation is easily accessible showing physical examinations 12 months prior to admission and annually thereafter. To prevent future occurrences the program specialist will review individual¿s appointments on a weekly basis and communicate to team leaders and staff all changes. 12/18/2017 Implemented
6400.141(c)(13)This section was not on Individual #3's physical exam dated 8/4/2017.The physical examination shall include: Allergies or contraindicated medications.A new appointment for the individual#3 has been set on 02/05/18 at 9:00 am for a general physical exam which will include allergies or contraindicated medications. Programs Specialist will ensure proper documentation is easily accessible showing physical examinations 12 months prior to admission and annually thereafter. To prevent future occurrences the program specialist will review individual¿s appointments on a weekly basis and communicate to team leaders and staff all changes. 12/18/2017 Implemented
6400.141(c)(14)This section was not on Individual #3's physical exam dated 8/4/2017.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. A new appointment for the individual#3 has been set on 02/05/18 at 9:00 am for a general physical exam which will include medical information pertinent to diagnosis and treatment in case of an emergency. Programs Specialist will ensure proper documentation is easily accessible showing physical examinations 12 months prior to admission and annually thereafter. To prevent future occurrences the program specialist will review individual¿s appointments on a weekly basis and communicate to team leaders and staff all changes. 12/18/2017 Implemented
6400.141(c)(15)This section was not on Individual #3's physical exam dated 8/4/2017.The physical examination shall include:Special instructions for the individual's diet. A new appointment for the individual#3 has been set on 02/05/18 at 9:00 am for a general physical exam which will include special instructions for the individual's diet. Programs Specialist will ensure proper documentation is easily accessible showing physical examinations 12 months prior to admission and annually thereafter. To prevent future occurrences the program specialist will review individual¿s appointments on a weekly basis and communicate to team leaders and staff all changes. 12/18/2017 Implemented
6400.163(c)Individual #3 is prescribed medications to treat a diagnosed psychiatric illness. He is not having 3 month medication reviews completed by a licensed physician. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Programs Specialist will review each individuals record and schedule for a medication review by a licensed physician for all individuals who have been prescribed medications to treat a diagnosed psychiatric illness. Medication review appointments have been set for all the individuals as follows: individual #1 12/29/17 at 1:45 pm, individual # 2, 1/03/18 at 10:40 am, individual # 3, 02/05/18 at 9:00 am A tracking sheet has been created by the Programs Specialist to prevent future occurrences. 12/18/2017 Implemented
6400.181(a)Individual #3 was admitted on 12/1/2016. As of the date of this inspection, an assessment hasn't been completed for him. ((Repeat violation 5/8/2017)). Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Programs Specialist will ensure each individual will have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment will include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Individual #1 who was admitted 3-1-17 and did not have an initial assessment completed within 60 calendar days after admission was corrected on 12/18/2017. Quality Assurance Manager will enforce that all initial assessments for incoming individuals will be supported by documentation and other variables in the home supporting these individuals. The program specialist will also ensure the assessments are completed and made available to ISP meetings which will be signed and dated by the program specialist within 60 calendar days after admission. The Programs specialist will be responsible to ensure continued compliance. The system implemented to make sure that the same violation will not occur is to have Quality Assurance Manager overseeing all program specialist responsibilities for initial assessments and to also review all current and future changes to 6400 licensing regulations and guidelines for the agency to execute. 12/18/2017 Implemented
6400.183(5)Individual #3 takes medications to treat symptoms of a diagnosed psychiatric illness. He currently does not have a SEE Plan.The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. A meeting with the team has been set for 12/28/17 for Individual#3. A notification has been sent to all team members for SEE Plan which will address the social, emotional and environmental needs of the individual. Moving forward the Programs Specialist will be responsible to attend all ISP revision meetings and also ensure individuals who take medications to treat symptoms of a diagnosed psychiatric illness have an SEE plan in place. 12/18/2017 Implemented
6400.184(b)Individual #3 was admitted on 12/1/2016. As of the date of this inspection, he hasn't had an ISP meeting with plan team members. At least three plan team members, in addition to the individual, if the individual chooses to attend, shall be present for an ISP, annual update and ISP revision meeting. A meeting with the team has been for Individual#1 on 12/28/17, individual#2 01/04/18 and Individual#3 on 01/16/18. A notification has been sent to all team members, Programs Specialist will be responsible to attend all ISP revision meetings. Program Specialist will complete all quarterly ISP reviews in a timely manner and will review it with the individual. All reviews will be properly documented and will accurately include dates of periods being covered, ISP outcomes and signatures of the individual.At least three plan team members, in addition to the individual, if the individual chooses to attend, shall be present for an ISP, annual update, and ISP revision meeting. Programs Specialist will be responsible to review all individual files to ensure that ISP meetings are held for all individuals. A tracking sheet has been created by the Programs Specialist to prevent future occurrences. 12/28/2017 Implemented
6400.186(a)Individual #3 was admitted on 12/1/2016. Since his admission, 3 month ISP Reviews have not been completed for him.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. Program Specialist will complete all quarterly ISP reviews in a timely manner and will review it with the individual. All reviews will be properly documented and will accurately include dates of periods being covered, ISP outcomes and signatures of the individual. A meeting with the team has been set for Individual#1 on 12/28/17, Individual#2 on 01/04/18, Individual #3 on 01/16/18. Programs Specialist will be responsible to review all individual files to ensure that quarterly reviews are completed in accordance with 55PA Code 6400.186(a) 12/18/2017 Implemented
6400.213(1)(i)Admission date, race, hair color, eye color identifying marks, communication spoken/understood, Religious affiliation, and next of kin were not listed in Individual #3's record.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. Individual#1's record has been updated to reflect Social Security Number, race, identifying marks, and religious affiliation. Individual #2's record has been updated to reflect weight, height, race, identifying marks, and religious affiliation. Individual#3's record has updated with admission date, race, hair color, eye color identifying marks, communication spoken/understood, religious affiliation, and next of kin. The Program Specialist will be responsible to ensure all individuals records are updated during and after admission and conduct weekly record checks to ensure compliance. 12/18/2017 Implemented
SIN-00115027 Unannounced Monitoring 05/08/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a) Individual #1 had no physical exam in his record.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Providence will ensure proper documentation is easily accessible showing physical examinations 12 months prior to admission and annually thereafter. The Programs Director will retrain and annually thereafter administrative staff including Program Specialist and House Managers on properly scheduling and documenting physical examinations. To prevent future occurrences the Program specialist will reschedule and review individual¿s appointments on a weekly basis and communicate to House Managers and staff on all changes. ((Individual #1 was discharged on 6/23/2017 and no longer resides in the home - CH 7/10/17)) 06/17/2017 Implemented
6400.181(a)Individual #1 had no assessment completed. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. As per 6400.181(a), Providence will ensure each individual will have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment will include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Individual #1 who was admitted and did have an initial assessment completed within 60 calendar days after admission on 11/28/2016. Programs Specialist will enforce that all initial assessments for incoming individuals will be supported by documentation and other variables in the home supporting these individuals. The program specialist will also ensure the assessments are completed and made available to ISP meetings which will be signed and dated by the program specialist within 60 calendar days after admission. The Programs Director will be responsible to ensure continued compliance. The system implemented to make sure that the same violation will not occur is to have a Programs director overseeing all Program Specialist responsibilities for initial assessments and to also review all current and future changes to 6400 licensing regulations and guidelines for the agency to execute, and also file them easy access. ((Individual #1 was discharged on 6/23/2017 and no longer resides in the home. - CH 7/10/17)) 11/28/2016 Implemented
6400.182(a) Individual #1 did not have an ISP completed by either his Supports Coordinator or his residential Program Specialist.(a) An individual shall have one ISP. The individual had an ISP, however it was not at accessible at the group home. The Programs Specialist has made one available at the group home. Moving forward Programs Director will do weekly checks to ensure compliance. ((Individual #1 was discharged on 6/23/2017 and no longer resides in the home - CH 7/10/17)) 07/30/2016 Implemented
SIN-00235184 Unannounced Monitoring 11/06/2023 Compliant - Finalized
SIN-00205758 Unannounced Monitoring 05/26/2022 Compliant - Finalized
SIN-00202829 Unannounced Monitoring 03/14/2022 Compliant - Finalized
SIN-00103383 Initial review 11/15/2016 Compliant - Finalized