Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00232296 Unannounced Monitoring 10/02/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The toilet in Individual #1's bedroom's attached bathroom was dirty at the time of inspection. The interior of the toilet bowl was lined with grey-colored stains in a drip pattern and the rim of the toilet bowl was sparsely covered in yellowish-grey discolorations consistent in appearance with dried urine. In the home's shared bathroom, there were very slight, light brown stains in a drip pattern on two of the walls.Clean and sanitary conditions shall be maintained in the home. October 3, 2023- The toilet in the individual¿s bathroom was cleaned and all discolored areas and stains were removed. 11/15/2023 Implemented
6400.67(b)A toaster in the home's kitchen had a crumb tray that was overly full, and many of the crumbs inside the crumb tray were blackened and burnt. The interior of the toaster also contained sparse crumbs, some of which appeared to be blackened or charred. In this state, the toaster posed a fire hazard in the home. Floors, walls, ceilings and other surfaces shall be free of hazards.October 3, 2023- The toaster crumb tray was cleaned. Fire training conducted October 2023 to emphasize to staff that this condition the toaster posed a fire hazard in the home. 11/15/2023 Implemented
6400.81(k)(2)Individual #2's bed lacked a fitted sheet, and the mattress was thusly exposed to the elements. The mattress was grey and discolored. There were several orange-red stains around the mattress consistent with food stains. Staff on site reported that the individual declines to use a fitted sheet and eats food in bed despite staff attempts at redirection---this report from staff was consistent with the observed state of the bed and mattress.In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. Bedding was provided and put on the individual's bed. 10/02/2023 Implemented
6400.144Individual #1 was prescribed a Pro Re Nata (PRN) psychotropic medication, Hydroxyzine Pam 50mg Capsule "TAKE ONE CAPSULE BY MOUTH THREE TIMES DAILY AS NEEDED FOR ANXIETY SUCH AS PACING, VERBALIZING WORRY ABOUT UPCOMING APPOINTMENT, VERBALIZING CONCERN OF PEOPLE THINKING BADLY OF HIM, OR NEGATIVE INTRUSIVE THOUGHTS." There was no evidence of a formalized protocol which established that the Chief Operating Officer (CEO) or a specific agency employee designated by the CEO must be called to give prior authorization to administer the medication each time the medication is administered to the individual and that this authorization must be documented in the Medication Administration Record (MAR). As such a policy had not been established by the provider for this PRN psychotropic medication, appropriate pharmaceutical services were not planned for the individual by the provider.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. Confirmation of psychiatric diagnosis and list of potential symptoms received by the physician. QuickMar was updated with this information and policy attached to MAR for reference. QuickMar updated to include area for staff to document what symptoms the individual was demonstrating and who gave approval to administer the PRN medication. 11/01/2023 Implemented
6400.171The home's refrigerator contained two food items that were not stored safely. Inside the refrigerator was an uncovered bowl of cooked chicken nuggets and ketchup that appeared to have been a partially eaten meal. There was also a glass-lid-covered cooking pot in which was an unidentifiable, brownish-white substance resembling either stuffing or seasoned mashed potatoes. The interior surface of the glass lid was covered in thick condensation, which collected in the bottom of the pot, creating a substantial puddle of water that mixed with the brownish-white substance. These food items were stored in a manner that made them susceptible to contamination.Food shall be protected from contamination while being stored, prepared, transported and served. The food that was unproperly stored was discarded. Staff and the individuals were provided guidance for proper food storage. 11/15/2023 Implemented
6400.166(a)(10)Individual #1 was prescribed Calcium Acetate 667mg Gelcap "TAKE ONE CAPSULE BY MOUTH DAILY AT NOON AND IN THE EVENING WITH MEALS TO LOWER PHOSPHATE LEVELS." The entry for this medication in the October 2023 Medication Administration Record (MAR) noted that the evening dose was scheduled to occur at 4:00pm; however, the pharmacy label on the medication packaging notes that the evening dose was scheduled to occur at 5:00pm. The actual evening administration time for this medication was unclear.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.A representative from Hartzell's Pharmacy came to the home on 10/3/23 to audit the MARS. Correction made to match up the medication label and the MAR by Hartzell's Pharmacy. 10/04/2023 Implemented
SIN-00230303 Unannounced Monitoring 08/31/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)There was no thermometer in the first aid kit. 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. WHAT HAPPENED AND WHY? 6400.77(b) VIOLATION DESCRIPTION: There was no thermometer in the first aid kit. CORRECTION REQUIRED: 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. Staff utilized the thermometer in the First Aid Kit but forgot to put it back in the First Aid Kit. WHAT ARE WE DOING NOW?: Another thermometer was placed at the home in the First Aid Kit immediately after inspection. 10/31/2023 Implemented
6400.163(a)Prescription and nonprescription medications shall be kept in their original labeled containers. Several blue and white capsules (later identified as Calcium Acetate) had been popped out of the blister packs and placed in a plastic sandwich baggie after being refused by Individual #1.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.What happened and why? Prescription and nonprescription medications shall be kept in their original labeled containers. Several blue and white capsules (later identified as Calcium Acetate) had been popped out of the blister packs and placed in a plastic sandwich baggie after being refused by 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
6400.166(c)If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication administration record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual. A plastic bag of loose, unlabeled capsules was found in the medication box. Staff stated that they were Calcium Acetate capsules that Individual #1 had refused to take. Staff had popped the capsules out of the blister pack and placed them in the plastic baggie. There was no record that the refusals were documented or that the prescriber was notified of the refusals. (Repeat Violation 5/17/23)If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual.What happened and why? If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication administration record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual. A plastic bag of loose, unlabeled capsules was found in the medication box. Staff stated that they were Calcium Acetate capsules that Individual #1 had refused to take. Staff had popped the capsules out of the blister pack and placed them in the plastic baggie. There was no record that the refusals were documented or that the prescriber was notified of the refusals. (Repeat Violation 5/17/23) 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-00204496 Unannounced Monitoring 04/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(b)According to April 2022 Medication Administration Record (MAR) Individual #3 is prescribed "Ammonium Lactate 12% Lotion apply to affect. Area(s) 2 x daily @ 8am -8pm" and Nystatin Apply to affect. area(s) 2 x daily @ 8am-8pm." The designated initial slot on the MAR for the 8pm dose of the Nystatin and Ammonium Lactate on 4/28/2022 were blank and neither initialed to indicate it was administered nor circled to indicate additional circumstances exist with the administration. The medication appeared to have been administered properly; however, the name of the person administering the medications was 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) According to April 2022 Medication Administration Record (MAR) Individual #3 is prescribed "Ammonium Lactate 12% Lotion apply to affect. Area(s) 2 x daily @ 8am -8pm" and Nystatin Apply to affect. area(s) 2 x daily @ 8am-8pm." The designated initial slot on the MAR for the 8pm dose of the Nystatin and Ammonium Lactate on 4/28/2022 were blank and neither initialed to indicate it was administered nor circled to indicate additional circumstances exist with the administration. The medication appeared to have been administered properly; however, the name of the person administering the medications was not recorded at the time the medication was administered. 06/10/2022 Implemented
SIN-00200468 Unannounced Monitoring 02/17/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)There were two hand-labeled spray bottles in the cabinet under the kitchen sink; one was labeled "windex solution" and one was labeled "fabuloso and water." Poisonous materials shall be stored in their original, labeled containers.Poisonous materials shall be stored in their original, labeled containers. During the inspection, there were two hand-labeled spray bottles in the cabinet under the kitchen sink; one was labeled "windex solution" and one was labeled "fabuloso and water." Poisonous materials shall be stored in their original, labeled containers (62c). Providence staff use cleaning products constantly at A9 to keep the home clean and sanitary, and with the incontinence issues and behaviors that Individual #3 exhibits with her urinary bag, it is even more imperative that staff clean surfaces on a daily basis. Some of these cleaners that have been used in the home for a long time are concentrated, and should be mixed with water (like Fabuloso-per instructions on the bottle), however, staff are NOT supposed to store the cleaning products in different containers- they must stay in the original labeled containers. Even if staff executed using a cleaner per instructions that said ¿mix 1 cup with 1 gallon of water¿ or something like that for example, the cleaner is not to be stored mixed or in different containers other than the original ones after use. 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
6400.32(s)(3)Individual # 2 and Individual #3 had pin key door locks on their bedroom doors. At the time of inspection, staff did not have a key or entry device to lock or unlock the doors. Direct service workers shall have the key or entry device to lock and unlock the door.Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.Individual # 2 and Individual #3 had pin key door locks on their bedroom doors. At the time of inspection, staff did not have a key or entry device to lock or unlock the doors. Direct service workers shall have the key or entry device to lock and unlock the door. Providence did not know that the doorknobs on the doors for individual #2 and Individual #3 were not compliant because they technically did have keys accessible to them- but they were pinhole lock keys (not traditional keys) and the individuals in the A9 home never wanted to lock their doors. After inspection, Residential Coordinator and Program Specialist purchased numerous doorknobs, and contacted Providence contractor to replace the knobs on individual #2 and Individual #3 bedroom doors with the knobs with the traditional key locks and make a copy for the individual as well as the staff copy leave stored at the home (see evidence email for photos of the knobs). 02/26/2022 Implemented
SIN-00199336 Unannounced Monitoring 01/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individual #2's Individual Support Plan states that the individual is not safe with poisons. There were two Glade plug-in air fresheners in the home, one in the kitchen and the other in Individual #2's bathroom. (REPEAT VIOLATION FROM 11/03/2021)Poisonous materials shall be kept locked or made inaccessible to individuals. During the unannounced inspection, Individual #2's Individual Support Plan states that the individual is not safe with poisons. There were two Glade plug-in air fresheners in the home, one in the kitchen and the other in Individual #2's bathroom. Poisonous materials shall be kept locked or made inaccessible to individuals (62a). Providence did not realize that the Glade wall plug-ins were considered hazardous poisons (because they are plugged into the wall-unlike any other object/device utilized in the home; honestly overlooked as falling under the category of an ingestible, hazardous poison). During the inspection, Pharmaceutical Nurse Educator who was on site at the time, removed the Glade Plug-ins and any replacement scented plugs in the storage closet, cabinets or drawers; all removed from the walls and they were discarded/destroyed at the office. Hazard was removed. 01/07/2022 Implemented
6400.64(a)Clean and sanitary conditions are not being maintained in the home. Individual #1's bedroom carpet has a large brown stain located in front of the door.Clean and sanitary conditions shall be maintained in the home. At the time of inspection, the inspector observed that clean and sanitary conditions are not being maintained in the home. Individual #1's bedroom carpet has a large brown stain located in front of the door (64a). Individual #1 consumes coffee daily. The carpets had recently been replaced and deep cleaned by Baco Cleaners and staff complete the Shift Safety Inspection Checklists at the end of every shift (the last 15 minutes). Right before the unannounced inspection, individual #1 spilled coffee on the carpet and staff did not get a chance to utilize the carpet shampooer yet (one was purchased for the 3 ParklandView apartments- it stays at J9 where it is used the most frequently but A9 and L9 staff or Residential Coordinator pick it up too to utilize for carpet cleaning). After inspection, the carpets were cleaned and the stain removed. 02/26/2022 Implemented
SIN-00195158 Unannounced Monitoring 10/26/2021 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individual #6 is not safe with poisons according to the Individual Support Plan. Softsoap Antibacterial Crisp Clean was located at the kitchen sink. The label stated to call poison control if ingested.Poisonous materials shall be kept locked or made inaccessible to individuals. Poisonous materials should be kept locked and inaccessible to group home residents if the ISP(s) state that the individual (s) are unsafe to use, identify or be around poisonous materials. Individual #6 is not safe with poisons according to her ISP. Softsoap Antibacterial Crisp Clean was located at the kitchen sink during the time of the inspection. The label stated to call poison control. Due to individual #6¿s behavior of smearing feces on the wall, her urinary bag, incontinence, reluctance to maintain proper hygiene, as well as the COVID-19 pandemic-it is very important for staff to wash their hands frequently and for them to encourage individual #6 to as well. Staff unintentionally left an unsafe hand soap at the sink. *please see individual #6¿s ISP-pages 3-4 attached in Providence evidence email. Immediately after inspection, the residence was inspected in all rooms for items identified as possibly poisonous materials with ¿contact poison control¿ on the label. All items noted were removed and secured in locked cabinet or location secured by lock. 11/12/2021 Not Implemented
6400.77(b)The first aid kit in the home did not contain 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 in the home did not contain tape. Providence staff should have alerted the Group Home Medical Coordinator Kathy Rodriques that there was not medical tape left in the first aid kit (that it had all been used). 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 would have made sure the first aid kits had all supplies if staff forgot to report it. Immediately after the inspection, Providence purchased brand new first aid kits on 10/29 for all the group homes and distributed them to all the group homes. The old first aid kits were disposed of. *Please see attached photo of new first aid kits in Providence evidence email. 11/10/2021 Implemented
6400.144Individual #6 has a medication Haloperidol for anxiety to be given as needed. Individual #7 has medications Lorazepam 1 mg and Hydroxyzine HCL 50 mg for anxiety to be given as needed. The instructions for administration for both Individual #6 and Individual #7's as needed medications do not contain the symptoms of the mental, emotional, or behavioral conditions that would indicate there is a need for the staff to administer the medication. Providence Home Care has not ensured proper medical services have been 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 Home Care has not ensured proper medical services have been provided. Individual #6 has a medication Haloperidol for anxiety to be given PRN. Individual #7 has medications Lorazepam 1 mg and Hydroxyzine HCL 50 mg for anxiety to be given PRN. The instructions for administration for both Individual #6 and Individual #7¿s PRN medications do not contain the 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
6400.213(3)During the inspection on 10/26/21, the record at the home did not include the physical examinations for Individual #6 and Individual #7.Each individual's record must include the following information: Physical examinations. The most current copies of record information: Physical examination were not at the A9 group home at the time of the inspection and should be on site. During the inspection on 10/26/21, the record at the home did include the physical examinations for Individual #6 and Individual #7. Providence has not had a group home manager overseeing the group homes in Breinigsville, PA including the A9 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 copies of the physical examinations 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 A9 group home). 11/05/2021 Implemented
6400.163(h)Individual #7's medication QC Antacids expired 9/1/2021 and their pro re nata (PRN) medication Deep Sea expired 4/2021. Both medications have not been disposed of in a safe manner.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Prescription medications that are discontinued or expired should be destroyed in a safe manner according to federal and state regulations. Individual #7¿s medication QC Antacids expired 9/1/2021 and their pro re nata (PRN) medication Deep Sea expired 4/2021. Both medications have not been disposed of in a safe manner. Unknown for sure why both medications for individual #7 were at the location and destroyed properly. Staff may have relocated medications to one of several locked closets or cabinets and reorganizing it was put back in the box by a new staff member and oversight by management- Providence has not had a group home manager directly overseeing the Breinigsville group homes since May 2021. Immediately after inspection, both medications were removed and disposed of properly by Group Home Medical Coordinator Kathy Rodriques. 10/30/2021 Not Implemented
SIN-00164043 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 10/4/2019 (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
6400.141(c)(6)Individual #2 was admitted on 6/22/2019. She didn't have a TB test until 10/5/2019.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. Individual #2 did not have record of a tuberculin test in her medical binder being done before the test conducted on 10/5/19. This happened because the record was somehow misplaced after being received from her previous residential facility. Now the record of her other tuberculin test from her previous residential facility has been found, and the test was conducted in January of 2019, so that falls within the time period before she moved into Providence¿s residential facility. Moving forward, during move-in and transition into Providence¿s program, Medical Coordinator at Providence will be more careful with organizing all incoming medical records to ensure that no important documents such as the tuberculin test are misplaced or lost. No staff training necessary. 10/31/2019 Implemented
6400.181(e)(2)Dislikes were not assessed in Individual #2's assessment dated 6/25/2019.The assessment must include the following information: The likes, dislikes and interest of the individual. The ¿dislikes¿ was not included in the residential individual assessment. Program specialist made a mistake when completing the assessment form for the individual. On the assessment forms ¿dislikes¿ are mentioned so that Program Specialist includes them on the form, however, this component was somehow forgotten when the assessment was done. Program Specialist will be more careful and thorough when completing assessments and will double check assessment before placing in the individual¿s record so that no component is forgotten. No staff training necessary. 10/31/2019 Implemented
6400.181(e)(9)This area was not assessed in Individual #2's assessment dated 6/25/2019.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)The ability to regulate water temperature was not assessed in Individual #2's assessment dated 6/25/2019.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
SIN-00162524 Unannounced Monitoring 09/04/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)There was not an up-to-date property record for Individual #1.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. What happened? Individual #1 did not have an up to date financial record showing all transactions including how spending money and cash purchases are tracked. Why? Receipts for purchases for anything $15 or more (other than groceries) made using the Bento debit card were turned into the office; and all purchases including home basic groceries, toiletries, and miscellaneous items are all electronically logged using banking records, however, cash purchases made by Individual #1 using his spending money were not tracked. Individual #1 has been holding his cash in his wallet and not turning in receipts for cash purchases. Providence Financial Controller Alex Gearhart, Group Home Manager Denise Yuppa and Program Specialist Sigrid Hurdle were not aware that cash purchases including spending money he was carrying himself had to be officially tracked. What do we do right now? A ledger book has been placed at Group Home A9 and Individual #1 cash purchases have started being tracked. The ledger book is being utilized and Providence staff working with Individual #1 were all contacted by Group Home Manager Denise Yuppa and told about the new protocol and the importance of tracking his cash purchases. How do we prevent reoccurrence? Spending ledger books will be placed at all of the Providence group homes. There will be a book for each individual, and staff must be diligent with recording spending purchases and gathering receipts, including cash purchases. Denise Yuppa the Group Home Manager will check the ledger books every week for discrepancies and accuracy, will make a copy of the up to date ledger page, and will collect all receipts weekly and bring them to the office for proper filing. Any discrepancies discovered will be investigated. Who is responsible? Denise Yuppa the Group Home Manager, with oversight and supervision from Sigrid Hurdle and Alex Gearhart Staff will get a ¿Spending Money and Financial Records¿ training by October 31, 2019. 10/31/2019 Implemented
6400.22(e)(3)According to Individual #1's ISP, he "is unable to manage money. He has great difficulty with numbers and does not understand the value of money." There is no record of receipts over $15 for Individual #1's spending. He receives $150.00 each month that is broken down as follows: $40 for week 1 and week 2, and $35 for week 3 and week 4. Both Individual #1 and his staff report he is given the total amount to put in his wallet each week. Individual #1 stated "I don't keep receipts." The home is responsible for individual funds as Individual #1 does not have the skills necessary to manage his finances. The home does not keep an accurate expense record of purchases for Individual #1. 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. What Happened? Individual #1 has been carrying his spending money (cash) on him in his wallet and his ISP states that he is unable to manage his own funds. Why? Providence Home Care allowed Individual #1 to carry his own spending cash because under regulations Providence did not want to restrict his rights to his own property/belongings. By his mother being his Rep-payee, Alex Gearhart our Financial Controller monitoring all Bento card purchases, Denise Yuppa collecting all receipts for anything purchased with the Bento card non-groceries over $15, and the office giving him his allotted spending cash his mother sends weekly, Providence was under the impression that we were managing his funds properly and at the same time not restricting his rights to his own property by allowing him to hold his spending cash. What do we do right now? Financial Controller Alex Gearheart made the decision to open an individual bank account for Individual #1 through Key Bank and have the spending cash that his mother sends weekly deposited directly into that account so that no cash has to be tracked. All group home individuals will have a bank account with Key Bank which will allow Alex Gearhart to deposit spending money for each individual onto. Alex has already opened the accounts for every individual. Providence is just waiting for all of the debit cards to arrive by the beginning of October. This way all purchases will automatically be electronically tracked. The ledger books will still be kept at the group homes because some individuals randomly receive cash from their parents/other family members when they go home to visit them or when they are picked up for an outing. Therefore some cash flow will still be present and will have to be tracked with the ledger books. How Do We prevent Reoccurence? All group home individuals will have their own bank account for their spending money and this will further clean up the tracking and recording issues. Also, all spending cards will be locked up either in the medication boxes or in a separate lock box in a locked cabinet at every group home just like we do not with the Bento cards. This will ensure that Alex Krakowski is following the protocol in his ISP that he is unable to manage his own funds because he will no longer be carrying any spending money of his own in any form. When staff take him out in the community, the staff person will take the spending card out of the locked location and will carry it so that Individual #1 can use the money while out in the community if he needs or wants to, then upon return to the home the card will be locked back up. This process will be followed with all of the group home individuals at every home to maintain consistency and to set a standard. Who is responsible? Alex Gearhart, Denise Yuppa Staff will get a ¿Spending Money and Financial Records¿ training by October 31, 2019. 10/31/2019 Implemented
6400.64(a)There were black & brown stains all over the carpeting throughout the unit. The majority of the stains were in Individual #1's bedroom. There were also sticky brown splashes on the walls in Individual #1's bedroom.Clean and sanitary conditions shall be maintained in the home. What happened? The carpet was dirty with stains at Group Home A9. Also the walls had brown splash marks in Individual #1's bedroom. Why? The carpet was in need of replacement and the maintenance department at the apartment complex was not contacted by staff. The walls were stained from the individual who previously lived in that bedroom, and had not been cleaned yet. Individual #1 had just recently moved back to A9. How to prevent reoccurrence? Providence Home Care replaced all of the carpet at Group Home A9, and now there are no stains on the carpets at the home. Also, the walls in the bedroom were painted so no splash marks are there anymore. Group Home manager Denise will be more diligent with checking walls and carpets for stains and scheduling cleanings. Who is responsible? Denise Yuppa No training necessary for this violation. 09/15/2019 Implemented
6400.66The only light source in Individual #1's bedroom is a lamp. It wasn't working at the time of this monitoring and Individual #1reported it was not working the previous day, as well.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. What happened? The lamp light would not turn on in Individual #1's bedroom. Why? The lamp was either broken or the bulb was old or broken. How to prevent reoccurrence? Replace lightbulbs and fixtures regularly. Individual #1's lamp will be tested again with another bulb, and if necessary a brand new lamp will be purchased. What are we doing now? Individual #1 now has a functioning, lighting lamp in his bedroom. Who is responsible? Denise Yuppa No training necessary for this violation. 09/25/2019 Implemented
6400.67(a)The cream dresser in Individual #1's bedroom had 2 broken handles on the drawers. The sectional leather couch in the living area appeared to be dry rotting and was torn in several places.Floors, walls, ceilings and other surfaces shall be in good repair. What happened? Individual #1's dresser in his bedroom had 2 broken handles and the couch in the living room appeared to be in bad condition. Why? Individual #1 loves his dresser and wants to keep it but he ripped off the handles. The couch in the living room has been there for awhile and apparently has become too worn. What to do to prevent reoccurrence? Individual #1;s dresser handles have been repaired. A new couch is being purchased and will be placed in the living room by the beginning of October. Who is responsible? Denise Yuppa No staff training necessary. 10/08/2019 Implemented
6400.67(b)The carpet was frayed at the edge going into the kitchen, which poses a tripping hazard. Individual #1 is diagnosed with Cerebral Palsy and utilizes a cane for strength and balance. Floors, walls, ceilings and other surfaces shall be free of hazards.What happened? The carpet was frayed on the edge where the living room meets the kitchen at Group Home A9. Why? The carpet was in need of replacement and the maintenance department at the apartment complex was not contacted by staff. How to prevent reoccurrence? Providence Home Care replaced all of the carpet at Group Home A9, and now there is no trip hazard at the home for Individual #1 or any other individuals. 09/15/2019 Implemented
6400.81(k)(6)Individual #1 does not have a mirror in his bedroom.In bedrooms, each individual shall have the following: A mirror. What happened? There was no mirror in Individual #1's bedroom at the A9 Group Home. Why? There was no mirror in the room because Individual #1 had just recently moved back to the A9 Group Home and the individual previously living in that room did not like mirrors. The violation occurred because during the transition of Individual #1 moving back to A9, our Group Home Manager did not immediately put a mirror in the bedroom; it had not been purchased and put there yet. As previously stated, the previous individual staying in that bedroom strongly disliked mirrors so it was taken down and a new one had not been purchased yet. What do we do right now? A new mirror has been purchased for Individual #1s bedroom at A9. This mirror has been placed on the outside of his closet door. How do we prevent reoccurrence? The mirror purchased is actually completely flat and sticky. This mirror is stuck firmly to the closet door using strong ¿gorilla¿ adhesive, and since it is completely thin and flat like a sticker, it is nearly impossible for any individual moving forward to remove it from the bedroom moving forward. These mirrors are and will be utilized in other group homes that have individuals who do not like mirrors or who are prone to throwing/breaking objects or may be likely to remove the mirror. All other bedrooms at all homes have been checked and have mirrors. Who is responsible? Denise Yuppa the Group Home Manager, with oversight and supervision from Sigrid Hurdle No staff training necessary for this violation. 09/25/2019 Implemented
6400.32(c)From 1/2018-8/2019, Individual #1 was paying too much in Room & Board. From 1/2018-3/2019, he was paying $768.98 when the amount should have been $540.45. In April and May of 2019, he was paying $801.96 and from June to August of 2019 he was paying $844.49. From April to August, the amount should have been $555.12. The total amount of overpayment was $4788.08. Individual #1 was neglected as Providence Home Health continued to receive overpayments but did not utilize the extra amount to the benefit of Individual #1.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.What happened? Individual #1 s mother overpaid Providence Home Care for Individual #1 stay in our 6400 group home program. Why? Alex Gearhart the Financial Controller was not aware initially of the overpayment until it was discovered that the amount of money that Individual #1 was receiving from the government, state, insurance, deceased father¿s SSD etc. (which was all going straight to his mother was incorrect. His mother provided false information (whether intentional or unintentionally) to Providence from the day he moved in, and she is his rep-payee. Denise Yuppa the Group Home Manager discovered that his mother was actually overpaying Providence, so Alex Gearhart spent a significant amount of time calculating and correcting the discrepancies and once rectified, sent his mother full reimbursement of the total overpayment. How Do We Prevent Reoccurence? his mother has been refunded and the appropriate amount that she is supposed to send has been adjusted so moving forward this will not happen again. She was sent the check on 8/30/19 and cashed it on 9/13/19. Who is Responsible? Alex Gearhart No Staff training necessary for this violation. 09/13/2019 Implemented
6400.32(i)Individual #1's rights were violated in that he didn't have the right of access to his video games. In the Consequence Strategies section for decreasing inappropriate behavior in his Behavior Support Plan, it states "Remove preferred activities/choices until appropriate behavior is displayed." Individual #1 stated that staff removed the cords to his Play Station 4 so he couldn't play his games when he refused his hygiene tasks.An individual has the right of access to and security of the individual's possessions.What happened? Individual #1 Behavioral Support Plan described strategies that were interpreted as possible rights violations. Why? Another agency provided BSS services for Individual #1 for several years, and the BSP that was on the ISP was created and written by Diana Swavely from Opportunity Behavioral Health. Individual #1 transferred his BSS services completely over to Providence officially at the end of July and we started the beginning of August working on all of the hours. Stella Omwega the BSS assigned to take over all the hours, needed to spend a few weeks collecting data, and spend more time with Individual #1 and staff in order to put together a brand new-revamped BSP. The new BSP had not been put into HCSIS yet. What do we do right now? As of this week, Stella Omwega has completed the new BSP for Individual #1 , and she will be working with his residential and CS staff to help him achieve goals and implement the most effective behavioral support strategies to help him. How do we prevent reoccurrence? Stella will follow his ISP and BSP and will hold regular trainings with staff to help them implement strategies so Individual #1 can achieve goals and progress. His BSP that Stella created was reviewed by our Director of Behavioral Therapy Elizabeth O¿Connor, and for every other individual that we provide BSS services for, the BSPs will be turned in by each BSS then reviewed and checked for any violations or unnecessary/inappropriate ideas by Elizabeth O¿Connor before submission into HCSIS and approval. Who is responsible? Elizabeth O¿Connor Staff will get monthly behavioral trainings from Stella Omwega regarding Alex Krakowski and his goals/behavioral strategies by October 31, 2019 10/31/2019 Implemented
6400.195(a)Individual #1's Behavior Plan in his ISP states that it is not restrictive. However, in the Consequence Strategies section for decreasing inappropriate behavior, it states "Remove preferred activities/choices until appropriate behavior is displayed." Individual #1 stated that staff have removed the cords to his Play Station 4 so he couldn't play his games until he completed hygiene tasks.For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures.What happened? Removing preferred activities/choices to induce appropriate behavior in the ISP was a strategy developed by BSS Diana Swavely from OBH. Providence has no knowledge about if OBH utilized a human rights team as part of the development and review prior to use of that procedure. Why? Providence Home Care residential staff followed the guidance of Diana during the time that she was providing the service and training Providence Residential staff. How to prevent reoccurrence? Providence BSS Stella Omwega is now on the ISP and has taken on all of the BSS hours. She spent several weeks collecting data, spending time with staff, and working closely with Alex to develop a new BSP without any restrictions. Moving forward, all BSPs will be reviewed and approved by Director of Behavioral Therapy Elizabeth O'Connor prior to submission into HCSIS. Who is responsible? Stella Omwega, Elizabeth O'Connor Staff will receive regular training from Stella Omwega on Alex's goals. 10/31/2019 Implemented
6400.210(a)Funds/property may not be used as a reward or punishment. Staff removed cords to the Playstation 4 of Individual #1 in order to restrict Individual #1 from using the game console when Individual #1 would refuse to perform hygiene tasks.Access to or the use of an individual's personal funds or property may not be used as a reward or punishment.What happened? Funds/property may not be used as rewards or punishment. There were allegations that staff used this technique (as directed by BSS Diana Swavely from OBH as per the BSP she wrote) to encourageIndividual #1 to complete hygiene tasks. Why? Staff were unaware initially that this was inappropriate but came to Administrator Heather Say and reported what they were being instructed to do by the BSS and felt that it was wrong. What is being done about it now? All staff working at the group home were interviewed, an official training was held, and staff were instructed not to reward or punish Individual #1 in any way to get him to accomplish tasks. They also were instructed that this must be followed when working with any individual in the 6400 group home program. How to prevent reoccurrence? Stella Omwega updated the BSP from Diana Swavely's after tracking data for a few weeks and spending time with Individual #1 and staff. She updated the BSP in mid-September 2019. The new BSP will be implemented by Stella and she will be training staff regularly (once per month) 10/31/2019 Implemented
SIN-00143546 Renewal 10/11/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment 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
6400.67(a)There was a broken mini-blind on a window in the living room.Floors, walls, ceilings and other surfaces shall be in good repair. Liz O¿Connor will perform the maintenance needed to bring the home up to code. Liz will ensure that she purchases a new set of mini-blinds for the window in the living room so that the broken mini-blinds will be removed. To ensure compliance in the future, Jude Felix will regularly check all blinds in all group homes for damage or breakage and will alert Liz immediately if he notices anything not up to code. No staff training necessary for this correction. This correction will be implemented as of January 1, 2019. 01/01/2019 Implemented
6400.112(e)The fire drills held between the months of October 2017 through September 2018 were all held during waking hours.A 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 was 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-00125931 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 completed.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 #1.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 #1. 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
6400.68(b)The water temp in this residence was 136.6, which exceeds the requirement by 16.6 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. Hot water temperature was adjusted down to a regulatory permissible temperature on 11/14/17. House Managers are responsible and supervises staff to ensure measure water temperature is measured at the beginning of their shift and document the result in a Safety Inspection Checklist Log. If on staff check, the water temperature exceeds 120F, staff will notify House Manager immediately to enable maintenance effect an immediate adjustment or resolution to the problem. House Managers will do monthly water temperature checks, ensuring the water temperature remains below 120 degrees. 11/14/2017 Implemented
6400.77(b)There was no thermometer in the First Aid Kit. 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 and also every month during fire drills. ((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(a)Individual #1 was admitted on 3/1/2017. There is no physical exam in his record.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Physical exams for individual#1 was completed on 12/18/17. A new appointment for the individual #2 and 3 have been set on 1/03/18 at 10:40 am and on 02/05/18 at 9:00 am for physical exams. 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. A tracking sheet has also been created to prevent future occurrences. 12/18/2017 Implemented
6400.151(a)Staff #1 was hired on 2/7/2017. As of the date of this inspection, a physical exam had not been completed. 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#2's physical exams appointment was completed on 11/15/17. Staff#3's physical exam was completed on 10/14/17, it was shown to the auditor at the time of inspection. Human Resource Personnel will ensure that a new hire is not staffed in an individual's home prior to completing a physical. Moving Forward, HR will utilize a pre-employment checklist to ensure that prospective employees have all required documentation including a physical examination within 12 months prior to employment and annually thereafter. Physicals 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. 10/14/2017 Implemented
6400.151(c)(2)Staff #1 was hired on 2/7/2017. There is no current TB test on record. His last TB test was done on 6/3/2014. 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. Staff#1's TB test was completed on 11/16/17 whiles awaiting physical exams to be completed by a physician on 12/29/17. Human Resource Personnel will ensure that a new hire is not staffed in an individual's home prior to completing a physical. Moving Forward, HR will utilize a pre-employment checklist to ensure that prospective employees have all required documentation including a physical examination within 12 months prior to employment and annually thereafter. Physicals 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. 11/16/2017 Implemented
6400.163(c)Individual #1 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 #1 was admitted on 3/1/2017. An assessment hasn't been completed yet. ((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
6400.184(b)Individual #1's plan year ended on 7/28/2017. At the time of this inspection, an ISP meeting with team members hasn't been held. 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 #1 was admitted on 3/1/2017. Since his admission, 3 month ISP Reviews have not been completed.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)Social Security Number, race, identifying marks, and religious affiliation are not listed in Individual #1'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
6400.213(9)Individual #1 didn't have a copy of his current ISP in his record. The plan year of the ISP in his file ended 7/28/2017. Each individual's record must include the following information: A copy of the current ISP. Individual¿s ISP has been updated with his current ISP, moving forward Programs Special will review individual charts weekly to ensure there is an updated ISP in individual records. Programs specialist will be responsible to ensure continuous compliance. 11/15/2017 Implemented
SIN-00208209 Renewal 07/18/2022 Compliant - Finalized
SIN-00205757 Unannounced Monitoring 05/26/2022 Compliant - Finalized
SIN-00202828 Unannounced Monitoring 03/14/2022 Compliant - Finalized
SIN-00103382 Initial review 11/15/2016 Compliant - Finalized