| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
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SIN-00232298
|
Unannounced Monitoring
|
10/02/2023
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(2) | Individual #6's bed set lacked a bed frame. The individual's mattress and box-spring were placed directly on top of the floor without the support of a frame. | In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. | On October 3 rd the bed frame was reassembled and placed back together along with the box
spring in compliance to regulations. |
11/15/2023
| Implemented |
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SIN-00230301
|
Unannounced Monitoring
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08/31/2023
|
Compliant - Finalized
|
|
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The carpeting in the home (bedrooms, dining area and living room) was heavily soiled. (Repeat Violation 1/10/23) | Clean and sanitary conditions shall be maintained in the home. | WHAT HAPPENED AND WHY?: 6400.64(a) VIOLATION DESCRIPTION: The carpeting in the home (bedrooms, dining area and living room) was heavily soiled. (Repeat Violation 1/10/23) Clean and sanitary conditions shall be maintained in the homes. Staff and individuals wear shoes in the home, and the carpet is a light color which soils easily. Management staff had not yet completed the regular carpet cleaning with the carpet shampooer by the day of the unannounced inspection.
WHAT ARE WE DOING NOW? Field Supervisor utilized the new industrial carpet shampooer to shampoo the carpets in the bedrooms, dining room and living room thoroughly immediately after inspection. |
10/31/2023
| 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. | 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 |
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|
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SIN-00217636
|
Renewal
|
01/10/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | Fire drills documented as being completed in 2022 did not provide an area for entry and documentation of any problems that may have been encountered during the fire drills. Documentation of any problems that may be encountered during a drill is required. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Fire drills documented as being completed in 2022 did not provide an area for entry and documentation of any problems that may have been encountered during the fire drills. Documentation of any problems that may be encountered during a drill is required.
Providence did not realize that the fire drill log needed to contain a specific section for the problems encountered during the fire drill. Therefore, it was not specifically noted at the top of the logs.
Since the inspection, Program Specialist updated the Residential Fire Drill Logs at all the homes to contain the section for any problems encountered during the drill-including examples to make it easier for staff. |
02/10/2023
| Implemented |
| 6400.112(e) | One sleep drill was documented as being conducted in 2022 on 8/12/22 at 2:00am. No other asleep fire drills were documented as being conducted every six months as required. | A fire drill shall be held during sleeping hours at least every 6 months. | At the time of inspection, it was discovered that one sleep drill was documented as being conducted in 2022 on 8/12/22 at 2:00am. No other asleep fire drills were documented as being conducted every six months as required.
Providence staff lacked management staff to maintain proper fire drill oversight of the overnight drills conducted by staff during 2022 to ensure they were conducted during sleep hours every 6 months at L9. Since the inspection, Providence has a new Residential Coordinator Assistant who is in every group home 5-7 days per week to provide oversight and to maintain compliance. |
02/10/2023
| Implemented |
| 6400.112(f) | All fire drills conducted in 2022 indicated that the "Back" exit of the home had been used during the drills. An additional exit through the kitchen at the front of the home is available for evacuation. Alternate exits shall be used during fire drills. | Alternate exit routes shall be used during fire drills. | At the time of inspection, it was observed in the fire log that all fire drills conducted in 2022 indicated that the "Back" exit of the home had been used during the drills. An additional exit through the kitchen at the front of the home is available for evacuation. Alternate exits shall be used during fire drills.
Providence staff lacked management staff to maintain proper fire drill oversight of the exit routes during drills, conducted by staff during 2022 to ensure they were conducted at alternating exits at L9. Since the inspection, Providence has a new Residential Coordinator Assistant who is in every group home 5-7 days per week to provide oversight and to maintain compliance. |
02/10/2023
| Implemented |
| 6400.112(h) | Fire drills documented as being completed in 2022 did not indicate that individuals evacuated to the designated meeting place outside of the home. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | During the inspection, Fire drills documented as being completed in 2022 did not indicate that individuals evacuated to the designated meeting place outside of the home.
Documentation of whether or not the individuals met at the designated meeting place outside the home was not something that Providence realized needed to be specifically documented on the fire drill log. The evacuation designated meeting places are posted in the homes and reviewed during fire training.
Since the inspection, Program Specialist updated the Residential Fire Drill Logs at all the homes to contain the section for whether or not the individuals evacuated to the designated meeting place |
02/10/2023
| Implemented |
| 6400.113(a) | Individual #2 has an admission date of 8/15/22. Fire Safety Training is documented as occurring on 9/14/22. Fire Safety Training is to be conducted upon admission. | 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. | At the time of inspection, it was discovered that Individual #2 has an admission date of 8/15/22. Fire Safety Training is documented as occurring on 9/14/22. Fire Safety Training is to be conducted upon admission.
Program Specialist and Residential Coordinator are now aware since the inspection that this is too many days after admission for the drill and is out of compliance. |
02/10/2023
| Implemented |
| 6400.141(a) | Individual #2 has a documented admission date of 8/15/22. A physical examination was not completed prior to their admission. Documentation that an initial appointment occurred on 9/8/22 for Individual #2. The appointment details submitted did not include completion of all regulatory items. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #2 has a documented admission date of 8/15/22. A physical examination was not completed prior to their admission. Documentation that an initial appointment occurred on 9/8/22 for Individual #2. The appointment details submitted did not include completion of all regulatory items.
Providence accepted individual #2 into the program without receiving the physical examination during the transition period and admission process. Providence accepted individual #2 without this information prior. |
02/10/2023
| Implemented |
| 6400.181(a) | Individual #2 has a documented admission date of 8/15/22. An assessment with a completion date of "12/19/23" was presented. Assessment timeframe extends beyond the 60 calendar days after admission. No other assessments were presented. | 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. | During the time of inspection, Individual #2 has a documented admission date of 8/15/22. An assessment with a completion date of "12/19/23¿ was presented. Assessment timeframe extends beyond the 60 calendar days after admission. No other assessments were presented.
The assessment was conducted on 12/19/2022, but the Program Specialist made a writing error due to the new year coming up around the corner. However, the assessment was out of the assessment time frame. Program Specialist thought the window of time to complete the initial assessment was longer than reality; individual #2 was also still under Respite leading the Program Specialist to believe that the window of time was not existent as described. |
02/10/2023
| Implemented |
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|
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SIN-00200452
|
Unannounced Monitoring
|
02/17/2022
|
Compliant - Finalized
|
|
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The back door located in the living room, had approximately 3 broken blinds and at least 4 other blinds were bent on the window. Surfaces shall be in good repair. | Floors, walls, ceilings and other surfaces shall be in good repair. | During the inspection, the back door located in the living room, had approximately 3 broken blinds and at least 4 other blinds were bent on the window. Surfaces shall be in good repair (67a).
After inspection, Residential Coordinator and Program Specialist purchased new blinds from Walmart for L9 and had them installed by the Providence contractor instead of waiting for maintenance at the apartment to install new blinds (please see evidence email photo).
This happened due to heavy use of the back door to enter and exit the home on a daily basis, and the blinds just happened to break down right before the inspector arrived for the unannounced inspection. The window in the living room has 2 layers of privacy- has curtains and blinds. The blinds on the window were fixed. |
02/26/2022
| Implemented |
| 6400.163(h) | Individual #1's EarWax treatment 6.5% drops was discontinued on 2/6/22, and their Hydrocortisone 2.5% ointment was discontinued on 2/13/22. Both medications remained with the individual's medications and was not disposed of properly. (Repeat violation 10/26/21) | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Upon the unannounced inspection, it was discovered that individual #1's EarWax treatment 6.5% drops was discontinued on 2/6/22, and their Hydrocortisone 2.5% ointment was discontinued on 2/13/22. Both medications remained with the individual's medications and was not disposed of properly. (Repeat violation 10/26/21). Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations (163h).
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 (upon inspection on 2/17 there were 2 discontinued medications still in the box for individual #1- the next medication box check had not been completed when the inspection occurred so the medications were still in the box).
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 |
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SIN-00199338
|
Unannounced Monitoring
|
01/07/2022
|
Non Compliant - Finalized
|
|
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Clean and sanitary conditions are not being maintained in the home. Individual #2's bedroom carpet has a large brown stain located next to the Individual's bed. | Clean and sanitary conditions shall be maintained in the home. | Clean and sanitary conditions are not being maintained in the home. Individual #2's bedroom carpet has a large brown stain located next to the Individual's bed. Clean and sanitary conditions shall be maintained in the home (64a).
Individual #2 consumes coffee, energy drinks and soda. 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). Individual #2 may have spilled 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 to utilize for carpet cleaning).
After inspection, the carpets were cleaned, and the stain removed. |
02/26/2022
| Implemented |
| 6400.214(a) | There is no record for Individuals #1, #2 and #3 located in the home containing the following information: name, sex, admission date, birth date, social security number, race, height, weight, color of hair, eye color, identifying marks, the language or means of communication spoken or understood by the individual, primary language spoken in the home if other than English, the religious affiliation, the next of kin, and a current dated photograph.(Repeat Violation 10/26/21) | Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home. | During the inspection, it was discovered that there is no record for Individuals #1, #2 and #3 located in the home containing the following information: name, sex, admission date, birth date, social security number, race, height, weight, color of hair, eye color, identifying marks, the language or means of communication spoken or understood by the individual, primary language spoken in the home if other than English, the religious affiliation, the next of kin, and a current dated photograph (214a).
Providence did not realize that the individuals¿ face sheets needed to be at the home. All information requested has always been on the face sheets in the individuals¿ files at the Providence office and is regularly and annually updated for current information and photograph.
After inspection, Providence made copies of the Face Sheets from the office and placed at the home in the ISP/BSP binders. |
01/14/2022
| Implemented |
| 6400.214(b) | The most current copies of record information for Individual #1, #2 and #3 including incident reports relating to the individual(s), dental examinations, dental hygiene plans, annual assessments and copies of psychological evaluations, if applicable, were not maintained and available in the residential home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| During the inspection, it was discovered that the most current copies of record information for Individual #1, #2 and #3 including incident reports relating to the individual(s), dental examinations, dental hygiene plans, annual assessments and copies of psychological evaluations, if applicable, were not maintained and available in the residential home. The most current copies of record information required in § 6400.213(2)(14) shall be kept at the residential home.
Providence did not realize that the individuals¿ face psych evaluations and incident reports needed to be at the home. All information requested (assessments, dental hygiene plans, dental exams, annual assessments were placed at the home after the unannounced inspection in November 2021. However, those documents must have been removed or misplaced.
Now that Providence is aware, Providence made copies of the incident reports relating to the individual(s), dental examinations, dental hygiene plans, annual assessments and copies of psychological evaluations from the office and placed at the home in the ISP/BSP binders. |
01/14/2022
| Implemented |
| 6400.165(c) | Individual #1 is prescribed Lisinopril 10mg. tablet, take 1 tablet by mouth daily at 8am; Cetirizine HCL 10mg. tablet, take 1 tablet by mouth daily at 8am; and Omeprazole DR 20mg. capsule, take 1 capsule by mouth daily at 7am. These medications were not administered as prescribed on 1/07/2022. The medication was documented on the Medication Administration Record (MAR) as administered, however the medication remained in the blister pack. Individual #3 is prescribed Metformin HCL 100mg. tablet, take 1 tablet by mouth 2 twice per day at 8am and 8pm. This medication was not administered as prescribed on 1/06/2022 at 8pm. The medication was documented on the MAR as being administered at prescribed, however the medication for this date and time remained in the blister pack. Individual #2 is prescribed Divalproex Sod ER 500mg. tablet, take 2 tablets (1000mg.) by mouth once daily at 8pm. This medication was not administered as prescribed on 1/06/2022. The medication was documented on the MAR as administered, however the medication for this date and time remained in the blister pack. Individual #2 is prescribed Levothyroxine 50mg. tablet, take 1 tablet by mouth once daily at 8am; Loratadine 10mg. tablet, take 1 tablet by mouth once daily at 8am; Minocycline 100mg. capsule, take 1 capsule by mouth once daily at 8am; and Omeprazole DR 40mg. capsule, take 1 capsule by mouth daily at 7am. These medications were documented on the MAR as being administered on 1/07/2022, however the medications remained in the blister pack. Individual #3 is prescribed Citalopram HBR 20mg. tablet, take 1 tablet by mouth daily at 8am. This medication was documented on the MAR as administered on 1/07/2022, however the medication remained in the blister pack. (Repeat Violation 10/8/21, 10/26/21) | A prescription medication shall be administered as prescribed. | During the unannounced inspections, Individual #1 is prescribed Lisinopril 10mg. tablet, take 1 tablet by mouth daily at 8am; Cetirizine HCL 10mg. tablet, take 1 tablet by mouth daily at 8am; and Omeprazole DR 20mg. capsule, take 1 capsule by mouth daily at 7am. These medications were not administered as prescribed on 1/07/2022. The medication was documented on the Medication Administration Record (MAR) as administered, however the medication remained in the blister pack. Individual #3 is prescribed Metformin HCL 100mg. tablet, take 1 tablet by mouth 2 twice per day at 8am and 8pm. This medication was not administered as prescribed on 1/06/2022 at 8pm. The medication was documented on the MAR as being administered at prescribed, however the medication for this date and time remained in the blister pack. Individual #2 is prescribed Divalproex Sod ER 500mg. tablet, take 2 tablets (1000mg.) by mouth once daily at 8pm. This medication was not administered as prescribed on 1/06/2022. The medication was documented on the MAR as administered, however the medication for this date and time remained in the blister pack. Individual #2 is prescribed Levothyroxine 50mg. tablet, take 1 tablet by mouth once daily at 8am; Loratadine 10mg. tablet, take 1 tablet by mouth once daily at 8am; Minocycline 100mg. capsule, take 1 capsule by mouth once daily at 8am; and Omeprazole DR 40mg. capsule, take 1 capsule by mouth daily at 7am. These medications were documented on the MAR as being administered on 1/07/2022, however the medications remained in the blister pack. Individual #3 is prescribed Citalopram HBR 20mg. tablet, take 1 tablet by mouth daily at 8am. This medication was documented on the MAR as administered on 1/07/2022, however the medication remained in the blister pack. A prescription medication shall be administered as prescribed (165c).
Pharmaceutical Nurse Educator/RN spoke with the staff that was on shift that day and was information that although the pills for the day we inquired about to determine whether the medication was administered. It appears that the medication was administered, but the staff that administered the medication was not yet trained on marking and popping for the days that correspond with the current date. |
02/11/2022
| Not Implemented |
| 6400.166(a)(13) | Individual #2 is prescribed Gabapentin 100mg. capsule, take 1 capsule by mouth 2x daily at 8am and 8pm; Levothyroxine 50mcg. tablet, take 1 tablet by mouth once daily at 8pm; Loratadine 10mg. tablet, take 1 tablet by mouth once daily at 9am; Minocycline 100mg. capsule, take 1 capsule by mouth once daily at 8am; Omeprazole DR 40mg. capsule, take 1 capsule by mouth daily at 7am; and Topiramate 25mg. tablet, take 1 tablet by mouth 2x daily at 8am and 8pm. These medications were not documented as administered on the Medication Administration Record (MAR) on 1/10/2022. Individual #3 is prescribed Benzoyl Peroxide 10% wash, use on face, chest and back once daily at 8am; Citalopram HBR 20mg tablet, take 1 tablet by mouth at 8am; Clindamycin Phos 1% lotion, apply topically to affected areas on face, chest, abdomen and back once daily at 8am; Ketoconazole 2% cream, apply to face 2 times daily at 8am and 8pm; Methylphenidate ER 27mg. tab, take 1 tablet by mouth daily; Naltrexone 50mg. tablet, take 1 tablet by mouth once daily at 8am; and Omeprazole DR 40mg capsule, take 1 capsule by mouth daily at 8am. These medications were not documented as administered on the MAR at 8am on 1/10/2022. (Repeat Violation 10/26/21) | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Upon inspection, it was discovered that Individual #2 is prescribed Gabapentin 100mg. capsule, take 1 capsule by mouth 2x daily at 8am and 8pm; Levothyroxine 50mcg. tablet, take 1 tablet by mouth once daily at 8pm; Loratadine 10mg. tablet, take 1 tablet by mouth once daily at 9am; Minocycline 100mg. capsule, take 1 capsule by mouth once daily at 8am; Omeprazole DR 40mg. capsule, take 1 capsule by mouth daily at 7am; and Topiramate 25mg. tablet, take 1 tablet by mouth 2x daily at 8am and 8pm. These medications were not documented as administered on the Medication Administration Record (MAR) on 1/10/2022. Individual #3 is prescribed Benzoyl Peroxide 10% wash, use on face, chest and back once daily at 8am; Citalopram HBR 20mg tablet, take a tablet by mouth at 8am; Clindamycin Phos 1% lotion, apply topically to affected areas on face, chest, abdomen and back once daily at 8am; Ketoconazole 2% cream, apply to face 2 times daily at 8am and 8pm; Methylphenidate ER 27mg. tab, take 1 tablet by mouth daily; Naltrexone 50mg. tablet, take 1 tablet by mouth once daily at 8am; and Omeprazole DR 40mg capsule, take 1 capsule by mouth daily at 8am. These medications were not documented as administered on the MAR at 8am on 1/10/2022 (166a13).
Pharmaceutical Nurse Educator/RN double checked what happened immediately after inspection. MAR attached (*see evidence email) showing that medication was indeed administered. |
01/11/2022
| Implemented |
|
|
|
SIN-00195161
|
Unannounced Monitoring
|
10/26/2021
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1, Individual #2 and Individual #3 have had their medical needs neglected. Individual #1, Individual #2 and Individual #3 are not receiving medications as prescribed as medications are not consistently in the home or refilled in a timely manner. Individual #1, Individual #2 and Individual #3's medications are not administered consistently as staff are not properly trained in medication administration management and when a properly trained staff is unavailable, individuals meds are not administered. ((repeat violation 10/8/2021)) | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Individual #1, Individual #2 and Individual #3 have had their medical needs neglected. Abuse of an individual is prohibited. Medications were not administered consistently¿repeat violation.
Immediately after unannounced inspection, Incident reports completed in EIM by Elizabeth Temprovich, which will include certified investigations by Providence contracted CI- Abdul Bundu, and physicians were contacted and informed of medication errors. |
11/30/2021
| Not Implemented |
| 6400.76(a) | Individual #2 has a broken bed frame that is located in the closet in his bedroom. | Furniture and equipment shall be nonhazardous, clean and sturdy. | All furniture and equipment should be non-hazardous, clean, and sturdy. Individual #2 had a broken bed frame that is in the closet in his bedroom upon inspection.
Individual #2 had the bed frame for a long-time because the bed was good quality and sturdy; the bed frame recently became broken due to long-term use (he was due for a new bed-Providence was in the process of acquiring a new frame- it was reported by individual #2 and his roommate individual #1 that he needed a new one).
Immediately after inspection, Providence had the new bed frame delivered and set up from Individual #2. *Please see attached photos in Providence evidence email. |
10/30/2021
| Not Implemented |
| 6400.77(b) | The home did not have a functioning 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. | All first aid kits must have a functioning thermometer. The home did not have a functioning thermometer. Providence staff should have alerted the Group Home Medical Coordinator Kathy Rodriques that the thermometer in the first aid kit was no longer functioning and needed a new battery(ies). Providence has not had a group home manager overseeing the group homes in Breinigsville, PA including the L9 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 |
| 6400.144 | Individual #1 is prescribed Fluticasone Prop 50mcg Spray, use two sprays in each nostril daily at 8AM. The Medication Administration Record (MAR) indicates that this medication was suspended from 10/16/21 to 10/22/21. The medication was not available in the home. Individual #1 indicated the medication had not been available for at least two weeks.Individual #2 is prescribed Methylphenidate ER 27mg Tab, 1 tablet by mouth daily at 8AM. This MAR indicates that this medication was suspended from 10/26/21 to 11/3/21, awaiting new RX. This medication is not available in the home. There are no physician orders to hold or stop the medications. The agency is not providing pharmaceutical services as prescriptions are not being refilled as needed. | 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.
| Pharmaceutical services and medications are not being filled as needed; no orders to hold or stop the medications from the physician. Individual #1 is prescribed Fluticasone Prop 50mcg Spray, use two sprays in each nostril daily at 8AM. The MAR indicates that this medication was suspended from 10/16/21 to 10/22/21. The medication was not available in the home. Individual #1 indicated the medication had not been available for at least two weeks. Individual #2 is prescribed Methylphenidate ER 27mg Tab, 1 tablet by mouth daily at 8AM. This MAR indicates that this medication was suspended from 10/26/21 to 11/3/21, awaiting new RX. This medication is not available in the 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 #1 and Individual #2¿s physicians were contacted and informed of the medication errors. |
11/05/2021
| Not Implemented |
| 6400.214(a) | Individual #1, Individual #2 and Individual #3 did not have a record maintained in the home. | Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home. | During inspection, individual #1, individual #2 and individual #3 did not have records maintained in the home- Providence failed to maintain proper record information in the L9 group home.
Providence has not had a group home manager overseeing the group homes in Breinigsville, PA including the L9 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 ISP/BSP and other required records for individual #1, individual #2 and individual #3 were unable to be found with ease by staff the day of the unannounced inspection.
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 sites (including L9 group home). |
11/05/2021
| Implemented |
| 6400.18(b)(2) | Individual #1 is prescribed Fluticasone Prop 50mcg Spray, use two sprays in each nostril daily at 8AM. The Medication Administration Record (MAR) indicates that this medication was suspended from 10/16/21 to 10/22/21. The medication was not available in the home. Individual #1 indicated the medication had not been available for at least two weeks however the medication was signed out as administered on 10/22/21, 10/23/21, 10/4/21 and 10/25/21. This medication error was not reported in the Enterprise Incident Management System (EIM) within 72 hours as required.
Individual #1 is prescribed Loratadine 10mg tablet, take 1 tablet by mouth once daily at 9AM. The medication was last filled on 8/1/21 with a 31-day supply. There are only 28 of the 31 pills removed from the blister pack since 8/1/21. It is unclear when the medication was missed as it is initialed as being administered on 10/1-10/9/21 and 10/12-10/16, 2021. The amount of medication remaining from the time of refill would indicate that the medication was not properly administered resulting in a medication error. This medication error was not reported in EIM within 72 hours are required.
Individual #1 is prescribed Levothyroxine 50mcg tablet, take I tablet by mouth once daily at 8AM. This medication was last filled on 8/1/21 with a 31-day supply. There are only 28 or the 31 pills removed from the blister pack since 8/1/21. It is unclear when the medication was missed as it is initialed as being administered on 10/1-9/21 and 10/12-10/16, 2021. The amount of medication remaining from the time of refill would indicate that the medication was not properly administered resulting in a mediation error. This medication error was not reported in EIM within 72 hours are required.
Individual #1 is prescribed Minocycline100mg capsule, take 1 capsule by mouth 1x daily at 8AM. This medication was last filled on 8/20/21 with a 30-day supply. There are only 26 pills removed from the blister pack since 8/30/21. It is unclear when the medication was missed as it is initialed as being administered on 10/1-9/21 and 10/12-10/16, 2021. The amount of medication remaining from the time of refill would indicate that the medication was not properly administered resulting in a medication error. This medication error was not reported in EIM within 72 hours as required.
Individual #1 is prescribed Mirtazapine 15mg Tablet, take 1 tablet by mouth daily at 8PM. This medication was last filled on 9/28/21 with a 30-day supply. There are only 14 pills removed from the blister pack since being refilled. There is documentation of medication refusal on 10/16/21 and 10/17/21. It is unclear when this medication was missed as it is initialed as being administer on 10/1/21, 10/5-10/9/21, 10/10-15/21, and 10/18-10/25/21. The amount of medication remaining from the time of refill would indicate that the medication was not properly administered resulting in a medication error. This medication error was not reported in EIM within 72 hours as required.
Individual #1 is prescribed Omeprazole DR 40mg capsule, take 1 capsule by mouth daily at 7AM. This medication was last filled on 9/18/21 with a 31-day supply. There are only 26 pills removed from the blister pack since being refilled. It is unclear when the medication was missed as it is initialed as being administered on 10/1-9/21 and 10/12-10/16, 2021. The amount of medication remaining from the time of refill would indicate that the medication was not properly administered resulting in a mediation error. This medication error was not reported in EIM within 72 hours as required.
Individual #1 is prescribed Loratadine 10mg tablet, take 1 tablet by mouth once daily at 9AM. This medication was last filled on 8/1/21 with a 31-day supply. There are only 28 of the 31 pills removed from the blister pack since 8/1/21. It is unclear when the medication was missed as it is initialed as being administered on 10/1-9/21 and 10/12-10/16, 2021. The amount of medication remaining from the time of refill would indicate that the medication was not properly administered resulting in a medication error. This medication error was not reported in EIM with 72 hours as required.
Individual #2, is prescribed Omeprazole Dr 40mg Capsule, take 1 capsule by mouth daily at 8AM. This medication was last filled on 9/17/21 with a 30-day supply. There is only 1 of the 30 pills removed from the blister pack since 9/17/21. There is a second blister pack that was filled on 9/17/21 with a 31-day supply. There are 21 of the 31 pills removed from the blister pack since 9/17/21. It is unclear when this medication was missed as it is initialed as being administered on 10/1/21-10/9/21 and 10/12/21-10/26. The amount of medication remaining in from the time of refill would indicate that the medication was not properly administered resulting in a medication error. This medication error was not reported in EIM within 72 hours as required.
Individual #2 is prescribed Doxycycline Hyclate 100mg Cap, take 1 cap by mouth 2x daily with food and water at 8AM and 8PM. This medication was last filled on 10/15/21 with a 30-day supply. There is only 1 of the 30 pills removed from the 8PM blister pack on 10/21/21. There is not blister pack for the 8AM dose available in the home. The MAR indicates that the medication has been administered both at 8AM and 8PM on 10/16/21-10/25/21 while the medication remains in the blister pack in the home. This medication error was not reported in EIM within 72 hours as required.
Individual #2 is prescribed Risperidone 1mg tablet, take 1 tablet by mouth daily at 8PM. This medication was filled on 10/1/21 with a 31-day supply. On 10/26/21, there had been 27 pills popped from the blister pack with 21 days initialed as administered on the Medication Administration Record. It is unknown when the medication error occurred. The medication error was not reported in EIM within 72 hours as required.
Individual #3 is prescribed Melatonin 3mg tablet, take 1 tablet by mouth at bedtime at 8PM. This medication was filled on 10/1/21 with a 31-day supply. On 10/26/21 there had been 28 pills popped from the blister pack with 21 days initialed as administered on the MAR. It is unknown when the medication error occurred. The medication error was not reported in EIM within 72 hours as required. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | Providence failed to report medication errors within 72 hours in EIM. Providence management was unaware of the medication errors at the time of inspection. 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 physicians were contacted and informed of medication errors. |
11/30/2021
| Implemented |
| 6400.51(b)(5) | Staff #1 was not trained in Job-related knowledge and skills. At the time of the inspection, Staff #1 did not know the names of the individuals who reside in the home. | The orientation must encompass the following areas: Job-related knowledge and skills. | The orientation must encompass the following areas: Job-related knowledge and skills. Staff #1 was not trained in Job-related knowledge and skills. At the time of the inspection, Staff #1 was unsure of the names of the individuals who reside in the home.
Providence staff are required to read the Policy and Procedures binder and the Onsite Orientation binder upon their first shifts at any Providence group homes for the first time. One of the policies in the Policy and Procedures binder is the ISP Policy explaining that staff must read all ISPs and sign that they understand them, and will complete corresponding progress notes addressing the goals in the individual¿s ISP. *Please see ISP Policy attached to Providence evidence email. |
11/10/2021
| Not Implemented |
| 6400.52(c)(6) | Staff #1, Staff #2, Staff #3, are not trained in Individual #1, Individual #2 and Individual #3's Individual Service Plans. Staff #1, Staff #2 and Staff #3 were unable to communicate whether or not individuals in the home were poison safe and safe with sharps.Staff #1, Staff #2 and Staff #3 are not trained in Individual #1. Individual #2 and Individual #3's behavioral support plans which is a part of the Individual Support Plan. | 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. | Staff #1, Staff #2, Staff #3, are not trained in Individual #1, Individual #2 and Individual #3¿s Individual Service Plans. Staff #1, Staff #2 and Staff #3 were unable to communicate whether or not individuals in the home were poison safe and safe with sharps.
Providence has not had a group home manager overseeing the group homes in Breinigsville, PA including the L9 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 management was unaware that updated copies of the ISP weren¿t at the home/were missing.
Immediately after unannounced inspection, Providence created new binders for every group home individual containing copies of all necessary documents (most up to date ISPs, medical documents) to be at the residential site and distributed to the sites (including L9 group home). |
11/15/2021
| Not Implemented |
| 6400.163(h) | Individual #1 is prescribed Milk of Magnesia 2 tbsp, 30ml by mouth as needed if no BM in3 days. Follow with 8oz. glass of water (constipation). The bottle located in the home expired on 7/1/21. The medication was not disposed of properly. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Medications that are discontinued or expired shall be destroyed in a safe manner according to federal and state regulations. Individual #1 is prescribed Milk of Magnesia 2 tbsp, 30ml by mouth as needed if no BM in3 days. Follow with 8oz. glass of water (constipation). The bottle located in the home expired on 7/1/21. The medication remained with the individual¿s medications and was not disposed of properly during the time of inspection.
Direct care staff who are medication administration trained and observe individual #1 administer his medications failed to notify Group Home Medical Coordinator Kathy Rodriques and new management staff Pharmaceutical Educator-RN Markel Dunn that there was an expired medication Milk of Magnesia in individual #1¿s medication box that needed to be removed and destroyed. Providence has not had a group home manager since May 2021, and that staff person assisted with oversight of similar very important tasks.
Immediately after inspection, the Milk of Magnesia was removed from individual #1¿s medication box at the L9 group home and discarded/destroyed appropriately by Kathy Rodriques. |
10/30/2021
| Not Implemented |
| 6400.165(c) | Individual #1 is prescribed Fluticasone Prop 50mcg Spray, use two sprays in each nostril daily at 8AM. The Medication Administration Record (MAR) indicates that this medication was suspended from 10/16/21 to 10/22/21. The medication was not available in the home. Individual #1 indicated the medication had not been available for at least two weeks however the medication was signed out as administered on 10/22/21, 10/23/21, 10/4/21 and 10/25/21. This medication was not administered as prescribed.
Individual #1 is prescribed Loratadine 10mg tablet, take 1 tablet by mouth once daily at 9AM. This medication is not being administered as prescribed as shown by the last refill date and the amount of pills remaining in the blister pack. The medication was last filled on 8/1/21 with a 31-day supply. There are only 28 of the 31 pills removed from the blister pack since 8/1/21. The medication is initialed as being administered on 10/1/21-10/9/21 and 10/12-10/16, 2021. Individual #1 is prescribed Levothyroxine 50mcg tablet, take I tablet by mouth once daily at 8AM. This medication is not being administered as prescribed as shown by the last refill date and the amount of pills remaining in the blister pack. The medication was last filled on 8/1/21 with a 31-day supply. There are only 28 or the 31 pills removed from the blister pack since 8/1/21. The medication is initialed as being administered on 10/1-10/9/21 and 10/12-10/26/21.
Individual #1 is prescribed Minocycline100mg capsule, take 1 capsule by mouth 1x daily at 8AM. This medication is not being administered as prescribed as shown by the last refill date and the amount of pills remaining in the blister pack. The medication was last filled on 8/20/21 with a 30-day supply. There are only 26 pills removed from the blister pack since 8/30/21. This medication was initialed as being administered on 10/1-10/9/21 and 10/12-10/26/21.
Individual #1 is prescribed Mirtazapine 15mg Tablet, take 1 tablet by mouth daily at 8PM. This medication is not being administered as prescribed as shown by the last refill date and the amount of pills remaining in the blister pack. The medication was last filled on 9/28/21 with a 30-day supply. There are only 14 pills removed from the blister pack since being refilled. There is documentation of medication refusal on 10/16/21 and 10/17/21.This medication was initialed as being administered on 10/1/21, 10/5-10/9/21, 10/10-15/21, and 10/18-10/25/21.
Individual #1 is prescribed Omeprazole DR 40mg capsule, take 1 capsule by mouth daily at 7AM. This medication is not being administer as prescribed as shown by the last refill date and the amount of pills remaining in the blister pack. The medication was last filled on 9/18/21 with a 31-day supply. There are only 26 pills removed from the blister pack since being refilled. This medication was initiated as being administered on 10/1/21-10/9/21 and 10/12/21-10/26/21.
Individual #2, is prescribed Omeprazole Dr 40mg Capsule, take 1 capsule by mouth daily at 8AM. This medication was last filled on 9/17/21 with a 30-day supply. There is only 1 of the 30 pills removed from the blister pack since 9/17/21. There is a second blister pack that was filled on 9/17/21 with a 31-day supply. There are 21 of the 31 pills removed from the blister pack since 9/17/21. It is unclear when this medication was missed as it is initialed as being administered on 10/1/21-10/9/21 and 10/12/21-10/26. The amount of medication remaining from the time of refill would indicate that the medication was not administered as prescribed.
Individual #2 is prescribed Doxycycline Hyclate 100mg Cap, take 1 cap by mouth 2x daily with food and water at 8AM and 8PM. This medication was last filled on 10/15/21 with a 30-day supply. There is only 1 of the 30 pills removed from the 8PM blister pack on 10/21/21. There is not blister pack for the 8AM dose available in the home. The MAR indicates that the medication has been administered both at 8AM and 8PM on 10/16/21-10/25/21 while the medication remains in the blister pack in the home. The amount of medication remaining in the home from the time of refill and the lack of 8AM meds in the home indicates that the medication is not being administered as prescribed.
Individual #2 is prescribed Risperidone 1mg tablet, take 1 tablet by mouth daily at 8PM. This medication was filled on 10/1/21 with a 31-day supply. On 10/26/21, there had been 27 pills popped from the blister pack with 21 days initialed as administered on the Medication Administration Record. It is unknown when the medication error occurred. The amount of medication missing and signed out indicates that this medication is not being administered as prescribed.
Individual #2 is prescribed Methylphenidate ER 27mg Tab, 1 tablet by mouth daily at 8AM. This MAR indicates that this medication was suspended from 10/26/21 to 11/3/21, awaiting new RX. This medication is not available in the home and is there is not a physician's order to suspend the medication. The medication is not being administered as prescribed.
Individual #3 is prescribed Cetirizine HCL 100mg tablet, take 1 tablet by mouth daily at 8AM. This medication is not being administered as prescribed. The MAR indicated that this was suspended from 10/8/21-10/14/21 while the provider was clarifying the dosage. This medication was not administered on 10/7/21 and 10/8/21, documentation indicates per Dr/RN order. There is Dr. order to withhold the medication. | A prescription medication shall be administered as prescribed. | Prescription medications at the L9 group home were not administered as prescribed on multiple dates for individual #1, individual #2, and individual #3.
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 were completed in EIM, and Individual #1, #2 and Individual #3¿s physicians were contacted and informed. |
11/05/2021
| Not Implemented |
| 6400.166(a)(13) | Individual #1 prescribed Clonidine HCL 0.1mg tablet, take 1 tablet by mouth daily at 9PM (HTN); Cyclobenzaprine 10mg tablet, 1 tab by mouth daily @8PM (muscle spasms); Divalproex SOD Er 500mg tab, take 2 tablets (1000mg) by mouth once daily at 8PM. (mental/mood D/O); Fluticasone PROP 50mcg Spray, Use 2 sprays in each nostril daily at 8PM; Mirtazapine 15mg Tablet, take 1 tablet by mouth daily at 8PM; and Montelukast SOD 10mg tablet, take 1 tablet by mouth at bedtime at 8PM. These medications appear to have been administered as they were removed from the blister pack but are not initialed on the Medication Administration Record (MAR) as being administered on 10/2/21, 10/3/21, 10/4/21 and 10/10/21.
Individual #1 is prescribed Loratadine 10mg tablet, take 1 tablet by mouth daily ay 9AM and Omeprazole DR 40mg capsule, take 1 capsule by mouth daily at 7AM. This medication appears to have been administered as it is removed from the blister pack but was not initialed as being administered on the MAR on 10/10/21.
Individual #1 is prescribed Levothyroxine 50mcg tablet take 1 tablet by mouth once daily at 8AM. This medication appears to have been administered as it was removed from the blister pack but was not initialed as being administered on the MAR on 10/10/21 and 10/11/21.
Individual #1 is prescribed Gabapentin 100mg capsule, take 1 capsule by mouth 2x daily at 8AM and 8PM. This medication appears to have been administer as it was removed from the blister pack but was not initialed as being administered on the MAR 10/2/21, 10/3/21, 10/4/21, at 8PM and on 10/10/21 and 10/21/21 at 8AM.
Individual #2 is prescribed Naltrexone 50mg Tablet, take 1 tablet by mouth daily at 8AM; Omeprazole DR 40mg Capsule, take 1 capsule by mouth daily at 8AM; Benzoyl Peroxide 10% wash, use to wash face, chest, and back once daily at 8AM; Citalopram HBR 40mg Tablet, take 1 tablet by mouth once daily at 8AM; and Clindamycin Phosp 1% lotion, apply topically to affected areas on face, chest back and ABD once daily at 8AM; these medications appear to have been administer as it was removed from the blister pack but was not initialed as administered on 10/10/21 and 10/11/21 on the MAR.
Individual #2 is prescribed Risperidone 1mg tablet, take 1 tablet by mouth daily at 8PM and Benztropine MES 0.5mg tab, take 1 tablet by mouth daily at 8PM. This medication appears to have been administer as it was removed from the blister pack but was not initialed as being administered on the MAR on 10/2/21. 10/3/21, 10/4/21 and 10/10/21.
Individual #3 is prescribed Ammonium Lactate 12% lotion, apply top to aff. area(s) 2x daily at 8AM and 8PM. This medication was not initialed on the MAR as being administered on 10/12/21 at 8AM and 8PM and on 10/11/21 at 8AM.
Individual #3 is prescribed Metformin HCL 1,000mg tablet, take 1 tablet by mouth twice daily at 8AM and 8PM. This medication appears to have been administered as it was removed from the blister pack but was not initialed on the MAR as being administered on 10/10/21 and 10/11/21 at 8AM and 8PM, on 10/11/21 at 8AM and on 10/2/21 and 10/3/21 at 8PM.
Individual #3 is prescribed NAC 600 mg Capsule, take 2 capsules (1200mg) by mouth 2x daily at 8AM and 5PM. This medication appears to have been administered as it was removed from the blister pack but was not initialed on the MAR as being administered on 10/10/21 and 10/11/21 at 8AM and 8PM, on 10/11/21 at 8AM and on 10/2/21 and 10/3/21 at 8PM.
Individual #3 is prescribed Glipizide 5mg tablet, take 1 tablet by mouth daily at 8AM; Invega ER 1.5mg Tablet, take 1 tablet daily at 8AM and Metamucil Fiber Thin, consume 1 wafer by mouth 1x daily at 8AM; These medications appear to have been administered as it was removed from the blister pack but was not initialed on the MAR as being administered on 10/10/21 and 10/11/21 at 8AM.
Individual #3 is prescribed Thera Tablet, take 1 tablet by mouth once daily at 8AM. This medication appears to have been administered as it was removed from the blister pack but was not initialed on the MAR as being administered on 10/2/21, 10/10/21 and 10/11/21 at 8AM.
Individual #3 is prescribed Omeprazole DR 20mg capsule, take 1 capsule by mouth once daily at 8AM. This medication appears to have been administered as it was removed from the blister pack but was not initialed on the MAR as being administered on 10/10/21 and 10/11/21 at 8AM.
Individual #3 is prescribed Vitamin D3 5,000 unit tablet, take 1 by mouth once daily at 8AM. This medication appears to have been administered as it was removed from the blister pack but was not initialed on the MAR as being administered on 10/2/21, 10/5/21, 10/10/21 and 10/11/21 at 8AM.
Individual #3 is prescribed Melatonin 3mg tablet, take 1 tablet by mouth at bedtime at 8PM. This medication appears to have been administered as it was removed from the blister pack but was not initialed on the MAR as being administered on 10/2/21,10/3/21 and 10/10/2 8PM. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Staff failed to initial their names accurately after numerous medication administrations in the MAR on multiple dates for individual #1, individual #2, and individual #3.
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 were completed in EIM, and Individual #1, #2 and Individual #3¿s physicians were contacted and informed. |
11/05/2021
| Not Implemented |
| 6400.167(b) | Individual #1 is prescribed Fluticasone Prop 50mcg Spray, use two sprays in each nostril daily at 8AM. The MAR indicates that this medication was suspended from 10/16/21 to 10/22/21. This medication was not available in the home. Individual #1 indicated the medication had not been available for at least two weeks however the medication was signed out as administered on 10/22/21, 10/23/21, 10/4/21 and 10/25/21. There is no documentation of this medication error, any follow up actions taken or the providers response.
Individual #1 is prescribed Loratadine 10mg tablet, take 1 tablet by mouth once daily at 9AM. The medication was last filled on 8/1/21 with a 31-day supply. There are only 28 of the 31 pills removed from the blister pack since 8/1/21. The medication is initialed as being administered on 10/1-9/21 and 10/12-10/16, 2021. It is unclear when the medication was missed as it is initialed as being administered on 10/1-9/21 and 10/12-10/16, 2021. The amount of medication remaining from the time of refill would indicate that the medication was not properly administered resulting in a mediation error. There is no documentation of this medication error, any follow up actions taken or the providers response.
Individual #1 is prescribed Levothyroxine 50mcg tablet, take I tablet by mouth once daily at 8AM. This medication was last filled on 8/1/21 with a 31-day supply. There are only 28 or the 31 pills removed from the blister pack since 8/1/21. The medication is initialed as being administered on 10/1-10/9/21 and 10/12-10/26/21. The amount of medication remaining from the time of refill would indicate that the medication was not properly administered resulting in a mediation error. There is no documentation of this medication error, any follow up actions taken or the providers response.
Individual #1 is prescribed Minocycline100mg capsule, take 1 capsule by mouth 1x daily at 8AM. This medication was last filled on 8/20/21 with a 30-day supply. There are only 26 pills removed from the blister pack since 8/30/21. This medication was initialed as being administered on 10/1-10/9/21 and 10/12-10/26/21. The amount of medication remaining from the time of refill would indicate that the medication was not properly administered resulting in a mediation error. There is no documentation of this medication error, any follow up actions taken or the providers response.
Individual #1 is prescribed Mirtazapine 15mg Tablet, take 1 tablet by mouth daily at 8PM. This medication was last filled on 9/28/21 with a 30-day supply. There are only 14 pills removed from the blister pack since being refilled. There is documentation of medication refusal on 10/16/21 and 10/17/21.This medication was initialed as being administered on 10/1/21, 10/5-10/9/21, 10/10-15/21, and 10/18-10/25/21. The amount of medication remaining from the time of refill would indicate that the medication was not properly administered resulting in a mediation error. There is no documentation of this medication error, any follow up actions taken or the providers response.
Individual #1 is prescribed Omeprazole DR 40mg capsule, take 1 capsule by mouth daily at 7AM. This medication was last filled on 9/18/21 with a 31-day supply. There are only 26 pills removed from the blister pack since being refilled. This medication was initialed as being administered on 10/1/21-10/9/21 and 10/12/21-10/26/21. The amount of medication remaining from the time of refill would indicate that the medication was not properly administered resulting in a mediation error. There is no documentation of this medication error, any follow up actions taken or the providers response.
Individual #2 is prescribed Doxycycline Hyclate 100mg Cap, take 1 cap by mouth 2x daily with food and water at 8AM and 8PM. This medication was last filled on 10/15/21 with a 30-day supply. There is only 1 of the 30 pills removed from the 8PM blister pack on 10/21/21. There is not blister pack for the 8AM dose available in the home. The MAR indicates that the medication has been administered both at 8AM and 8PM on 10/16/21-10/25/21 while the medication remains in the blister pack in the home. The amount of medication remaining from the time of refill would indicate that the medication was not properly administered resulting in a mediation error. There is no documentation of this medication error, any follow up actions taken or the providers response.
Individual #2, is prescribed Omeprazole Dr 40mg Capsule, take 1 capsule by mouth daily at 8AM. This medication was last filled on 9/17/21 with a 30-day supply. There is only 1 of the 30 pills removed from the blister pack since 9/17/21. There is a second blister pack that was filled on 9/17/21 with a 31-day supply. There are 21 of the 31 pills removed from the blister pack since 9/17/21. It is unclear when this medication was missed as it is initialed as being administered on 10/1/21-10/9/21 and 10/12/21-10/26. The amount of medication remaining from the time of refill would indicate that the medication was not properly administered resulting in a mediation error. There is no documentation of this medication error, any follow up actions taken or the providers response.
Individual #2 is prescribed Risperidone 1mg tablet, take 1 tablet by mouth daily at 8PM. This medication was filled on 10/1/21 with a 31-day supply. On 10/26/21, there had been 27 pills popped from the blister pack with 21 days initialed as administered on the Medication Administration Record. The amount of medication removed from the time of refill would indicate that the medication was not properly administered (too much medication had been administered) resulting in a mediation error. There is no documentation of this medication error, any follow up actions taken or the providers response.
Individual #2 is prescribed Methylphenidate ER 27mg Tab, 1 tablet by mouth daily at 8AM. This MAR indicates that this medication was suspended from 10/26/21 to 11/3/21, awaiting new RX. This medication is not available in the home and is there is not a physician's order to suspend the medication. The medication is not being administered as prescribed resulting in a medication error. There is no documentation of this medication error, any follow up actions taken or the providers response.
Individual #3 is prescribed Melatonin 3mg tablet, take 1 tablet by mouth at bedtime at 8PM. This medication was filled on 10/1/21 with a 31-day supply. On 10/26/21 there had been 28 pills popped from the blister pack with 21 days initialed as administered on the MAR. The amount of medication removed from the time of the refill indicates that the medication was not properly administered (too much medication had been administered) resulting in a medication error. There is no documentation of this medication error, any follow up actions taken or the providers response. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | Upon inspection and discovery of numerous medication issues, follow-up action taken and the prescriber¿s response, if applicable, shall be kept in the individual¿s record.
Providence did not have follow-up action, where applicable, available during the time of inspection because the medication issues/errors were not known at the time by new management Pharmaceutical Educator-RN Markel Dunn so follow-up action was not yet taken. 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).
Since the inspection, necessary follow-up action has been taken by Pharmaceutical Educator-RN Markel Dunn to contact physicians and received responses/documentation uploaded into QuickMar system in individual¿s electronic files. |
11/05/2021
| Not Implemented |
| 6400.167(c) | Individual #1 is prescribed Fluticasone Prop 50mcg Spray, use two sprays in each nostril daily at 8AM. The Medication Administration Record (MAR) indicates that this medication was suspended from 10/16/21 to 10/22/21. At the time of the inspection, the medication was not available in the home. Individual #1 indicated the medication had not been available for at least two weeks however the medication was signed out as administered on 10/22/21, 10/23/21, 10/4/21 and 10/25/21. This medication error was not reported as an incident.
Individual #1 is prescribed Loratadine 10mg tablet, take 1 tablet by mouth once daily at 9AM. This medication is not being administered as prescribed. The medication was last filled on 8/1/21 with a 31-day supply. There are only 28 of the 31 pills removed from the blister pack since 8/1/21. This amount of medication remaining from the time of refill would indicate that the medication was not properly administered resulting in a mediation error. This medication error was not reported as an incident.
Individual #1 is prescribed Levothyroxine 50mcg tablet, take I tablet by mouth once daily at 8AM. This medication was last filled on 8/1/21 with a 31-day supply. There are only 28 or the 31 pills removed from the blister pack since 8/1/21. The medication is initialed as being administered on 10/1-10/9/21 and 10/12-10/26/21. The amount of medication remaining from the time of refill would indicate that the medication was not properly administered resulting in a mediation error. This medication error was not reported as an incident.
Individual #1 is prescribed Minocycline100mg capsule, take 1 capsule by mouth 1x daily at 8AM. This medication was last filled on 8/20/21 with a 30-day supply. There are only 26 pills removed from the blister pack since 8/30/21. This medication was initialed as being administered on 10/1-10/9/21 and 10/12-10/26/21. The amount of medication remaining from the time of refill would indicate that the medication was not properly administered resulting in a mediation error. This medication error was not reported as an incident.
Individual #1 is prescribed Mirtazapine 15mg Tablet, take 1 tablet by mouth daily at 8PM. This medication was last filled on 9/28/21 with a 30-day supply. There are only 14 pills removed from the blister pack since being refilled. There is documentation of medication refusal on 10/16/21 and 10/17/21.This medication was initialed as being administered on 10/1/21, 10/5-10/9/21, 10/10-15/21, and 10/18-10/25/21. The amount of medication remaining from the time of refill would indicate that the medication was not properly administered resulting in a mediation error. This medication error was not reported as an incident.
Individual #1 is prescribed Omeprazole DR 40mg capsule, take 1 capsule by mouth daily at 7AM. This medication was last filled on 9/18/21 with a 31-day supply. There are only 26 pills removed from the blister pack since being refilled. This medication was initiated as being administered on 10/1/21-10/9/21 and 10/12/21-10/26/21. The amount of medication remaining from the time of refill would indicate that the medication was not properly administered resulting in a mediation error. This medication error was not reported as an incident.
Individual #2, is prescribed Omeprazole Dr 40mg Capsule, take 1 capsule by mouth daily at 8AM. This medication was last filled on 9/17/21 with a 30-day supply. There is only 1 of the 30 pills removed from the blister pack since 9/17/21. There is a second blister pack that was filled on 9/17/21 with a 31-day supply. There are 21 of the 31 pills removed from the blister pack since 9/17/21. It is unclear when this medication was missed as it is initialed as being administered on 10/1/21-10/9/21 and 10/12/21-10/26. The amount of medication remaining from the time of refill would indicate that the medication was not properly administered resulting in a mediation error. This medication error was not reported as an incident.
Individual #2 is prescribed Doxycycline Hyclate 100mg Cap, take 1 cap by mouth 2x daily with food and water at 8AM and 8PM. This medication was last filled on 10/15/21 with a 30-day supply. There is only 1 of the 30 pills removed from the 8PM blister pack on 10/21/21. There is not blister pack for the 8AM dose available in the home. The MAR indicates that the medication has been administered both at 8AM and 8PM on 10/16/21-10/25/21 while the medication remains in the blister pack in the home. This medication error was not reported as an incident.
Individual #2 is prescribed Risperidone 1mg tablet, take 1 tablet by mouth daily at 8PM. This medication was filled on 10/1/21 with a 31-day supply. On 10/26/21, there had been 27 pills popped from the blister pack with 21 days initialed as administered on the Medication Administration Record. The amount of medication removed from the time of refill would indicate that the medication was not properly administered (too much medication administered) resulting in a mediation error. This medication error was not reported as an incident.
Individual #2 is prescribed Methylphenidate ER 27mg Tab, 1 tablet by mouth daily at 8AM. This MAR indicates that this medication was suspended from 10/26/21 to 11/3/21, awaiting new RX. This medication is not available in the home and is there is not a physician's order to suspend the medication. The medication is not being administered as prescribed resulting in a medication error. This medication error was not reported as an incident.
Individual #3 is prescribed Melatonin 3mg tablet, take 1 tablet by mouth at bedtime at 8PM. This medication was filled on 10/1/21 with a 31-day supply. On 10/26/21 there had been 28 pills popped from the blister pack with 21 days initialed as administered on the MAR. The amount of medication removed from the time of the refill indicates that the medication was not properly administered (too much medication had been administered) resulting in a medication error. This medication error was not reported as an incident. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | Numerous medication errors discovered upon inspection for individual #1, individual #2 and individual #3. Providence failed to report these medication errors in EIM.
Providence did not report within 72 hours because management was unaware of the errors at the time of the inspection. 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 physicians were contacted and informed of medication errors. |
11/30/2021
| Implemented |
| 6400.169(a) | Staff #1, Staff #2 and Staff #3 administer medications and are not trained in Medication Administration. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Upon inspection, Staff #1, Staff #2 and Staff #3 were determined to not be trained in medication administration. Only staff who receive Department-approved medication administration course renewal requirements, may administer medications, injections, procedures, and treatments.
Immediately after inspection, HR Manager Melissa Bent Obtained Staff #1 and Staff #3 Medication Administration training records from their files. *Please see staff training certificates in Providence evidence email. Providence has been short staffed on and off since 2020 due to the COVID-19 pandemic. This has affected consistent medication administration training of staff and available staff. |
11/30/2021
| Implemented |
|
|
|
SIN-00164046
|
Renewal
|
10/08/2019
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | There is no up-to-date property record 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. | 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 |
| 6400.68(b) | The water temperature was 124.9 degrees. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The water temperature at the group home was 124.9 degrees Fahrenheit. The temperature went beyond the required 120 degrees or lower temperature for the water. Providence does tests on the water temperature regularly, which is documented at the house at a minimum of once a month. The Group Home Manager tested the water 1 week before the audit and the temperature was below the 120 degrees, however, by the audit on 10/8/19 the water was at 124.9 degrees. Providence is aware of the requirement, and that is why regular testing is done to maintain compliance. Moving forward, Providence decided on a plan for the Group Home Manager to meet with Maintenance and the office staff of the apartment community that the group home is in (Parkland View Luxury Apartments) and will explain what the 6400 regulation is and the importance of it. Hopefully the apartment staff will understand and will attempt to keep the water within the required temperature. If this plan does not work, then Providence will be installing temperature regulators onto the faucets and showers where possible, to regulate the temperature. This plan and the backup plan described will be implemented by the end of November. |
11/30/2019
| Implemented |
| 6400.112(e) | The last sleep drill was held on 3/25/2019, which exceeds the 6 month requirement (Repeat Violation: 10/11/2018). | A fire drill shall be held during sleeping hours at least every 6 months. | The last sleep drill completed at the group home was on 3/25/19, which was past the required 6 month time frame since the previous sleep drill was conducted on 10/11/18. The previous Providence Group Home Manager made a mistake with calculating the timing of the sleep drill, therefore it was not held at the correct time. Since then, that Group Home Manager was terminated, and the current Group Home Manager is aware of the requirements to maintain compliance. Moving forward, the current Group Home Manager will maintain the schedule that is necessary. No staff training required. |
11/30/2019
| Implemented |
| 6400.113(a) | Individual #3 did not receive fire safety training annual. His most current fire safety training is dated 8/21/2017. | 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. |
10/31/2019
| Implemented |
| 6400.141(c)(14) | This section was blank on Individual #3's physical exam dated 12/26/2018. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | In the physical exam for the individual, no information pertinent to the diagnosis and treatment in case of emergency was documented. Medical Coordinator was not aware that this information needed to be part of the physical exam form. Now that the Medical Coordinator is aware, this information will be added to every physical form moving forward. Providence created ¿transport packets¿ approximately a year ago that are a folder for every individual that contains his or her face sheet, diagnosis/es information and a current copy of the MAR. These packets are taken to the hospital whenever an individual goes to the emergency room or is hospitalized. However, these packets are not a component of the physical exam. Moving forward, Providence Medical Coordinator understands the addition of diagnosis pertinent to treatment in case of emergency to the physical exam document and will make sure it is added to assist with medical care and regulation compliance. Program Specialist will supervise.
((The physical examination for all individuals served by the agency shall be reviewed and the individuals' physicians shall be contacted in order to obtain all required information by 12/1/19 -10/30/19)) |
10/31/2019
| Implemented |
| 6400.181(e)(2) | Dislikes were not assessed in Individual #2's assessment dated 5/2/2019. | 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.
((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)(9) | This area was not assessed in Individual #2's assessment dated 5/2/2019. | 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)(13)(vi) | This area was not assessed in Individual #2's assessment dated 5/2/2019. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | The ¿recreation¿ 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 ¿recreation¿ is 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.
((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 |
| 6400.34(a) | Individual #3 was informed of his rights on 4/18/2018. He wasn't informed of them again until 8/3/2019, which exceeds the annual requirement. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Individual #3 was not informed of his individual rights within the proper annual time frame. Providence Program Specialist was under the impression that the individual rights document needed to be read and signed by the individual within the calendar year at any point but was incorrect as far as the time frame. Therefore, the Program Specialist presented the individual rights on a date that was outside the requirement, 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 |
| 6400.165(g) | Psych Med Reviews were not held every 3 months. Individual #3 had his Psychiatric Medication Reviews on 9/25/2018, 1/11/2019, 5/3/2019 and 9/6/2019. | 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 the individual as required. Medical Coordinator had difficulty scheduling the psych medication reviews on time for the individual 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 |
| 6400.166(b) | The following medications were not initialed as administered for Individual #3: 4/12/2019: Depakote 250mg (8PM); 4/30/2019: Lopressor 50mg (8PM); 5/15/2019: Paxil 20mg (8PM); 5/31/2019: Chlorpromazine 200mg (8AM); 8/31/2019: Neurontin 600mg (2PM); 9/2/2019: Chlorpromazine 200mg (8AM), Lopressor 50mg (8AM), Depakote 250mg (8am & 2PM), Neurontin 600mg (8AM & 2PM), Seroquel 200mg (8AM & 2PM); 9/15/2019: Depakote 250mg, Neurontin 600mg, and Seroquel 200mg (all at 2PM); and 9/30/2019: Paxil 20mg (8AM). | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The MAR had missing initials for administrations on several dates for the individual. Providence group home staff did not follow the regulations and medication administration training protocol of placing initials after every administration. Staff scheduled during each of these times forgot to initial the MAR. Now Medical Coordinator and Program Specialist are aware of staffs errors on the MAR for this individual, so a plan has been put in place. To ensure that this does not occur again moving forward, Medical Coordinator, Program Specialist and Group Home Manager will be holding a training to openly discuss the importance of thorough, detailed documentation with all group home staff. This training will be titled ¿Medication Documentation and Administration Responsibility¿ by the end of November, 2019. |
11/30/2019
| Implemented |
| 6400.169(a) | Staff #2 had a Medication Practicum on 3/18/2018. The next Medication Practicum wasn't completed until 7/18/2019, which exceeds the requirement. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Staff #2 had the med practicum on 3/18/18 and the next practicum was done in July of 2019, which went past the required annual practicum time frame. The error occurred because the Medication Trainer did not schedule the med training for staff #2 within the correct time frame. Since the audit, the Medication Trainer has been terminated. Also, 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. Also, Providence is in the process of obtaining a new Medication Trainer that is aware of the regulations and follows them. Staff training of HR completed-given new regulations by Program Specialist. |
11/30/2019
| Implemented |
| 6400.207(4)(I) | A chemical restraint is a prohibitive procedure. Individual #3 is prescribed Ativan (1mg QD PRN) for Anxiety. The specific symptoms of Anxiety to be treated are not listed. Individual #3 was administered this medication on 12/11/2018, 4/1/2019 and 6/14/2019 | 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 Ativan (1mg) 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 Ativan. 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 Ativan-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 Ativan 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. Individual #3 will be getting his physician order completed for his Anxiety symptoms list to be added to the MAR on 11/22/19. |
11/22/2019
| Implemented |
|
|
|
SIN-00143550
|
Renewal
|
10/11/2018
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency failed to complete a self-assessment of the home within 3 to 6 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 months 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 |
| 6400.62(a) | Poisonous materials were found unlocked and accessible in the home. "719 Walnut Ave" brand grapefruit-mandarin liquid hand soap, which was labelled "if swallowed, get medical help or contact poison control," was found on the kitchen counter. Listerine Ultra Clean brand mouthwash, which was labelled "contact poison control if ingested," was found in the hall bathroom. Head & Shoulders brand dandruff shampoo, which was labelled, "contact poison control if ingested," was found in the master bathroom. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Immediately after the inspection, all poisonous materials were stored and locked away. Moving forward, Jude Felix the Group Home Manager will remove any liquid hand soaps, shampoos or other substances labeled "if swallowed, get medical help or contact poison control," or labeled "contact poison control if ingested," and place them in locked cabinets immediately after purchase or delivery. Jude will ensure compliance with this regulation by training all group home staff on poisonous materials and the importance of keeping certain items locked up and will sign that they received the training. Jude will conduct this training by January 31, 2019 and will conduct the training monthly thereafter with all new employees of the group homes. |
01/31/2019
| Implemented |
| 6400.112(e) | A fire drill was held during sleeping hours on 2/2618. The fire drills held during the months of March 2018 through September 2018, were all held during awake 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 it indicated that the individuals evacuated to a designated meeting place. ((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-00125934
|
Renewal
|
11/14/2017
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC 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 |
| 6400.21(d) | The criminal check for staff #3 states Request Under Review For Control.' A final copy is not in her record. | A copy of the final reports received from the State Police and the FBI, if applicable, shall be kept.
| Criminal check for staff#3 which states 'Request Under Review For Control' came out cleared. A copy of the final reports received from the State Police and the FBI, is kept on her record. Human Resource Manager will be responsible to ensure State Police, and FBI checks are completed. A tracking sheet has been created to prevent future occurrences. |
12/21/2017
| Implemented |
| 6400.22(d)(1) | A current property record is not being kept for Individual #2. | 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 |
| 6400.46(c) | Staff #2 did not have 24 hours of training relevant to human services or administration. | The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually. | 24 hours training for the CEO was completed.Training face sheet that sums 24hr training relevant to human services and administration is now kept on all employee files. To prevent future occurrences, the Human Resource Manager will keep a training face sheet on file. To ensure compliance, the Human Resource Manager will conduct weekly audits. |
11/15/2017
| 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 |
| 6400.104 | Notification 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 1/29/18)) |
11/15/2017
| Implemented |
| 6400.141(a) | Individual #2 was admitted on 3/8/2017. 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) | There is no physical exams for staff #2 and staff #3 in their records. | 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 |
| 6400.163(c) | Individual #2 is prescribed medications to treat a diagnosed psychiatric illness. He is not having 3 month medication reviews done 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 #2 was admitted on 3/8/2017. An assessment for him 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
((Individual #2 had an assessment completed -CH 1/29/18)) |
12/18/2017
| Implemented |
| 6400.186(a) | Individual #2 was admitted on 3/8/2017. 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) | Weight, height, race, identifying marks, and religious affiliation are not listed in Individual #2'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.
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12/18/2017
| Implemented |
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SIN-00205759
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Unannounced Monitoring
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05/26/2022
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Compliant - Finalized
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SIN-00202830
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Unannounced Monitoring
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03/14/2022
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Compliant - Finalized
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