Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00232299 Unannounced Monitoring 10/02/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #4's Individual Support Plan (ISP) states Individual #4 mother is his payee and manages his money and ensure his bills are paid. She sends $200 for spending money every month to Providence Home Care Agency in addition to the Room and Board payment. The $200 is then transferred by Providence onto a debit card with Individual #4's name on it. Only Individual #4' spending money goes on that card for staff to utilize on new clothing for him, takeout food for him, and community activities for him. Individual #4 is not able to manage any of his money. An up-to-date financial record is not being kept for him. The Licensing Representative was on-site on 10/2/2023 for a monitoring. Individual #4's financial ledger in the home only went up to 8/29/2023. Individual #4 he had an ending balance of $0.00, and Staff#1 reported that money was requested, but that Individual #4 had no money. Providence Home Care was able to provide the licensing representative with a Bento Account Transaction Report that noted a deposit for Individual #4 on 9/8/22 for $98.57, a deposit on 9/19/23 for $130.00, and a deposit on 10/2/23 for $128.57. Individual #4 has a total balance of $357.14 available in their account, however this available balance is not being accurately maintained at the home.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. October 3,2023- the individuals financial record was immediately updated in the home to reflect the available balance on the Bento Card. 10/20/2023 Implemented
6400.22(e)(1)Individual #4's Individual Support Plan (ISP) states Individual #4 mother is his payee and manages his money and ensure his bills are paid. She sends $200 for spending money every month to Providence Home Care Agency in addition to the Room and Board payment. The $200 is then transferred by Providence onto a debit card with Individual #4's name on it. Only Individual #4' spending money goes on that card for staff to utilize on new clothing for him, takeout food for him, and community activities for him. Individual #4 is not able to manage any of his money. The Licensing Representative was on-site on 10/2/2023 for a monitoring. Individual #4's financial ledger in the home only went up to 8/29/2023. Individual #4 he had an ending balance of $0.00, and Staff#1 reported that they are unaware of where Individual #4's money is, and they money was requested. and Staff#1 reported that Individual #4's had no money is, and that money was requested, but that Individual #4 had no money. Providence Home Care was able to provide the licensing representative with a Bento Account Transaction Report that noted a deposit for Individual #4 on 9/8/22 for 98.57, a deposit on 9/19/23 for $130.00, and a deposit on 10/2/23 for $128.57. Individual #4 has a total balance of $357.14 available in their account. However, an accurate financial record including the dates with the amounts of deposits and withdrawals is not being maintained at the home. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. October 3,2023- the individuals financial record was immediately updated in the home to reflect the available balance on the Bento Card. 10/03/2023 Implemented
6400.62(a)Poisonous materials shall be kept locked or made inaccessible to individuals. Individual #4's Individual Support Plan (ISP) states he cannot read warning labels or danger signs and therefore has a limited understanding of proper safety precautions while handling or storing poisonous substances. Individual #4 requires line of sight supervision in this area. At the time of the inspection, located in the bathroom located near the kitchen on the bathroom cabinet was a spray bottle of Febreze light air and the label states to get medical attention. (Repeat Violation 5/16/23)Poisonous materials shall be kept locked or made inaccessible to individuals. On October 2, 2023 the spray bottle of Fabreeze light was immediately removed from the top of the Cabinet in the bathroom and placed in a locked cabinet. 10/02/2023 Implemented
6400.64(a)Clean and sanitary shall be maintained in the home. At the time of the inspection, the gray nonslip mat located in the bathtub/shower had multiple areas with a black like substance on it resembling mold/mildew. Along the tilt floor next to the bathtub and along the wall from the bathtub to the bathroom sink cabinet was multiple areas on the floor tiles that had a black like substance on it resembling mold/mildew. The metal shower bar had multiple areas of rust on it. The upstairs toilet bowl lid was being held down to the toilet bowl with multiple layers of black duct tape. (Repeat Violation 5/16/23)Clean and sanitary conditions shall be maintained in the home. October 3, 2023- the grey nonslip mat was replaced with a new mat. All areas with black like substance on it resembling mold/mildew were cleaned. The metal shower bay was sanded and resprayed. 10/15/2023 Implemented
6400.67(a)Other surfaces shall be in good repair. Going up the steps from the living room area to floor where bedrooms are located there was three holes located on the left side of the wall. One hole was approximately the size of a golf ball, and the other 2 holes were approximately 1/4 inch wide. At the top of the steps the dresser located in Individual #4's bedroom was missing 3 drawers. (Repeat Violation 5/16/23)Floors, walls, ceilings and other surfaces shall be in good repair. The holes in the walls were repaired and the walls painted. Dresser was replaced. 11/15/2023 Implemented
6400.81(i)Bedroom windows shall have drapes, curtains, shades, blinds, or shutters. At the time of the inspection, approximately ¼ of the lower section of the privacy frost on the top section of the left bedroom window located in Individual #4's bedroom was missing. (Repeat Violation 5/16/23)Bedroom windows shall have drapes, curtains, shades, blinds or shutters. The privacy frost on the individual¿s bedroom window was replaced. All other windows in other homes were checked and were in good condition. 10/26/2023 Implemented
6400.81(k)(3)Bedding, including pillow, linens, and blankets appropriate for the season. At the time of the inspection, Individual #4 did not have a pillow on his bed or in his bedroom. Individual #4 also did not have a fitted sheet on his mattress there was a comforter and 2 throw blankets on the bed.In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season.An extra set of bedding and an extra pillow were available. Staff made up the individual's bed will the extra bedding and pillow. 10/02/2023 Implemented
6400.111(e)A fire extinguisher shall be accessible to staff persons and individuals. At the time of the inspection, the fire extinguisher located on the level with the bedrooms was locked in the room next to the bathroom. A fire extinguisher shall be accessible to staff persons and individuals. Research completed on different options for the safest way to install the fire extinguisher. Providence purchased a fire extinguisher cabinet with an ADA recessed handle. Upon receiving, it will be installed on the second floor at the top of the stairs. 11/15/2023 Implemented
6400.111(f)A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. At the time of the inspection, the fire extinguisher located in the kitchen had a pen mark "X" for 2023, but the month of the inspection was not indicated with a punch The tag states "void 1 year from MO punched". The months APR, May, and June had pen mark swirls and scribbles across them, but not a clear and concise indicator or punch of what month the extinguisher was inspected. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. A new fire extinguisher was placed in the home. A tag with the inspection date of 10/24/2023 was placed on the extinguisher by a fire safety expert. 11/01/2023 Implemented
6400.165(c)Individual #4 is prescribed Ear wax removal kit 6.5%, place 5-10 drops into each ear every other Saturday at 8am & at 8pm for earwax. At the time of the inspection, located with Individual #4's medications were an empty bottle of the Ear wax removal kit 6.5% that had a dispense date on the pharmacy label of 12/27/2022. Also, located with Individual #4 medication was a brand new prescription/bottle of the Ear wax removal kit 6.5% date filled 9/14/2023, and the bottle remained unopened with the plastic seal on it. Individual #4's September 2023 Medication Administration Record (MAR) only has a documented administration date of the medication on 9/24/23 at 8am and 8pm for the entire month of September. 9/24/23 was a Sunday not a Saturday. A prescription medication shall be administered as prescribed. (Repeat Violation: 1/10/23, 5/17/23)A prescription medication shall be administered as prescribed.Staff will be trained on the importance of Medication administration as prescribed and proper documentation in the electronic MAR. Training was conducted by the Director of Compliance. Additional training planned to address this issue. 11/15/2023 Implemented
6400.166(a)(7)Individual #4 is prescribed Ear wax removal kit 6.5%, place 5-10 drops into each ear every other Saturday at 8am & at 8pm for earwax. The medication administration record (MAR) shall keep the dose of medication. The MAR does note clearly states how many drops to administer.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.A representative from Hartzell's Pharmacy came to the home on 10/3/23 to audit the MARS. Correction made to match up the medication label and the MAR by Hartzell's Pharmacy. 10/03/2023 Implemented
SIN-00230304 Unannounced Monitoring 08/31/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The air conditioner in the living room area of the home contained a significant amount of dust covering the entire front of the air conditioner. Staff indicated that this is a functional air conditioner and is regularly used to cool the home.Clean and sanitary conditions shall be maintained in the home. WHAT HAPPENED & WHY? 6400.64(a) VIOLATION DESCRIPTION: The air conditioner in the living room area of the home contained a significant amount of dust covering the entire front of the air conditioner. Staff indicated that this is a functional air conditioner and is regularly used to cool the home. CORRECTION REQUIRED: Clean and sanitary conditions shall be maintained in the home. Staff were not using the AC as often because the weather was cooling down, and didn¿t realize how much dust had collected on it upon the time of inspection (the AC is located high up on the wall in the dining/living room area). WHAT ARE WE DOING RIGHT NOW? Immediately after inspection, the AC was cleaned and the dust removed by one of the Team Leads. 10/31/2023 Implemented
6400.111(a)There was not an operable fire extinguisher with a minimum 2-A rating located in the basement.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. WHAT HAPPENED & WHY? HCN1 VIOLATION 2 55 PA CODE CHAPTER: 6400.111(a) VIOLATION DESCRIPTION: There was not an operable fire extinguisher with a minimum 2-A rating located in the basement. CORRECTION REQUIRED: There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. A 2-A fire extinguisher was located in the basement but was misplaced during an organization and cleaning of the basement by management and staff. WHAT ARE WE DOING NOW? On the day of inspection, a new fire extinguisher was obtained by the Field Supervisor and placed securely in the basement. 10/31/2023 Implemented
SIN-00225076 Unannounced Monitoring 05/17/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. There is no record of a Pennsylvania criminal history check being completed for Staff #6.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. CORRECTION REQUIRED: An application for a Pennsylvania criminal history record check shall be submitted to the state police for prospective employees of the home who will have direct contact with individuals, including part time and temporary staff persons who will have direct contact with individuals by the date of hire. PROVIDER'S PLAN OF CORRECTION: Staff #4, was an actual employee of the Agency and has on record Pennsylvania criminal history record check. The Agency has no record of the person identified as Staff #6 employed to the Agency. This person acted in place of Staff #4 working as a DSP 4/29/23 into 4/30/23. Upon receiving Knowledge of staff #6 working for staff #4, the Agency management has taken the following steps to remediate the situation: Terminated Staff #5 for allowing the person identified in the report as staff#6 who is not an employee of the agency to work in the home in the place of Staff #4 as a Direct Support Professional (DSP). Terminated Staff #4 for allowing someone to work in his place as a direct support professional. 07/12/2023 Not Implemented
6400.21(b)If a prospective employee who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check within 5 working days after the person's date of hire. There is no record or documentation on file for Staff #6 on file with the agency therefore there is no way of knowing if Staff #6 was a resident of Pennsylvania.If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire. CORRECTION REQUIRED: A prospective employee who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of investigation FBI criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check within five days after the person's date of hire. PROVIDER'S PLAN OF CORRECTION: Staff #4, was an actual employee of the Agency and was a resident of Pennsylvania for over two years and was excluded from the Federal Bureau of investigation (FBI) criminal history record check. The person identified in the report as ¿staff #6 was not an employee of Providence Home Care Agency. This person acted in place of Staff #4 working as a DSP 4/29/23 into 4/40/23. Staff #4, however, was an actual employee of the Agency and has on record Pennsylvania criminal history record check. Upon receiving Knowledge of staff #6 working for staff #4, the Agency management has taken the following steps to remediate the situation: Terminated Staff #5 on for allowing the person identified in the report as staff#6 who is not an employee of the agency to work in the home in the place of Staff #4 as a Direct Support Professional (DSP). Terminated Staff #4 for allowing someone to work in his place as a direct support professional. 07/12/2023 Not Implemented
6400.62(a)Poisonous materials shall be kept locked or made inaccessible to individuals. A 20 pound back of rock salt was located off the steps on the back deck, and the label stated to call Poison Control Center. REPEAT VIOLATION 1/12/23.Poisonous materials shall be kept locked or made inaccessible to individuals. A 20 pound back of rock salt was located off the steps on the back deck, and the label stated to call Poison Control Center. REPEAT VIOLATION 1/12/23. CORRECTION REQUIRED: Poisonous materials shall be kept locked or made inaccessible to individuals PROVIDER¿S CORRECTION DATE: 05/17/23 PROVIDER¿S PLAN OF CORRECTION: Immediately after inspection, Residential Coordinator removed the bag of rock salt from the home and brought it to the office for safe storage. 05/17/2023 Implemented
6400.64(a)The 3-bulb light fixture above the sink in the downstairs bathroom had a film of dust on it as well as a coating of cobwebs. There was a yellow commercial mop bucket located in the kitchen filled approximately ½ way with brown water. The staff were not mopping the floors at the time of inspection, and the mop appeared to be dry that was sitting in the drain portion of the mop bucket. Agency staff did dispose of the brown water from the mop bucket at the time of inspection after it was addressed by the licensing representative. In the upstairs bathroom, next to the left corner of the bathroom cabinet on the floor was a brown substance with a clump of hairs located in the brown substance. At the time of inspection, Individual #2 was asleep on the couch and their catheter bag was full and needed to be emptied. Staff emptied Individual #2's catheter into a blue mop bucket in the living room and did not discard of the urine it was left in the bucket in the living room. Clean and sanitary conditions shall be maintained in the home. REPEAT VIOLATION 1/12/23.Clean and sanitary conditions shall be maintained in the home. At the time of inspection the side entrance of the home which leads to the laundry area did not have an exterior light. Outside doorways and fire escapes shall be lighted to assure safety. REPEAT VIOLATION 1/12/23. CORRECTION REQUIRED: Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents PROVIDER¿S PLAN OF CORRECTION: Immediately after inspection, the light bulb in the exterior light fixture outside of the side entrance to the home which burned out was replaced with a new, working bulb. 06/15/2023 Implemented
6400.64(f)Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. At the time of inspection, there were 4 tied/closed black garbage bags stacked on the deck next to the house, and there was 1 black garbage bag that was laying on the deck that was not tied/closed. REPEAT VIOLATION 1/12/23.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. At the time of inspection, there were 4 tied/closed black garbage bags stacked on the deck next to the house, and there was 1 black garbage bag that was laying on the deck that was not tied/closed. REPEAT VIOLATION 1/12/23. CORRECTION REQUIRED: Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. PROVIDER¿S PLAN: During the inspection, one of the staff came to the home and removed the garbage bags from the back deck and disposed of them properly. The bags had accumulated because the Residential Coordinator had just cleaned out the basement earlier that morning. All of that debris was from the basement. 06/15/2023 Implemented
6400.66At the time of inspection the side entrance of the home which leads to the laundry area did not have an exterior light. Outside doorways and fire escapes shall be lighted to assure safety. REPEAT VIOLATION 1/12/23.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. At the time of inspection the side entrance of the home which leads to the laundry area did not have an exterior light. Outside doorways and fire escapes shall be lighted to assure safety. REPEAT VIOLATION 1/12/23. CORRECTION REQUIRED: Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents PROVIDER¿S PLAN OF CORRECTION: Immediately after inspection, the light bulb in the exterior light fixture outside of the side entrance to the home which burned out was replaced with a new, working bulb. 06/15/2023 Implemented
6400.67(a)Ceilings and other surfaces shall be in good repair: Approximately 3 ceiling tiles in the living room had a brown stain on them. The downstairs bathroom doorknob was loose and pulled away from the door approximately ¾ of an inch. The dresser located in the living room was missing 2 drawers. The dresser located in Individual #2's bedroom was missing 4 drawers. 2 of the handles to Individual #2's dresser were missing, and 2 other handles on this dresser were broken. REPEAT VIOLATION 1/12/23.Floors, walls, ceilings and other surfaces shall be in good repair. Ceilings and other surfaces shall be in good repair: Approximately 3 ceiling tiles in the living room had a brown stain on them. The downstairs bathroom doorknob was loose and pulled away from the door approximately ¾ of an inch. The dresser located in the living room was missing 2 drawers. The dresser located in Individual #2's bedroom was missing 4 drawers. 2 of the handles to Individual #2's dresser were missing, and 2 other handles on this dresser were broken. REPEAT VIOLATION 1/12/23. CORRECTION REQUIRED: Floors, walls, ceilings and other surfaces shall be in good repair PROVIDER¿S PLAN: After the inspection, the dresser in the living room was removed as well as the dresser in individual #2¿s bedroom, and replaced. The doorknob on the bathroom door was tightened and secured, and the ceiling tiles that were discovered to be stained were fixed. 06/15/2023 Implemented
6400.71At the time of the inspection on 5/17/23 the telephone located in the living room did not have the numbers of the nearest hospital, police department, fire department, ambulance, and poison control center on or by it at the time of inspection.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. At the time of the inspection on 5/17/23 the telephone located in the living room did not have the numbers of the nearest hospital, police department, fire department, ambulance, and poison control center on or near the house phone. One of the individuals residing in the home must have ripped the phone list down as this has occurred many times in the past. PROVIDENCE¿S PLAN OF CORRECTION: A new emergency contact list was hung up on the wall next to the house phone. 06/15/2023 Implemented
6400.81(i)Both Individual #1 and Individual #2's bedroom windows did not have drapes, curtains, shades, blinds, or shutters at the time of inspection.Bedroom windows shall have drapes, curtains, shades, blinds or shutters. DESCRIPTION: Both Individual #1 and Individual #2's bedroom windows did not have drapes, curtains, shades, blinds, or shutters at the time of inspection. The curtains in individual #2¿s bedroom had been pulled down during a behavioral episode and the windows in individual #1¿s bedroom were frosted with a glaze that provided a sufficient window covering for privacy that individual #1 couldn¿t rip down. Over time, the glaze has faded. PLAN OF CORRECTION: Immediately after inspection, new glass frosting material was purchased so that the Residential Coordinator could re-frost the windows in individual #1¿s bedroom. 06/15/2023 Implemented
6400.82(f)At the time of inspection both bathrooms in the home did not have individual clean paper or cloth towels in them. REPEAT VIOLATION 1/12/23.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. At the time of inspection both bathrooms in the home did not have individual clean paper or cloth towels in them. REPEAT VIOLATION 1/12/23. CORRECTION REQUIRED: Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. The individuals living in the home tend to throw the paper towels or stuff them in the toilet clogging the pipes. PLAN OF CORRECTION: Immediately after inspection, Residential Coordinator placed new paper towels (large, industrial size) at both bathroom sinks. 06/15/2023 Implemented
6400.101Stairways, halls, doorways, and exits from rooms and from the building shall be unobstructed. At the time of the inspection on 5/17/23 the exit from the kitchen door leading through the deck was obstructed. There were approximately 5 garbage bags, multiple boxes laying and stacked on the deck, as well as plastic totes, broken drawers, screens, a wooden chair, metal pipe, toilet seat, and various other items on the deck blocking a clear path from the kitchen door through the deck exitStairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Stairways, halls, doorways, and exits from rooms and from the building shall be unobstructed. At the time of the inspection on 5/17/23 the exit from the kitchen door leading through the deck was obstructed. There were approximately 5 garbage bags, multiple boxes laying and stacked on the deck, as well as plastic totes, broken drawers, screens, a wooden chair, metal pipe, toilet seat, and various other items on the deck blocking a clear path from the kitchen door through the deck exit. Residential Coordinator had just cleaned out the basement at the home that morning to prepare for a new washer and dryer installation. When the inspector arrived, the items from the basement were still laying around. The garbage and debris was removed while the inspector was there. PLAN OF CORRECTION: Garbage and debris was removed while the inspector was there. 06/15/2023 Implemented
6400.111(f)A fire extinguisher shall be inspected and approved annually by a fire safety expert. The fire extinguisher located in the kitchen had a tag that was last inspected 2/2022. This exceeds the annual requirement. Before the licensing representative left the home the agency had brough a current inspected extinguisher for the kitchen. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The fire extinguisher located in the kitchen had a tag that was last inspected 2/2022. This exceeds the annual requirement. Before the licensing representative left the home the agency had brough a current inspected extinguisher for the kitchen. CORRECTION REQUIRED: A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. PLAN OF CORRECTION: Residential Coordinator took the fire extinguisher that was in the kitchen to the fire safety/inspection company that Providence works with-Kistler O¿Brien for the extinguisher to be inspected and recharged. 06/15/2023 Implemented
6400.32(c)An individual may not be abused, neglected, mistreated, exploited, abandoned, or subjected to corporal punishment. Individual #1's Individual Support Plan (ISP) states that Individual #1 is currently receiving 2:1 staff at all times, even when he is sleeping. He does not like someone in his room with him when he is sleeping, so a staff member sits outside the room with the door ajar. Another staff member is within hearing distance downstairs. At the time of inspection, on 5/17/23 when the licensing representative arrived at the home Staff #1, Staff #2, and Staff #3 were all located in the living room area and Individual #1 was upstairs in their bedroom. The licensing representative conducted an inspection of the home, and even opened individual #1's bedroom door, and at no point were staff positioned outside Individual #1's bedroom door. The agency neglected to provide the needed supervision to Individual #1. Staff #4 was unable to work their scheduled overnight shift on 4/29/23 into 4/30/23. Staff #5 approved a friend of Staff #4's who was not an employee of the agency, Staff #6, to work the overnight shift on 4/29/23 into 4/30/23 at the home of Individual #1. Individual #1's Individual ISP states that Individual #1 is currently receiving 2:1 staff at all times, even when he is sleeping. Staff #6 worked the overnight shift with another Staff; however, Staff #6 was not an employee of the agency. On the 4/29/23 into 4/30/23 overnight shift when Staff #6 worked Individual #1 had a behavioral incident (yelling and destroying things) that resulted in staff calling 911, the Police coming to the home, and Individual #1 was able to be deescalated. The agency failed to provide the required supervision to Individual #1 on the overnight shift of 4/29/23 into 4/30/23 as Individual#1 requires 2:1 staffing and only 1 staff member from the agency provided supervision. The agency neglected Individual #1 and Individual #2 by allowing Staff #6 who was not an employee of the agency, not trained in the needs of the individuals or any Department required trainings, and did not complete any of the required criminal clearances to work in the home as a Direct Support Professional.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.CORRECTION REQUIRED: An individual may not be abused, neglected, mistreated, exploited abandoned or subjected to corporal punishment. PROVIDER'S PLAN OF CORRECTION: The Agency neglected individual #1 and individual #2 by allowing by allowing the person identified in the report as staff #6 who was not an employee of the agency not trained in the needs of the individual or any department required trainings and did not complete any of the required criminal clearances to work in the home as a direct support professional. The person identified in the report as ¿staff #6 is not and has never been an employee of Providence Home Care Agency. This person acted in place of Staff #4 working as a DSP 4/29/23 into 4/40/23. Staff #4, however was an actual employee of the Agency and was trained in the needs of the individual, completed department required trainings and completed all the required criminal clearances to work in the home as a direct support professional. Upon receiving Knowledge of staff #6 working for staff #4, the Agency management has taken the following steps to remediate the situation: Terminated Staff #5 on for allowing the person identified in the report as staff#6 who is not an employee of the agency to work in the home in the place of Staff #4 as a Direct Support Professional (DSP). Terminated Staff #4 for allowing someone to work in his place as a direct support professional. The agency failed to provide the required supervision to Individual #1 on the overnight shift of 4/29/23 into 4/30/23 as Individual#1 requires 2:1 staffing and only 1 staff member from the agency provided supervision. The Agency management has taken the following steps to remediate the situation: Agency will retrain and sensitize staff on the individual #1's Individual Support Plan (ISP) states that Individual #1 is currently receiving 2:1 staff at all times, even when he is sleeping. Implemented a supervision hourly rotation log sheet, which requires staff to be close to the individual bedroom to be signed by staff. 08/01/2023 Not Implemented
6400.32(d)Staff #4 was unable to work their scheduled overnight shift on 4/29/23 into 4/30/23. Staff #5 approved Staff #6 , who was not an employee of the agency to work the overnight shift on 4/29/23 into 4/30/23 at the home of Individual #1 and Individual #2. Individual#1 and Individual #2 were not treated with dignity and respect as Staff #6 who was untrained and had not received any of the necessary criminal history clearances was allowed to work in the home in the capacity of a Direct Support Professional.An individual shall be treated with dignity and respect.CORRECTION REQUIRED: an individual shall be treated with dignity and respect. PROVIDER'S PLAN OF CORRECTION: Individual #1s and individual #2s dignity and respect was violated by the Agency allowing the person identified in the report as staff #6 who was untrained and had not received any of the necessary criminal history clearances, to work in the home 4/29/23 into 4/30/23 as a direct support professional. The person identified in the report as ¿staff #6 is not and has never been an employee of Providence Home Care Agency. This person acted in place of Staff #4 working as a DSP 4/29/23 into 4/30/23. Staff #4, however was an actual employee of the Agency and was trained in the needs of the individual, completed department required trainings and completed all the required criminal clearances to work in the home as a direct support professional. Upon receiving Knowledge of staff #6 working for staff #4, the Agency management has taken the following steps to remediate the situation: Terminated Staff #5 on for allowing the person identified in the report as staff#6 who is not an employee of the agency to work in the home in the place of Staff #4 as a Direct Support Professional (DSP). Terminated Staff #4 for allowing someone to work in his place as a direct support professional. 08/01/2023 Not Implemented
6400.32(h)An individual has the right to privacy of person and possessions. Staff #4 was unable to work their scheduled overnight shift on 4/29/23 into 4/30/23. Staff #5 approved a friend of Staff #4's who was not an employee of the agency, Staff #6, to work the overnight shift on 4/29/23 into 4/30/23 at the home of Individual #1 and Individual #2. By Staff #6 who was not an employee of the agency entering and working a shift at the residence of Individual #1 and #2 their privacy was violated.An individual has the right to privacy of person and possessions.CORRECTION REQUIRED: An individual has the right to privacy of person and possessions. PROVIDER'S PLAN OF CORRECTION: Agency violated Individual #1 and individual #2 right to privacy of person and possessions by allowing the person identified in the report as staff #6, who was untrained and had not received any of the necessary criminal history clearances to work in the home 4/29/23 into 4/30/23 as a direct support professional. The person identified in the report as ¿staff #6 is not and has never been an employee of Providence Home Care Agency. This person acted in place of Staff #4 working as a DSP 4/29/23 into 4/30/23. Staff #4, however was an actual employee of the Agency and was trained in the needs of the individual, completed department required trainings and completed all the required criminal clearances to work in the home as a direct support professional. Upon receiving Knowledge of staff #6 working for staff #4, the Agency management has taken the following steps to remediate the situation: Terminated Staff #5 on for allowing the person identified in the report as staff#6 who is not an employee of the agency to work in the home in the place of Staff #4 as a Direct Support Professional (DSP). Terminated Staff #4 for allowing someone to work in his place as a direct support professional. 08/01/2023 Not Implemented
6400.46(a)There is no documentation that Staff #6 receive training in fire safety prior to working with individuals on 4/29/23 as there is no record of Staff #6 being an employee of the agency.Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.CORRECTION REQUIRED: Program specialists and direct service workers shall be trained before working with individuals in general far 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. PROVIDER'S PLAN OF CORRECTION: The Agency neglected individual #1 and individual #2 by allowing by allowing the person identified in the report as staff #6 who was not an employee of the agency and not trained in fire safety prior to working with the individual or any department required trainings ,and did not complete any of the required criminal clearances to work in the home as a direct support professional. The person identified in the report as ¿staff #6 was not and has never been an employee of Providence Home Care Agency. This person acted in place of Staff #4 working as a DSP 4/29/23 into 4/40/23. Staff #4, however was an actual employee of the Agency and was trained in fire safety, completed department required trainings and completed all the required criminal clearances to work in the home as a direct support professional. Upon receiving Knowledge of staff #6 working for staff #4, the Agency management has taken the following steps to remediate the situation: Terminated Staff #5 on for allowing the person identified in the report as staff#6 who is not an employee of the agency to work in the home in the place of Staff #4 as a Direct Support Professional (DSP). Terminated Staff #4 for allowing someone to work in his place as a direct support professional. 08/01/2023 Not Implemented
6400.51(b)(1)There is no record of Staff #6 receiving orientation training prior to their shift on 4/29/23 on the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.CORRECTION REQUIRED: the orientation must encompass the following areas: the application of person-centered practices community integration, individual choice and supporting individuals to develop and maintain relationships. PROVIDER'S PLAN OF CORRECTION: The Agency neglected individual #1 and individual #2 by allowing by allowing the person identified in the report as staff #6 who was not an employee of the agency to work in the home as a direct support professional without receiving orientation regarding the application of person-centered practices community integration, individual choice and supporting individuals to develop and maintain relationships. The person identified in the report as ¿staff #6 as not and has never been an employee of Providence Home Care Agency. This person acted in place of Staff #4 working as a DSP 4/29/23 into 4/40/23. Staff #4, however, was an actual employee of the Agency and has on record to have completed all department required trainings to work in the home as a direct support professional. Upon receiving Knowledge of staff #6 working for staff #4, the Agency management has taken the following steps to remediate the situation: Terminated Staff #5 on for allowing the person identified in the report as staff#6 who is not an employee of the agency to work in the home in the place of Staff #4 as a Direct Support Professional (DSP). Terminated Staff #4 for allowing someone to work in his place as a direct support professional. 08/01/2023 Not Implemented
6400.51(b)(2)There is no record of Staff #6 receiving orientation training prior to their shift on 4/29/23 The prevention, detection and reporting of abuse, suspected abuse and alleged abuse.The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations.CORRECTION REQUIRED: the orientation must encompass the following areas the prevention detection and reporting of abuse suspected abuse and alleged abuse in accordance with the older adults Protective Services act the Child Protective Services law the adult Protective Services act and applicable Protective Services regulations. PROVIDER'S PLAN OF CORRECTION: The Agency neglected individual #1 and individual #2 by allowing by allowing the person identified in the report as staff #6 who was not an employee of the agency to work in the home as a direct support professional without receiving orientation regarding the prevention detection and reporting of abuse suspected abuse and alleged abuse in accordance with the older adults Protective Services act the Child Protective Services law the adult Protective Services act and applicable Protective Services regulations. The person identified in the report as ¿staff #6 as not and has never been an employee of Providence Home Care Agency. This person acted in place of Staff #4 working as a DSP 4/29/23 into 4/40/23. Staff #4, however, was an actual employee of the Agency and has on record to have completed all department required trainings to work in the home as a direct support professional. Upon receiving Knowledge of staff #6 working for staff #4, the Agency management has taken the following steps to remediate the situation: Terminated Staff #5 on for allowing the person identified in the report as staff#6 who is not an employee of the agency to work in the home in the place of Staff #4 as a Direct Support Professional (DSP). Terminated Staff #4 for allowing someone to work in his place as a direct support professional. 08/01/2023 Not Implemented
6400.51(b)(3)There is no record of Staff #6 receiving orientation training prior to their shift on 4/29/23 on individual rights.The orientation must encompass the following areas: Individual rights.CORRECTION REQUIRED: the orientation must encompass the following areas: Individual rights PROVIDER¿S CORRECTION DATE: PROVIDER'S PLAN OF CORRECTION: The Agency neglected individual #1 and individual #2 by allowing by allowing the person identified in the report as staff #6 who was not an employee of the agency to work in the home as a direct support professional without receiving orientation regarding Individual rights. The person identified in the report as ¿staff #6 was not and has never been an employee of Providence Home Care Agency. This person acted in place of Staff #4 working as a DSP 4/29/23 into 4/40/23. Staff #4 however, was an actual employee of the Agency and has on record to have completed all department required trainings, including that on Individual rights to work in the home as a direct support professional. Upon receiving Knowledge of staff #6 working for staff #4, the Agency management has taken the following steps to remediate the situation: Terminated Staff #5 on for allowing the person identified in the report as staff#6 who is not an employee of the agency to work in the home in the place of Staff #4 as a Direct Support Professional (DSP). Terminated Staff #4 for allowing someone to work in his place as a direct support professional. 08/01/2023 Not Implemented
6400.51(b)(4)There is no record of Staff #6 receiving orientation training prior to their shift on 4/29/23 on recognizing and reporting incidents.The orientation must encompass the following areas: recognizing and reporting incidents.CORRECTION REQUIRED: The orientation must encompass the following areas: recognizing and reporting incidents. PROVIDER'S PLAN OF CORRECTION: The Agency neglected individual #1 and individual #2 by allowing by allowing the person identified in the report as staff #6 who was not an employee of the agency to work in the home as a direct support professional without receiving orientation regarding recognizing and reporting incidents. The person identified in the report as staff #6 was not and has never been an employee of Providence Home Care Agency. This person acted in place of Staff #4 working as a DSP 4/29/23 into 4/40/23. Staff #4 however, was an actual employee of the Agency and has on record to have completed all department required training, including that on Individual rights to work in the home as a direct support professional. Upon receiving Knowledge of staff #6 working for staff #4, the Agency management has taken the following steps to remediate the situation: Terminated Staff #5 on for allowing the person identified in the report as staff#6 who is not an employee of the agency to work in the home in the place of Staff #4 as a Direct Support Professional (DSP). Terminated Staff #4 for allowing someone to work in his place as a direct support professional. 08/01/2023 Not Implemented
6400.51(b)(5)There is no record of Staff #6 receiving orientation training prior to their shift on 4/29/23 on job-related knowledge and skills.The orientation must encompass the following areas: Job-related knowledge and skills.At the time of inspection, there was no record of Staff #6 receiving orientation training prior to their shift on 4/29/23 on job-related knowledge and skills. CORRECTION REQUIRED: The orientation must encompass the following areas: Job-related knowledge and skills. PROVIDER¿S CORRECTION DATE: PROVIDER'S PLAN OF CORRECTION: The Agency neglected individual #1 and individual #2 by allowing by allowing the person identified in the report as staff #6 who was not an employee of the agency to work in the home as a direct support professional without receiving orientation regarding: Job-related knowledge and skills. The person identified in the report as ¿staff #6 as not and has never been an employee of Providence Home Care Agency. This person acted in place of Staff #4 working as a DSP 4/29/23 into 4/40/23. Staff #4 however, was an actual employee of the Agency and has on record to have completed all department required trainings to work in the home as a direct support professional. Upon receiving Knowledge of staff #6 working for staff #4, the Agency management has: Terminated Staff #5 for allowing the person identified in the report as staff#6 who is not an employee of the agency to work in the home in the place of Staff #4 as a Direct Support Professional (DSP). Terminated Staff #4 for allowing someone to work in his place as a direct support professional. 08/01/2023 Not Implemented
6400.163(a)Prescription medications shall be labeled with a label issued by a pharmacy. At time of inspection on 5/17/23 a bottle of Ammonium Lactate 12% Lotion was in use for Individual #2. The pharmacy label had deteriorated such that the label could not be read.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.CORRECTION REQUIRED: Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medication shall be labeled with a label issued by a pharmacy. PROVIDER¿S CORRECTION DATE: PROVIDER'S PLAN OF CORRECTION: Pharmacy will be contacted by Residential Medical Coordinator to reissue all labels that are deteriorated so that the labels can be read. 06/15/2023 Implemented
6400.165(c)Individual #1 is prescribed Fluticasone 50 mcg nasal spray, use 2 sprays in each nostril at 8 am for allergies. There were no initials on the Medication Administration Record (MAR) as the medication being administered to Individual #1 at 8am on 5/2/23. It is unable to be determined if the medication was administered as prescribed. Individual #2 is prescribed Ammonium Lactate Lotion 2%, apply to affect area(s) 2 x daily @ 8A-8P (Dry Skin). There were no initials on the MAR for the medication being administered to Individual #2 at 8am on 5/2, at 8pm on 5/5, at 8pm on 5/13, and at 8pm on 5/14. It is unable to determine if the medication was administered as prescribed.A prescription medication shall be administered as prescribed.CORRECTION REQUIRED: A prescription medication shall be administered as prescribed. PROVIDER¿S CORRECTION DATE: PROVIDER'S PLAN OF CORRECTION: Staff will be trained on the importance of Medication administration as prescribed and proper documentation in the electronic MAR. Training was conducted by the Director of Compliance on 6/8/2023 and is the first in a series of training planned to address this issue. 08/01/2023 Implemented
6400.166(a)(13)A medication record shall be kept for each individual for whom a prescription medication is administered including the name and initials of the person administering the medication. Individual #1 is prescribed Clonazepam 1 mg tablet, take one tablet by mouth three times a day in the morning, and at bedtime for anxiety. The medication appears to have been administered at 8am on 5/2, 8pm on 5/5, 8pm on 5/7, 2pm on 5/13, and 8pm on 5/13 as the medication was removed from the blister pack but there are no initials on the Medication Administration Record (MAR) for those days of administration. Individual #1 is prescribed Divalproex Sodium ER 500 mg, take 2 tablets by mouth twice daily for mood disorder. The medication appears to have been administered at 8am on 5/2, 8pm on 5/5, 8pm on 5/7, and 8pm on 5/13 as there were no medication pouches from those days and times remaining in the home, but there are no initials on the MAR for those days of administration. Individual #1 is prescribed Risperidone 3 mg tablet, take one tablet mt mouth twice daily at 8am and 8pm for psychosis. The medication appears to have been administered at 8am on 5/2, 8pm on 5/5, 8pm on 5/7, and 8pm on 5/13 as the medication was removed from the blister pack but there are no initials on the MAR for those days of administration. Individual #1 is prescribed Sertraline Hcl 100 mg tablet, take 2 tablets by mouth every morning for mood disorder. The medication appears to have been administered daily at 8am on 5/2/23 as they were no medication pouches from that day in the home, but there were no initialed on the MAR as being administered at 8am on 5/2/23. Individual #2's (MAR) did not include the initials of the person administering all of the medications for Individual #2 at 8am on 5/2/23, and at 8pm on 5/5/23, 5/7/23, and 5/13/23. In addition, Individual #2 is prescribed Haloperidol take one tablet by mouth three times daily in the morning, afternoon, and bedtime for psychosis. The medication appears to have been administered in the afternoon on 5/13/23 as they were no medication pouches from that day in the home, but there were no initialed on the Mediation Administration Record (MAR) as being administered at 2:00 pm on 5/13/23. Individual #2 is prescribed Levothyroxine 25 mg tablet, take one tablet by mouth daily at 7 am for hypothyroidism. The medication appears to have been administered daily at 7am on 5/2/23 as they were no medication pouches from that day in the home, but there were no initialed on the Mediation Administration Record (MAR) as being administered at 7am on 5/2/23.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.ORRECTION REQUIRED: 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. PROVIDER¿S CORRECTION DATE: PROVIDER'S PLAN OF CORRECTION: The provider currently has an electronic MAR in place. However, we recognize that closer monitoring and staff training is required to ensure that accurate medication recording to reflect the name and initials of the person administering the medication is needed. Training was conducted by the Compliance Department on 6/8/2023 and is the first in a series of training planned to address this issue. 08/01/2023 Implemented
6400.166(c)Individual #2 is prescribed Ammonium Lactate Lotion 2%, apply to affect area(s) 2 x daily @ 8A-8P (Dry Skin). Individual #2 has refused the medication at 8pm on 5/1/23, 8pm on 5/4/23, 8pm on 5/6/23, 8am on 5/7/23, 8pm on 5/8/23, 8pm on 5/15/23, 8am on 5/16, and 8am on 5/17/23. There is no documentation that the refusals have been reported to the prescriber. Individual #2 is prescribed Miralax Powder 17Gm, mix ½ capful into 8 0zof liquid and drink by mouth daily. Individual #1 refused the medication at 8am on 5/16/23. There is no documentation that the refusal has been reported to the prescriber.If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual.CORRECTION REQUIRED: If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall then be reported to the prescriber as directed by the prescriber or if there is there is harm to the individual. PROVIDER¿S CORRECTION DATE: PROVIDER'S PLAN OF CORRECTION: Staff Training conducted 6/8/2023 outlining the importance of documenting on the medication record a with emphasis on the refusal Policy which states that: All refusal of medication by an individual must be documented in the e- Mar and all refusal the Residential Medical Coordinator who will then report to the prescriber. 08/01/2023 Implemented
6400.186Individual #1's Individual Support Plan (ISP) states that Individual #1 is currently receiving 2:1 staff at all times, even when he is sleeping. He does not like someone in his room with him when he is sleeping, so a staff member sits outside the room with the door ajar. Another staff member is within hearing distance downstairs. At the time of inspection on 5/17/23 when the licensing representative arrived at the home Staff #1, Staff #2, and Staff #3 were all located in the living room area and Individual #1 was upstairs in their bedroom. The licensing representative conducted an inspection of the home, and even opened individual #1's bedroom door, and staff were not positioned outside their bedroom door. The home shall implement the individual plan.The home shall implement the individual plan, including revisions.Individual #1's Individual Support Plan (ISP) states that Individual #1 is currently receiving 2:1 staff at all times, even when he is sleeping. He does not like someone in his room with him when he is sleeping, so a staff member sits outside the room with the door ajar. Another staff member is within hearing distance downstairs. At the time of inspection on 5/17/23 when the licensing representative arrived at the home Staff #1, Staff #2, and Staff #3 were all located in the living room area and Individual #1 was upstairs in their bedroom. The licensing representative conducted an inspection of the home, and even opened individual #1's bedroom door, and staff were not positioned outside their bedroom door. The home shall implement the individual plan. Staff did not implement the supervision level correctly. Staff must provide the required supervision level at all times. PLAN OF CORRECTION: Training session in person will be held with 29 N 4th Street staff on the proper implementation of the ISP, and staff will sign that they understood the training and participated. 08/01/2023 Implemented
SIN-00217637 Renewal 01/10/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)At the time of inspection there were several receipts from McDonald's that appeared to have purchases that were more than for the individual's benefit. Example of this was multiple large sandwiches and drinks on one transaction. Dates of these receipts were 8/19/22 in the amount of $16.49; 8/14/2022 in the amount of $21.48; 7/18/22 in the amount of $28.34; 11/12/22 in the amount of $15.86; 11/14/22 in the amount of $14.17. Due to the number of items purchased on each receipt and the amounts spent it is not clear that the individual is using her money for her benefit only.Individual funds and property shall be used for the individual's benefit. Since the inspection, the log has been reviewed in depth. The individual utilizes her spending money when going out with staff and when going out alone with her father on a weekly basis. Providence started working on colloborating with her BSS, her father and staff on detailed logging, exploitation and her rights. 03/01/2023 Implemented
6400.22(d)(2)Individual #1 is not able to manage her own finances as per her assessment. Individual has a rep payee to assist with finances. Providence has a policy for individual funds and property. This policy states that any funds received must be recorded in the individual's account ledger with the date, amount, memo, and from whom the payment was made. This will be kept in electronic spreadsheet record and is available through the financial department. At the time of inspection, I was looking at the financial transactions on the ledger. Staff report that individual has a debit card, and the remaining balance is not always known. The only information on the ledger was the purchase amount and place of purchase. Also, at the time of the inspection individual #1 had $11.65 cash. There was no documentation when this money was received on the ledger. It was suggested that individual father gave her $20 during a visit. This was not documented in the log, nor was any cash purchase documented on the log. Disbursements made to or for the individual should be documented.(2) Disbursements made to or for the individual. Providence Financial Department will be updating policy and contacting individual #1¿s repayee with information. Also, the present log has already been reviewed in depth. The individual utilizes her spending money when going out with staff and when going out alone with her father on a weekly basis. Providence started working on colloborating with her BSS, her father and staff on detailed logging, exploitation and her rights. 03/31/2023 Implemented
6400.62(a)At the time of inspection, it was stated that all poisons are made inaccessible to individuals. The side door of the home had a large bag of rock salt which was not locked and accessible should an individual use that exit.Poisonous materials shall be kept locked or made inaccessible to individuals. Poisons should not be accesible to the individuals in the home. Staff were using it due to inclement weather and icy outside conditions, and at the time of inspection had not locked it back up. Immediately after inspection, it was removed from the home completely by management. 02/10/2023 Implemented
6400.64(a)The bathroom on second floor did not uphold clean and sanitary conditions. The shower had what appeared to be mold like substance around the edge of the tub, in addition to what appeared to be soap scum build up on the tub walls. There was also a broken loofah, and a very dirty wash cloth on the windowsill which was reported to be the individuals for bathing purposes.Clean and sanitary conditions shall be maintained in the home. The individuals residing in the home shower and take baths frequently and there may have been residual soap scum after the morning shower right before inspection. After the inspection, Program Specialist spoke with the staff about the build up. The loofah and washcloth were removed immediately. 02/10/2023 Implemented
6400.64(f)At the time of inspection, the outside garbage was overfilled with trash. The receptacle bins did have lids; however, the bins were not able to be closed due to the excess garbage.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.Another trash bin was purchased immediately. The receptacle bins all have lids, but garbage is accumulating faster now that there are 2 individuals living in the home instead of 1. The bins were overflowing at the time of inspection- another bin was needed. 02/10/2023 Implemented
6400.66The side entrance of the home which leads into the laundry area did not have an exterior light. Outside doorways and fire escapes shall be lighted to assure safety.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. During inspection, The back door which leads to the side of the home did not have a light on the exterior. Outside doorways shall be lighted to assure safety. Since the inspection, the lightbulb was replaced. Moving forward, Providence¿s new Residential Coordinator Assistant will ensure that anything that needs to be replaced is reported immediately and that the Maintenance, Repair and Replacement forms are submitted by staff in a timely manner-the forms were created last year. 02/10/2023 Implemented
6400.67(a)The upstairs bathroom window was not able to be opened. In addition, there were 2 cupboards in the kitchen which were cracked. The top right white cupboard with the lock was cracked, as well as the bottom black middle cupboard was cracked. Surfaces shall be in good repair.Floors, walls, ceilings and other surfaces shall be in good repair. During the inspection, The upstairs bathroom window was not able to be opened. In addition, there were 2 cupboards in the kitchen which were cracked. The top right white cupboard with the lock was cracked, as well as the bottom black middle cupboard was cracked. Surfaces shall be in good repair. Individual #2 and #1 can be very property destructive. The window in the bathroom does open and shut- but Program Specialist had difficulty during the time of the inspection. The cupboards in the kitchen were punched and pulled by the individuals living in the home and deteriorated over time. Since the inspection, a work order to the Providence maintenance contractors was submitted, however, the cupboards have been broken again since then. Maintenance has been re-contacted for repair of the cupboards. 03/01/2023 Implemented
6400.70At the time of inspection, the landline did not have a dial tone, making the landline not operable.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. At the time of inspection, the landline did not have a dial tone, making the landline not operable. There must be an operating, landline phone in every home. Providence just changed the house phone from a cordless to a corded house phone due to the individual #1 frequently throwing the cordless house phone at staff and across the room when upset. During the time of inspection, the dial tone was not operating for some reason. Immediately after, a cell phone was placed with a charger at the home to be accessible to the staff and individual #1, and upper management was contacted to reach out to RCN to have the phone line reconnected. The landline phone dial tone has since been working and the new house corded phone is in use, and the cell phone was removed. 02/10/2023 Implemented
6400.72(a)Individual #2-bedroom window to the right did not have a screen.Windows, including windows in doors, shall be securely screened when windows or doors are open. During the inspection, it was observed that Individual #2-bedroom window to the right did not have a screen. The window screen issue was reported to Providence maintenance and Program Specialist reached out to Licensing to inquire about how to maintain compliance with the window. It is frequent that individual #2 will push out the screen, then throws clothing and shoes out the window when in his bedroom, which then land on the roof of the home. Providence maintenance then regularly must remove the items from the roof. 03/01/2023 Implemented
6400.81(f)The bathroom on first floor and on second floor did not have hand soap.Each bedroom shall have direct access to a corridor, living area, dining area or outdoors. During time time of inspection, the bathroom on first floor and on second floor did not have hand soap. Providence is aware that the hand soap (free and clear) is required to be present in the bathrooms at all times unlocked. Providence staff get refills of the soap at the Providence office. Staff must have been obtaining refills the day of inspection. 02/10/2023 Implemented
6400.81(k)(3)Individual #2 did not have appropriate bed linens. The pillow did not have a pillowcase on it. The bed did not have blankets appropriate for the season. The bed had a thin flat sheet and a thin flannel sheet on top of the bare mattress.In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season.At inspection, Individual #2 did not have appropriate bed linens. The pillow did not have a pillowcase on it. The bed did not have blankets appropriate for the season. The bed had a thin flat sheet and a thin flannel sheet on top of the bare mattress. The bed sheets and pillowcases were being laundered at the time of inspection. Individual #2 is incontinent on the bed every night of both bowel and bladder. Program Specialist requested additional bed sheets and pillow case packs to be ordered by the office. Individual #2 also does not like to keep sheets, blankets or pillow cases on the bed when sleeping through the whole night. 02/10/2023 Implemented
6400.110(a)The second floor of this home did not have an operable smoke alarm. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. At inspection time, the second floor of this home did not have an operable smoke alarm. Individual #2 tears down various items he is able to reach when upset-the smoke alarm in the hallway outside the bedrooms is one of them. Right before inspection, he tore down the alarm. Staff did not contact Providence management in a timely manner. After inspection, Program Specialist requested from the office a new smoke alarm and it was replaced. Residential Coordinator Assistant ensure replacement was completed immediately. 02/10/2023 Implemented
6400.111(e)The second floor of this home has a spare room which is reported to be a locked room. The fire extinguisher was located inside this room, which would not allow for easy accessibility in the event of an emergency. A fire extinguisher shall be accessible to staff persons and individuals. During the inspection, the second floor of this home has a spare room which is reported to be a locked room. The fire extinguisher was located inside this room, which would not allow for easy accessibility in the event of an emergency. The fire extinguisher was most likely moved to a different spot (staff office-locked room) due to individual #1 and individual #2¿s tendencies to throw items when upset-staff probably moved it during a behavioral episode and forgot to move it back out. Since the inspection, the fire extinguisher on the 2nd floor is being kept right inside the doorway of the attic for easy accessibility to grab during a fire emergency. There is also a fire extinguisher up at the top of the attic stairs. 02/10/2023 Implemented
6400.112(c)Fire drills documented as being completed in 2022 did not indicate any problems 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. During the inspection, it was found that Fire drills documented as being completed in 2022 did not indicate any problems 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(d)The fire drill held on 3/27/2022 had an evacuation time of 3 minutes and 20 seconds. The fire drill held on 5/26/22 had an evacuation time of 2 minutes and 47 seconds. Both of these drills' evacuation time exceeds the 2 and half minute time frame. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. At inspection, it was discovered that the fire drill held on 3/27/2022 had an evacuation time of 3 minutes and 20 seconds. The fire drill held on 5/26/22 had an evacuation time of 2 minutes and 47 seconds. Both of these drills' evacuation time exceeds the 2 and half minute time frame. Providence did not realize that the exceeding the recommended safe window of 2 and a half minutes was a violation. Staff obviously have to assist some individuals with evacuation, and help them get out as quickly as possible without getting hurt or inducing a behavior that could cause a real fire situation to become even more dangerous. Since the inspection, Program Specialist updated the Residential Fire Drill Logs at all the homes to contain all necessary and pertinent information. The bottom of the log includes the expected 2.5 minute evacuation time that is considered safe. If evacuation occurs out of the 2.5 timeframe, a second fire drill will be held later in the same month. If that evacuation fails to meet the expected 2.5 minute timeframe, Providence will re-assess the needs of the individuals, the evacuation plan being utilized by staff, and consult a fire safety expert if necessary. 02/10/2023 Implemented
6400.112(e)There was a sleep drill documented on 3/27/22 at 12:45am and again on 5/26/22 at 2:10am. The sleep drills should be held every 6 months. According to the fire drill log, another sleep drill should have occurred in November 2022.A fire drill shall be held during sleeping hours at least every 6 months. There was a sleep drill documented on 3/27/22 at 12:45am and again on 5/26/22 at 2:10am. The sleep drills should be held every 6 months. According to the fire drill log, another sleep drill should have occurred in November 2022. 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 4th Street. 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. ((Sleep drills have since been conducted and evacuation occurred within the 2.5 minute timeframe -CH 3/29/23)) 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
6400.141(c)(3)Individual #1 had a physical exam dated 2/22/22. On this exam it was documented that this individual had her last tetanus vaccine on 5/19/2012. The public health dept recoomeds that the tetanus is updated every 10 years. The individual should have had an updated tetanus vaccine in May of 2022. This is out of compliance.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. It was discovered at inspection, that Individual #1 had a physical exam dated 2/22/22. On this exam it was documented that this individual had her last tetanus vaccine on 5/19/2012. The public health dept recommends that the tetanus is updated every 10 years. The individual should have had an updated tetanus vaccine in May of 2022. This is out of compliance. Individual #1 was very resistant to attending appointments or receiving medical procedures during that time (May-Summer 2022) due to an increase in behaviors and significant mood changes leading to hospital visits. Individual #1 has an appointment for her annual physical at her PCP on 2/28/23 at 2:25pm, and will be receiving the tetanus shot at that time. 02/28/2023 Implemented
6400.142(a)Individual #1 had a dental exam on 11/22/21. There was no dental exam during the year of 2022. Staff report that due to an insurance change, they are in the process of looking for a new dentist. Proof of that was requested during inspection as the dental exam was due in November 2022 and it is currently January 2023. No correspondence was provided to reflect that there were attempts to schedule this apt for the individual.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. At inspection, it was found that Individual #1 had a dental exam on 11/22/21. There was no dental exam during the year of 2022. Staff report that due to an insurance change, they are in the process of looking for a new dentist. Proof of that was requested during inspection as the dental exam was due in November 2022 and it is currently January 2023. No correspondence was provided to reflect that there were attempts to schedule this apt for the individual. There was difficulty scheduling a dental appointment with individual #1¿s insurance change. Since the inspection, a dental appointment has been scheduled for 2/15/23 at 11:30am in Lancaster, PA. 02/15/2023 Implemented
6400.151(a)Staff #1 date of hire was reported to be 7/19/22. The staff physical exam was completed on 8/25/22. The physical exam should be completed prior to the start date of the staff having contact with individuals. 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. During inspection, it was observed that Staff #1 date of hire was reported to be 7/19/22. The staff physical exam was completed on 8/25/22. The physical exam should be completed prior to the start date of the staff having contact with individuals. HR Manager was unable to obtain physical exam copy from staff #1. Since the inspection, HR Manager has an assistant helping with compliance and time tables. 03/01/2023 Implemented
6400.32(r)(5)Individual #2 had a lock on his bedroom door. Staff did not have a key to unlock this door.Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.During inspection, Individual #2 had a lock on his bedroom door. Staff did not have a key to unlock this door. Proper key for knob unable to be located-lost. Individual does not ever lock door or stay in bedroom alone-staffed 2:1. Since the inspection, the key was searched for that fits the knob with no success. A request for a new doorknob with 2 sets of keys requested for by Program Specialist to office. 03/01/2023 Implemented
6400.165(c)Individual #1 is prescribed Polyethylene Glycol Powder. ½ cup into 8oz of liquid daily at 8am. At the time of inspection on 1/11/22 at approx. 10am the medication was not able to be located in the home. The medication administration log was also not signed for this medication for the entire month of January. The medication states it should be taken daily at 8am on the medication administration record, but it also has PRN next to the medication. The contradiction makes it unable to be determined how the medication should be prescribed and if it is being administered as prescribed. The agency purchased a new bottle of the medication for the home that day.A prescription medication shall be administered as prescribed.During the inspection, Individual #1 is prescribed Polyethylene Glycol Powder. ½ cup into 8oz of liquid daily at 8am. At the time of inspection on 1/11/22 at approx. 10am the medication was not able to be located in the home. The medication administration log was also not signed for this medication for the entire month of January. The medication states it should be taken daily at 8am on the medication administration record, but it also has PRN next to the medication. The contradiction makes it unable to be determined how the medication should be prescribed and if it is being administered as prescribed. The agency purchased a new bottle of the medication for the home that day. Providence was switching over to a completely new pharmacy for all of the program¿s individuals on 12/30/22. This process of transition, due to the amount of medications overall, created some inconsistencies on some of the MARs. 02/10/2023 Implemented
6400.166(a)(10)Individual #1 has medications that did not specify the time of administration on the medication administration log. The medications included escitalopram, pantoprazole sod dr, topiramate, and vitamin b-12.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.Providence was switching over to a completely new pharmacy for all of the program¿s individuals on 12/30/22. This process of transition, due to the amount of medications overall, created some inconsistencies on some of the MARs. 02/10/2023 Implemented
SIN-00204493 Unannounced Monitoring 04/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(b)According to April 2022 Medication Administration (MAR) Individual #1 is prescribed Fluticasone Prop 50 Mcg spray use 2 sprays in each nostril once daily at 8am. The designated initial slot on the MAR for the 8am dose of the Fluticasone Prop 50 Mcg spray on 4/28/22 was blank and the medication was not initialed to indicate it was administered nor circled to indicate additional circumstances exist with the administration. The medication was administered as demonstrated by review of the pill pack. The administration of this medication was not recorded as required by this regulation.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.1) According to April 2022 Medication Administration (MAR) Individual #1 is prescribed Fluticasone Prop 50 Mcg spray use 2 sprays in each nostril once daily at 8am. The designated initial slot on the MAR for the 8am dose of the Fluticasone Prop 50 Mcg spray on 4/28/22 was blank and the medication was not initialed to indicate it was administered nor circled to indicate additional circumstances exist with the administration. The medication was administered as demonstrated by review of the pill pack. The administration of this medication was not recorded as required by this regulation. Staff on shift administering medications must initial the MAR in the designated slot with their initials to document accurately that the medication was given. Staff failed to initial the MAR on 4/28/22 after administering the 8:00am dose of Fluticasone Prop 50 Mcg spray. Staff working with individual #1 must be alert and attentive and provide intensive support for individual #1, so that morning he may have had a behavioral episode during administration time that caused the staff to make the error of forgetting to sign for that medication that was administered. 06/10/2022 Implemented
SIN-00202831 Unannounced Monitoring 03/14/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The floor, sink and toilet in the first floor bathroom located off of the kitchen were very dirty with areas of black grime on the floor and what appeared to be dust build up. (Repeat Violation 10/26/21, 1/7/22)Clean and sanitary conditions shall be maintained in the home. The floor, sink and toilet in the first-floor bathroom located off the kitchen were very dirty with areas of black grime on the floor and what appeared to be dust build up. Clean and sanitary conditions shall be maintained in the home. The floors in the downstairs bathroom were old and becoming worn, and despite being cleaned daily, presented the appearance of being grimy and dusty no matter what cleaning staff completed. CEO was notified upon inspection exit call on 3/31/22 that the first-floor bathroom cleanliness was a concern, and due to the age of the floors, reached out to one of the Providence contractors to check out the first-floor bathroom at 29 N 4th Street for potential repair. 04/09/2022 Implemented
6400.80(a)Snow had not been removed from the walkway outside the back door of the home. Outside walkways shall be free from ice, snow, obstructions and other hazards. During the unannounced inspection, it was discovered that snow had not been removed from the walkway outside the back door of the home. Outside walkways shall be free from ice, snow, obstructions and other hazards. Prior to the unannounced inspection, over the weekend, there was a winter storm with snow/rain/ice mix. When the inspection occurred, the back pathway outside had not been cleared of the light coating of snow that remained (not completely melted) from the weekend storm. Due to the very slight amount of snow that remained on the walkway, the staff did not think it was a safety hazard and did not engage in removal or breakdown (utilizing a shovel, salt/ice melt). After the unannounced inspection, the snow melted off the walkway on its own from sunlight and temperature changes with the fluctuating weather patterns. 05/01/2022 Implemented
SIN-00200479 Unannounced Monitoring 02/17/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)On the first-floor bathroom, there was a container of "Wipe Out" antibacterial cucumber melon liquid hand soap which stated to contact poison control if ingested. According to individual #5 Individual Support Plan all poisons should be locked. (Repeat violation 10/26/21 and 10/8/210)Poisonous materials shall be kept locked or made inaccessible to individuals. On the day of inspection, in the first-floor bathroom, there was a container of "Wipe Out" antibacterial cucumber melon liquid hand soap which stated to contact poison control if ingested. According to individual #5 Individual Support Plan all poisons should be locked. (Repeat violation 10/26/21 and 10/8/210). Providence staff who work at the 4th Street home use the bathroom on the first floor- Individual #5 loves to use the bathroom on the second floor for some reason (feels comfortable with it-near his bedroom and the shower/bathtub are in there for him to wash up easily with staff assistance), so he never goes in the first floor bathroom. Staff must have taken out the Cucumber Melon Handsoap (which was no longer supposed to be at the home- only Softsoap free and clear) and used it in the bathroom, and when the Inspector arrived at the home, forgot to lock it back up (perhaps rushed out of the bathroom). After the inspection, Providence Medical Coordinator and Program Specialist spent hours online doing research, and went to a cleaning supply company called Master Supply in Macungie, PA, and were educated by the Manager on safe, more eco-friendly cleaning products. Then, safer, less toxic, more effective and fewer cleaning and laundry products were purchased for every home on 2/25/22. 02/28/2022 Implemented
6400.64(a)The kitchen was straightened however there was a film of grease over the garbage cans and stove. The corrective action plan reflects that a cleaning company would come in monthly to deep clean. Today's visit did not appear the home was deep cleaned. (Repeat violation 1/7/22 and 10/8/21)Clean and sanitary conditions shall be maintained in the home. During inspection, the kitchen was straightened however there was a film of grease over the garbage cans and stove. The corrective action plan reflects that a cleaning company would come in monthly to deep clean. Today's visit did not appear the home was deep cleaned. (Repeat violation 1/7/22 and 10/8/21) After inspection, the fridge and stove were thoroughly cleaned again (please see photos in evidence email). Also, effective March 2022 Baco Cleaners who have been coming to ¿deep clean¿ the group homes once every month will no longer be cleaning the homes due to insufficient services to the standard expected for ¿deep cleaning¿. Providence instead purchased 2 more carpet shampooers (see evidence email photo), updated the Shift Inspection Checklist (see checklist in evidence email), and Providence Medical Coordinator and Program Specialist spent hours online doing research, and went to a cleaning supply company called Master Supply in Macungie, PA, and were educated by the Manager on safe, more eco-friendly cleaning products. Then, safer, less toxic, more effective and fewer cleaning and laundry products were purchased for every home on 2/25/22. 02/28/2022 Implemented
6400.67(a)The attic had what appeared to be water damage on the ceiling. The attic had a window and the part of the ceiling above the window area was very much deteriorated. There was a separation in the ceiling where pieces of the drywall were crumbling on the floor beneath. There was a lot of paint chips and ceiling particles on the floor under the portion of the ceiling which had said damage. (Repeat violation 1/7/22, 10/14/21 and 10/8/21)Floors, walls, ceilings and other surfaces shall be in good repair. During the inspection, it was discovered that the attic had what appeared to be water damage on the ceiling. The attic had a window and the part of the ceiling above the window area was very much deteriorated. There was a separation in the ceiling where pieces of the drywall were crumbling on the floor beneath. There was a lot of paint chips and ceiling particles on the floor under the portion of the ceiling which had said damage. (Repeat violation 1/7/22, 10/14/21 and 10/8/21). The attic is not utilized for anything so the deterioration went unnoticed by staff. After the inspection, Residential Coordinator contacted the Providence contractor who checked out the attic ceiling and window after inspection to plan how to fix it. 03/10/2022 Implemented
6400.67(b)The basement door had various cleaning supplies and ice melt which were stored directly inside the doorway. The products blocked the ability to access the steps. All products had to be moved to allow access to the basement during the inspection. The upstairs bathroom windowsill was not free from hazards. The window was cracked to allow steam from the shower out. Upon inspecting the bathroom it was noted that inside the windowsill there was old screws, what appeared to be pieces of drywall or plaster, and paint shavings Floors, walls, ceilings and other surfaces shall be free of hazards.At the time of inspection, the basement door had various cleaning supplies and ice melt which were stored directly inside the doorway. The products blocked the ability to access the steps. All products had to be moved to allow access to the basement during the inspection. The upstairs bathroom windowsill was not free from hazards. The window was cracked to allow steam from the shower out. Upon inspecting the bathroom it was noted that inside the windowsill there was old screws, what appeared to be pieces of drywall or plaster, and paint shavings. There were so many cleaning and laundry products being used at the home, and the staff were running out of storage to the point where it was taking up quite a bit of the space in the basement doorway. The basement is not utilized for anything except storage. The window in the upstairs bathroom is old, and so many repairs have been done to the home, so the screws and paint shavings found in the windowsill while it was open to air out the bathroom must have come loose and fallen into the sill. After inspection, the debris was cleaned out of the window sill by the Program Specialist (please see photo in evidence email). Providence Medical Coordinator and Program Specialist then went to every group home and collected the cleaning, hand soap (other than free and clear) and laundry products and brought all of them to the office to be discarded- but replaced them with the new, safer, less toxic products (please see photo in evidence email). Less chemicals in the home that are toxic and hazardous= safer environment for the individuals. 02/28/2022 Implemented
6400.82(f)First floor bathroom, and second floor bathroom did not have paper towels. Second floor bathroom also did not have a hand soap. (Repeat violation 1/7/22 and 10/8/21)Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. During the inspection, the first floor bathroom, and second floor bathroom did not have paper towels. Second floor bathroom also did not have a hand soap. (Repeat violation 1/7/22 and 10/8/21) Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle (82f). Individual #5 utilizes the second floor bathroom and throws things because he can¿t always verbally express his wants and needs. Staff must have put the handsoap out of reach of throwing when not in use, and forgot to put it back, and the paper towels- same thing. The first floor bathroom probably needed a fresh, new roll because they ran out, and upon inspection had not put the new roll in the bathroom yet. After inspection, Residential Coordinator and Program Specialist contacted Providence contractor. Providence Contractor installed an automatic paper towel dispenser on the wall of the first floor bathroom (see evidence photo) to ensure that paper towels flow easily in that bathroom and refill need is evident. 03/10/2022 Implemented
6400.165(c)Individual #5 was prescribed Risperidone 4mg tablet, one tablet to be administered at 7pm. Prior to the medication inspection, licensing asked agency how the medication blister packs correlate with the date. Agency reports that the blister packs follow the day of the month which the medication is popped for. The medication was signed out on the medication administration log for 2/16/2022. However, there were 2 blister packs of Risperidone and both packs were full. It was unable to determine if the medication was administered. Individual #5 is prescribed Divalproex SOD ER 500 mg and 1 tablet is to be taken at 8pm. The day of the inspection was on 2/17/2022. Upon inspecting the medication, licensing rep asked agency staff about the medication blister packs and how it correlates to the date. Agency reports that the blister packs follow the day of the month which the medication is popped for, for example on 2/17/2022 the 17th blister would be popped for the administration for the medication. This medication was to be provided at 8pm. The inspection was conducted at 10am. The medication Divalproex was signed out for 2/16/2022, however the medication was missing from the 17th blister. It was unable to determine if the medication was administered. (Repeat violation 1/7/22 and 10/8/21)A prescription medication shall be administered as prescribed.Individual #5 was prescribed Risperidone 4mg tablet, one tablet to be administered at 7pm. Prior to the medication inspection, licensing asked agency how the medication blister packs correlate with the date. Agency reports that the blister packs follow the day of the month which the medication is popped for. The medication was signed out on the medication administration log for 2/16/2022. However, there were 2 blister packs of Risperidone and both packs were full. It was unable to determine if the medication was administered. Individual #5 is prescribed Divalproex SOD ER 500 mg and 1 tablet is to be taken at 8pm. The day of the inspection was on 2/17/2022. Upon inspecting the medication, licensing rep asked agency staff about the medication blister packs and how it correlates to the date. Agency reports that the blister packs follow the day of the month which the medication is popped for, for example on 2/17/2022 the 17th blister would be popped for the administration for the medication. This medication was to be provided at 8pm. The inspection was conducted at 10am. The medication Divalproex was signed out for 2/16/2022, however the medication was missing from the 17th blister. It was unable to determine if the medication was administered. (Repeat violation 1/7/22 and 10/8/21). Since the inspection, Pharmaceutical Nurse Educator/RN created a new checklist for Daily Medication box checks, and has traveled to every Providence group home on a daily basis since 2/24/22 checking every box for every individual at every Providence group home in Lehigh County and utilizing the new Daily version of the checklist (please see new checklist in evidence email). Pharmaceutical Nurse Educator/RN also fully Medication Administration trained 2 more Providence Direct Care/CS staff since the inspection on 2/17/22 help maintain compliance (please see certificates in evidence email). 05/26/2022 Implemented
SIN-00199340 Unannounced Monitoring 01/07/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The bathroom located on the second floor of the home had a strong smell of urine although no visible urine was found. The vanity located in the first floor bathroom had an oval shaped area on the inside bottom, approximately 12 inches by 6 inches, that was covered with a black, mold-like substance. The ceiling vent fan in the first floor bathroom was covered with a layer of dust and dirt. The front of the refrigerator was covered in smears that appeared to be dirt that was wiped with a dirty rag. The bottom vent on the refrigerator was covered with dust and dirt. The side and part of the front of the stove was covered with what appeared to be grease and food spills. REPEAT VIOLATION from: 10/08/21-10/14/21 (SIN-00194368) 10/08/19-10/09/19 (SIN-00164047) 10/11/18 (SIN-00143549)Clean and sanitary conditions shall be maintained in the home. Clean and sanitary conditions shall be maintained in the home. During the unannounced inspection, the bathroom located on the second floor of the home had a strong smell of urine (although no visible urine was found). The vanity located in the first-floor bathroom had an oval shaped area on the inside bottom, that was covered with a black, mold-like substance. The ceiling vent fan in the first-floor bathroom was covered with a layer of dust and dirt. The front of the refrigerator was covered in smears that appeared to be dirt that was wiped with a dirty rag. The bottom vent on the refrigerator was covered with dust and dirt. The side and part of the front of the stove was covered with what appeared to be grease and food spills. Immediately after inspection, Providence Group Home Residential Coordinator along with the staff cleaned the second-floor bathroom floor by mopping (eliminating the urine smell). The vanity cabinet in the downstairs bathroom was scrubbed on the spot where the black stain was discovered, and it was removed. The vent in the downstairs bathroom was wiped and cleaned of the dust/dirt. The front of the refrigerator was cleaned utilizing a special cleaner purchased immediately after inspection for the stainless-steel surface (*see email evidence pics), as well as the bottom vent that had dust/dirt. The front and sides of the stove were scraped with an oven cleaning tool and cleaner immediately after inspection. 02/26/2022 Not Implemented
6400.67(a)The lid of the toilet tank had been broken and the tank was covered with duct tape and cardboard. The toilet paper holder was broken off from the wall with the pieces laying on the floor. REPEAT VIOLATION : 10/14/21)Floors, walls, ceilings and other surfaces shall be in good repair. Floors, walls, ceilings and other surfaces shall be in good repair (67a). During the unannounced inspection, the lid of the toilet tank had been broken and the tank was covered with duct tape and cardboard. The toilet paper holder was broken off from the wall with the pieces laying on the floor. Immediately after inspection, the toilet paper holder in the upstairs bathroom was fixed by the Residential Coordinator (*see evidence email pic). The toilet paper holder was ripped off by individual #1 (he is very property destructive due to inability to verbally communicate all of his wants and needs). 01/14/2022 Implemented
6400.68(b)The hot water temperature measured in the second floor bathroom at the time of the inspection was 132.9 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. During the unannounced inspection, the hot water temperature measured in the second-floor bathroom at the time of the inspection was 132.9 degrees Fahrenheit (68b). Hot water temperatures in bathtubs and showers may not exceed 120°F. This is a safety concern for Individual #1. After the unannounced inspection, it was discovered that the water heater was broken at the 4th street home. The water temperature was turned all the way down on the heater in the basement, so the water should have been actually below 120 degrees Fahrenheit, but was registering at 132.9 during the inspection. After Residential Coordinator figured out that the water heater must be broken and that is what caused the high temperature, she immediately contacted the Providence contractor who checked the heater and confirmed the whole system needed to be replaced. 01/31/2022 Implemented
6400.82(f)The second floor bathroom did not have a wall mirror, soap, toilet paper or individual clean paper or cloth towels.(Repeat Violation 10/8/21)Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. At the time of the unannounced inspection, the second-floor bathroom did not have a wall mirror, soap, toilet paper or individual clean paper or cloth towels. Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle 82(f). Individual #1 is property destructive and tends to throw items. The hand towels, soap, small garbage can, and mirror were out of reach of individual #1 because of this except for when Individual #1 and his staff were in the bathroom and the items were then taken out and in use. Staff were spoken to regarding leaving out the items by Residential Coordinator. 01/10/2022 Not Implemented
6400.110(a)The attic door was locked and staff did not have a key. The licensing inspector was unable to verify that there was an operable smoke detector on the attic level. (REPEAT VIOLATION 10/8/21) A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. During the unannounced inspection, the attic door was locked and staff did not have a key. The licensing inspector was unable to verify that there was an operable smoke detector on the attic level. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic (110a). After inspection the lock was removed. There is a smoke alarm on the attic ceiling that the inspector was unable to view (*see evidence email pic). 01/10/2022 Implemented
6400.110(c)There were no smoke detectors located in the second floor hallway near the bedroom doorways. There was a smoke detector located in the second bedroom; however, smoke detectors are required to be located in common areas or hallways.The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. There were no smoke detectors located in the second-floor hallway near the bedroom doorways. There was a smoke detector located in the second bedroom; however, smoke detectors are required to be located in common areas or hallways (110c). Individual #1 had just ripped down the smoke detector after a behavioral episode, which is something he has done before (he can reach them-he is tall and can rip them out of the low ceilings on the second floor). Immediately after inspection, Residential Coordinator went to the home and put the smoke detector back up and secured it. 01/08/2022 Implemented
6400.111(a)The attic door was locked and staff did not have a key. The licensing inspector was unable to verify that there was an operable fire extinguisher with a minimum 2-A rating on the attic level.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. During the inspection, the attic door was locked, and staff did not have a key. The licensing inspector was unable to verify that there was an operable fire extinguisher with a minimum 2-A rating on the attic level. There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic (111a). After inspection the lock was removed. There is a fire extinguisher that is recharged and ready for use in the attic that the inspector was unable to view (*see evidence email pic). 01/08/2022 Implemented
6400.165(c)The January 2022 Medication Administration Record (MAR) for Individual #1 includes the following medication order: "Earwax treatment 6.5% drops, place 5-10 drops in each ear every other Saturday at 8AM and 8PM." The January 2022 MAR contains documentation that the medication was administered on 1/03/2022 by Staff #1 and Staff #2. 1/03/2022 was a Monday, not a Saturday as ordered by the prescribing physician. The January 2022 Medication Administration Record (MAR) for Individual #1 includes the following medication order: "Hydrogen peroxide 3% solution, place 4-5 drops in each ear every other Saturday at 8AM." The January 2022 MAR contains documentation that the medication was administered on 1/10/2022 by Staff #1. 1/10/2022 was a Monday, not a Saturday as ordered by the prescribing physician. (Repeat Violation 10/8/21)A prescription medication shall be administered as prescribed.During the inspection, the January 2022 Medication Administration Record (MAR) for Individual #1 includes the following medication order: "Earwax treatment 6.5% drops, place 5-10 drops in each ear every other Saturday at 8AM and 8PM." The January 2022 MAR contains documentation that the medication was administered on 1/03/2022 by Staff #1 and Staff #2. 1/03/2022 was a Monday, not a Saturday as ordered by the prescribing physician. The January 2022 Medication Administration Record (MAR) for Individual #1 includes the following medication order: "Hydrogen peroxide 3% solution, place 4-5 drops in each ear every other Saturday at 8AM." The January 2022 MAR contains documentation that the medication was administered on 1/10/2022 by Staff #1. 1/10/2022 was a Monday, not a Saturday as ordered by the prescribing physician. (Repeat Violation 10/8/21). A prescription medication shall be administered as prescribed (165c). The medication order has been reviewed and updated to reflect the correct time. Spoke with the Pharmacy manager to determine the reason that the order was put into the system the way it was. It was determined that the system did not correctly assign the dates properly. The pharmacy manager assured that this would not happen again. 02/01/2022 Not Implemented
6400.195(a)At the time of inspection, both the hot and cold water of the sink in the second-floor bathroom had been shut off at the valves under the sink by the staff. Staff #1 turned the water back on at the valves so the licensing inspector could measure the temperature of the hot water. Staff #1 explained that the water was turned off at the valves so that Individual #1 would not drink water directly from the faucet. The staff explained that the water was turned off to protect the Individual from both germs and drinking too much water, a documented behavior. Individual #1 is not capable of turning the valves on and off independently. There is no restrictive plan in place to address the documented behavior and restricting access to water or other beverages. For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team as required in 6400.194 (relating to human rights team), prior to use of a restrictive procedure.For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures.At the time of inspection, both the hot and cold water of the sink in the second-floor bathroom had been shut off at the valves under the sink by the staff. Staff #1 turned the water back on at the valves so the licensing inspector could measure the temperature of the hot water. Staff #1 explained that the water was turned off at the valves so that Individual #1 would not drink water directly from the faucet. The staff explained that the water was turned off to protect the Individual from both germs and drinking too much water, a documented behavior. Individual #1 is not capable of turning the valves on and off independently. There is no restrictive plan in place to address the documented behavior and restricting access to water or other beverages. For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team as required in 6400.194 (relating to human rights team), prior to use of a restrictive procedure (195a). After inspection, Residential Coordinator met with staff #1 regarding the ISP/BSP and what is considered restrictive. It was explained that the water can¿t be controlled and shut off by staff if it is not on a Restricted plan. 02/10/2022 Implemented
SIN-00195163 Unannounced Monitoring 10/26/2021 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Both Individual #4 and Individual #5 are not safe with poisons according to their Individual Support Plans. A bottle of Ecosense Sol-U-Mel stain remover was located under the kitchen sink cabinet. The label stated to call poison control.Poisonous materials shall be kept locked or made inaccessible to individuals. Poisonous materials should be kept locked and inaccessible to group home residents if the ISP(s) state that the individual (s) are unsafe to use, identify or be around poisonous materials. During the unannounced inspection, a bottle of Ecosense Sol-U-Mel stain remover was located under the kitchen sink cabinet. The label stated to call poison control. Both individuals #4 and #5 are unsafe around poisons according to their ISPs-due to incontinence issues and behavioral issues involving destruction of property and urinating on furniture, clothing, floors with both individuals, staff have to constantly clean. Therefore, staff accidently placed poisonous stain remover bottle in cabinet that did not have a lock during cleaning process. Immediately after inspection, the residence was inspected in all rooms for items identified as possibly poisonous materials with ¿contact poison control¿ on the label. All items noted were removed and secured in locked cabinet or location secured by lock. 11/12/2021 Not Implemented
6400.144Individual #4 has a medication Alprazolam 0.5 mg for anxiety to be given as needed. The instructions for administration do not contain the symptoms of the mental, emotional, or behavioral conditions that would indicate there is a need for the staff to administer the medication. Providence Home Care has not ensured proper medical services have been provided.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Providence did not ensure proper medical services were provided. Individual #4 has a medication Alprazolam 0.5 mg for anxiety to be given PRN. The instructions for administration do not contain the symptoms of the mental, emotional, or behavioral conditions that would indicate there is a need for the staff to administer the medication. Providence Pharmaceutical Educator (RN) Markel Dunn created a policy for PRN medications that was provided for the staff to reference as a general document for signs and symptoms to illicit utilization of PRN anxiety medication for group home individuals. Markel was unaware that this document was not sufficient for staff to utilize as a reference at the time he created and distributed it. The original policy was removed immediately after inspection. 11/05/2021 Not Implemented
SIN-00194368 Unannounced Monitoring 10/08/2021 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Both Individual #1 and Individual #2 are not safe with poisons and they need to be locked up according to their Individual Support Plan (ISP). Located next to the stackable washer and dryer were 1 gallon of Behr premium interior cabinet & trim enamel, 1 gallon of Glidden Premium Exterior paint and primer, and 2 gallons of Behr premium floor low lustre coating enamel porch and patio floor paint. In the downstairs bathroom under the sink cabinet were Windex Multi Surface disinfectant cleaner, Lysol Clean and Fresh Rain scent toilet bowl cleaner, Scrubbing Bubbles Bathroom Grime Fighter, and Varnish drop.Poisonous materials shall be kept locked or made inaccessible to individuals. Both individual #1 and Individual #2 are not safe around poisons according to both of their ISPs. All poisons must be locked up to ensure that they both stay safe, because they are both unable to safely be around poisons. At 29 N 4th Street group home, Providence had 4 gallons of various enamel, paint, primer, etc. located next to the stackable washer and dryer and in the downstairs bathroom under the sink cabinet (unlocked) Windex, Lysol, toilet cleaner, Scrubbing Bubbles and Varnish drop. Providence maintenance was in the process of painting and repairing various parts of the home due to constant destruction of home by individual #2 and maintenance was unaware of the regulations and left the poisons next to the washer/dryer; cleaning products left under the bathroom sink were stored there by staff after cleaning (staff use downstairs bathroom most often)-staff did not follow protocol of putting poisons back in a locked cabinet. All poisons removed from downstairs bathroom cabinet and placed in locked cabinets by CEO Michael Frazer. The 4 gallons of various enamel, paint, primer, etc. next to the stackable washer and dryer removed from the home by CEO Michael Frazer. 11/05/2021 Not Implemented
6400.64(a)Clean and sanitary conditions shall be maintained in the home. During the monitoring on 10/8/21, the three electrical outlets in the kitchen were covered with a black and brown residue. The refrigerator shelves and door shelves were covered with stains from what appeared to be spilled liquids and food. The kitchen floor was dirty and had remains of food on it such as grapes and cheerios. The kitchen wall cabinets had dirty splatters of orange and brown spots on them which resembled food residue. The downstairs bathroom had several vertical brown stains in the toilet bowl. The upstairs bathroom has a shower/tub combination, and the entire rim of the tub had a red and brown stain around it that resembled a mold like substance. The non-slip bathmat that was hanging over the side of the tub was stained with reddish-brown color. The front left corner of the tub had approximately 5 inches of what resembled a green residue between the tub and the wall. There was fecal matter smeared on the walls in the upstairs bathroom.Clean and sanitary conditions shall be maintained in the home. The kitchen (outlets, refrigerator, countertops, etc.), upstairs bathroom, downstairs bathroom, and hallway were not clean and sanitary- 6400.64(a)- Clean and sanitary conditions shall be maintained in the home. Due to the behavioral issues and supervision levels required per the ISPs of individual #1 and individual #2, the staff at 29 N 4th street had difficulty keeping up with the required cleaning and maintenance at the home. Providence also did not have a Group Home Manager overseeing the staff at the homes since May 2021 to assist with cleaning and sanitizing, and this lack of oversight affected keeping the home in a consistently acceptable state. Providence hired a cleaning crew (Baco Cleaners LLC.) which went over to 29 N 4th Street to clean the home thoroughly after 10/8/21¿provided services on 10/30/21-11/1/21; CEO regularly going to home to ensure cleanliness of home is maintained since 10/8/21*please see photo of contract with Baco Cleaner¿s, LLC. attached in Providence POC email. 11/01/2021 Not Implemented
6400.64(b)There may be no evidence of infestation of insects in the home. Three fly strips were hanging in the kitchen, and two fly strips were hanging in the living room area of the home. All five of the hanging fly strips had an abundance of dead flies on them. While conducting the monitoring on 10/8/21 several flies were flying around the home.There may not be evidence of infestation of insects or rodents in the home. There should be no evidence of infestation in the home. The home should be clean and sanitary and free of infestation. Fly strips were found in the kitchen and living room with dead flies on them during the monitoring visit on 10/8/2021, as well as several flies flying throughout the home. Due to the incontinence of both individual #1 and individual #2, and the frequency of individual #2 coming down into the living room/common area and laying on the couch in his brief (adult diaper), the couches/furniture become soiled attracting flies to the home (especially in the warmer months of the year-the temperature is just starting to cool down). Providence was due for Viking Pest Control to come out and extinguish the flies (last visit was 8/30/21); now that individual #1 is living at the home with individual #2, the issue of furniture soiling/potential incontinence attracting flies has exponentially increased. CEO purchased 2 new couches for the home and had 2 of them removed and disposed of *See evidence photos in Providence POC email. 10/30/2021 Implemented
6400.67(a)Surfaces shall be in good repair. Approximately three ceiling tiles in the living room appear to be buckling. A softball size hole was in the wall at the entryway of the home. Another hole approximately the size of a golf ball was located in the downstairs bathroom wall. The upstairs toilet did not have a handle on it. The upstairs bathroom sink vanity cabinet doors were ripped off and laying inside of the cabinet. The small table on the front porch was covered in rust.Floors, walls, ceilings and other surfaces shall be in good repair. Floors, walls, ceilings, and other surfaces shall be in good repair. The home must be kept in good condition and broken furniture/structures inside and outside the home should be fixed or replaced as quickly as possible. During the monitoring, ceiling tiles in the living room were buckling, a softball size hole in the wall was found in the entryway, another golf ball sized hole was found in the downstairs bathroom wall, and the upstairs toilet had no handle. The upstairs bathroom sink vanity cabinet doors were ripped off and laying inside of the cabinet. The small table on the front porch was covered in rust. Due to the behaviors of individual #1 and individual #2, the required maintenance at the home is constant and serious damage beyond simple repairs are not always fixed instantly (holes in the wall and buckling ceiling/severe structural damage require contractor to come in and fix); so, the damage accumulated by the day of the monitor visit (contractor had not come in yet). Ceiling, wall holes, bathroom cabinet sink doors, toilet handle, and small table outside on the front porch were all repair- wall holes were filled and painted, ceiling tiles were removed, and damaged/rotting wood replaced with new wood tiles and repainted, cabinet sink doors re-attached securely, toilet handle replaced, and small table outside on front porch (and the chairs) rust removed and spray painted white *see attached photos in Providence POC email 10/31/2021 Not Implemented
6400.67(b)The wall vent located in the upstairs bathroom was bent in half while still attached to the wall exposing sharp edges causing a safety hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.During the monitoring, the wall vent located in the upstairs bathroom was bent in half while still attached to the wall exposing sharp edges causing a safety hazard. Providence must ensure that all floors, walls, ceilings, and other surfaces shall be free of hazards to keep the group home individuals safe. Due to a behavioral episode with individual #2, he pulled out the wall vent in the bathroom and it was supposed to be fixed by a contractor but had not been fixed yet when the monitoring visit occurred. Providence CEO Michael Frazer had the wall vent fixed after the 10/8/21 monitoring visit by a contractor so it is no longer sticking out of the wall and posing a safety hazard. *see photo evidence in Providence POC email. 10/31/2021 Not Implemented
6400.80(b)A metal frame to a hospital bed and an old inoperative toilet were both located on the back porch. The hospital bed frame had a puddle of stagnant water in it. The outside of the building shall be well maintained. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.During the monitoring, a metal frame to a hospital bed and an old inoperative toilet were both located on the back porch. The hospital bed frame had a puddle of stagnant water in it. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions to maintain the health and safety of the group home individuals. The metal hospital bed frame belonged to individual #1 and he did not want to use it in his bedroom (it was brought outside until proper disposal was determined). The inoperative toilet had just been removed prior to the monitor visit by a contractor- awaiting proper disposal as well. Both the hospital bed frame and the inoperable toilet that were located on the back porch were removed since the 10/8/21 monitor visit. *please see photos of back porch in Providence POC email. 10/31/2021 Not Implemented
6400.82(f)The upstairs bathroom did not have a mirror, soap, clean paper or cloth towels, garbage can, shower curtain for privacy, or curtain on the window. The downstairs bathroom did not have individual clean paper or cloth towels.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. During the monitoring visit, the upstairs bathroom did not have a mirror, soap, clean paper or cloth towels, garbage can, shower curtain for privacy, or curtain on the window. The downstairs bathroom did not have individual clean paper or cloth towels. Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. This is to ensure individuals can maintain proper hygiene and the home remains clean and sanitary. Providence did not have garbage cans in the bathroom because individual #2 tends to throw them, and he also rips down the shower curtain. The paper towels get thrown as well when he has a behavioral episode, and the soap is locked up that is why it was not out. Individual #2 also has broken things such as mirrors so the mirror was not in the bathroom. Providence is installing industrial paper towel holders into the walls in the upstairs bathroom and downstairs bathroom (one already installed in the kitchen), placing sticky mirrors in the bathrooms (that are hard to take off the wall), and already placed free and clear Soft-soap hand soap and Kleenex brand hand towels in both bathrooms, as well as garbage cans. *Please see photos in Providence POC email. 11/05/2021 Not Implemented
6400.110(a)The home shall have a minimum of one operable automatic smoke detector on each floor. The basement did not have a smoke detector located in it the time of the monitoring on 10/8/21. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. The home shall have a minimum of one operable automatic smoke detector on each floor. The basement did not have a smoke detector located in it the time of the monitoring on 10/8/21. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. To ensure the health and safety of the group home individuals, there must be working smoke alarms in the home. The batteries and wiring system of the alarms were no long functioning and syncing together- Providence needed to purchase new alarms. CEO Michael Frazer purchased new Kidde smoke detectors for each floor, the basement and attic and they are all operable. 10/29/2021 Not Implemented
6400.111(f)On the 4th level of the home which appeared to be the attic level there was a fire extinguisher that was last inspected in February 2019. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. During the monitor visit, on the 4th level of the home which appeared to be the attic level there was a fire extinguisher that was last inspected in February 2019. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. All extinguishers must be up to date. Providence has not had a group home manager since May 2021- the fire extinguisher in the attic was an oversight. CEO brought fire extinguisher to Kistler O¿Brien since 10/8/2021 and all the extinguishers are now up to date. 10/29/2021 Not Implemented
6400.144Individual #1 has a medication Hydroxyzine 50 mg for anxiety to be given as needed. The instructions for administration do not contain the symptoms of the mental, emotional, or behavioral conditions that would indicate there is a need for the staff to administer the medication. Providence Home Care has not ensured proper pharmaceutical services have been provided.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Individual #1 has a medication Hydroxyzine 50 mg for anxiety to be given as needed. The instructions for administration do not contain the symptoms of the mental, emotional, or behavioral conditions that would indicate there is a need for the staff to administer the medication. Providence Home Care has not ensured proper pharmaceutical services have been provided. The instructions describing the symptoms were not available for staff. Individual #1 does not currently have a psych doctor; all medications provided through PCP Dr. Natalie Bieber. Pharmaceutical Nurse Educator/RN Markel Dunn wrote policy/memo describing symptoms and behavioral conditions necessary for the PRN to be administrated by staff and placed the document with the medication for individual #1 with the medication and letter was sent to PCP Dr. Natalie for signature. 11/05/2021 Not Implemented
6400.32(c)On 10/8/21, at approximately 9:00am when the licensing representative arrived at the home for a monitoring visit Individual #1 was only supervised by 1 staff member on the front porch of the home. Staff #1 informed the licensing representative that the second staff went to the main office. Staff #2 returned to the home and was gone for approximately one hour. As per Individual #1's Individual Support Plan (ISP) he is to receive 2:1 direct supervision from staff during awake hours. Individual #2 was only supervised by 1 staff at the home for the entire monitoring on 10/8/21. Individual #2 is to receive 2:1 staffing at all times, even during periods of sleep as per the ISP. Providence Home Care neglected to provide the required supervision to both Individual #1 and Individual #2.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.This regulation is important because the individuals must be provided with the required supervision level described in both individual #1 and individual #2¿s ISPs in order to ensure both individual¿s health and safety are maintained. Providence failed to provide necessary supervision to individual #1 and individual #2 on 10/8/21. Due to the COVID-19 pandemic, and Individual #1 frequent hospitalizations complex behavioral issues, staffing for the 29 N 4th Street group home became extremely difficult. CEO Michael Frazer has been assisting with shift coverage, additional staff have been hired since 10/8/2021, and another agency has been contracted to assist with staffing- Everyday Home Care. 10/28/2021 Not Implemented
6400.162(b)(2)(i)Individual #1 is not self-administering. Individual #1 is purchasing and self-administering the following medications: Antacids Chewables and Stacker 2 B12 Plus Extreme Energy capsules. According to agency staff Individual #1 bought both Antacids and the Stacker 2 B12 Plus Extreme Energy capsules and administered them. Medications must be administered by staff who have completed the Department's Medication Administration Training Course.A prescription medication that is not self-administered shall be administered by one of the following: A person who has completed the medication administration course requirements as specified in § 6400.168 (relating to medication administration training) for the administration of the following: Oral medications.Individual #1 is not self-administering. Individual #1 is purchasing and self-administering the following medications: Antacids Chewables and Stacker 2 B12 Plus Extreme Energy capsules. Both over-the-counter medications were found in his medication lock box during the monitoring visit. According to agency staff Individual #1 bought both Antacids and the Stacker 2 B12 Plus Extreme Energy capsules and administered them. Medications must be administered by staff who have completed the Department's Medication Administration Training Course. Staff placed these medications into his lock box thinking it would be safer for individual #1 if they were locked up (he purchased them himself). After the 10/8/21 monitoring visit (the afternoon of 10/8/21 immediately after), Antacids Chewables and Stacker 2 B12 Plus Extreme Energy capsules found in the medication box- Kathy Rodriques Group Home Medical Coordinator informed PCP Dr. Natalie Bieber; the Antacids were added to QuickMar by Markel Dunn- Pharmaceutical Nurse Educator/RN, and the Stacker 2 B12 Plus Extreme Energy capsules that remained were removed from the box. 11/05/2021 Not Implemented
6400.163(h)Individual #1's pro re nata (PRN) medication Polyethylene Glycol expired 3/2021.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.During the monitoring visit it was found in the medication box that Individual #1's pro re nata (PRN) medication Polyethylene Glycol expired 3/2021. Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. Providence was not properly managing the medication lock boxes to ensure expired medications weren¿t still in the boxes. Providence did not have a group home manager since May of 2021-this person assisted with oversight of the medication boxes. Markel Dunn- Pharmaceutical Nurse Educator/RN properly destroyed of the medication after the 10/8/21 monitor visit. 11/01/2021 Not Implemented
6400.165(c)A prescription medication shall be administered as prescribed. Individual #1's October Medication Administration Record (MAR) showed that staff had administered their Polyethylene Glycol on October 2, 4, 5, 6. 7, and 8th. The MAR reads mix 1 capful with 8 oz liquid and drink daily @ 8a x3 days begin 9/14. The medication was not administered as prescribed.A prescription medication shall be administered as prescribed.A prescription medication shall be administered as prescribed. Individual #1's October Medication Administration Record (MAR) showed that staff had administered their Polyethylene Glycol on October 2, 4, 5, 6. 7, and 8th. The MAR reads mix 1 capful with 8 oz liquid and drink daily @ 8a x3 days begin 9/14. Providence staff did not properly administer the Polyethylene Glycol to individual #1 which put the health of the individual at risk. The medication was supposed to be discontinued but was not properly discontinued or removed from the medication box. Since the monitoring visit on October 8th, 2021, Markel Dunn- Pharmaceutical Nurse Educator/RN removed the Polyethylene Glycol from the medication box for individual #1 and properly destroyed it. 11/01/2021 Not Implemented
6400.165(e)Individual #1 medication Hydroxyzine 50 mg medication label stated to take 1 tablet by mouth daily as needed for allergies and the medication label was blacked out with a sharpie and altered to read anxiety as the diagnosis or purpose for the medication. There was no indication that the label was altered by a pharmacist.Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received.Upon inspection of the medications box during the monitoring visit, Individual #1 medication Hydroxyzine 50 mg medication label stated to take 1 tablet by mouth daily as needed for allergies and the medication label was blacked out with a sharpie and altered to read anxiety as the diagnosis or purpose for the medication. There was no indication that the label was altered by a pharmacist. Providence did not properly make a change to the medication prior to administering it. The pharmacy Providence works with- Newhard¿s pharmacy in Northampton- blacked out the medication label with the sharpie (which is improper and non-compliant). Providence should not have proceeded with administration and Markel Dunn- Pharmaceutical Nurse Educator should have requested new labeling from Newhard¿s Pharmacy when the label was received in the non-compliant way. Markel Dunn- Pharmaceutical Nurse Educator contacted the pharmacy since 10/8/21. 11/01/2021 Not Implemented
6400.166(a)(11)Individual #1's October Medication Administration Record did not include a diagnosis or purpose for their medication Terbinafine.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Individual #1's October Medication Administration Record did not include a diagnosis or purpose for their medication Terbinafine. All medications must include a purpose for administration or diagnosis- Providence failed to provide this for this medication. Markel Dunn- Pharmaceutical Nurse Educator did not realize it; it was a fungal medication for short term use that came when the individual moved from his previous residential provider. Terbinafine was discontinued and is no longer on the MAR. 11/01/2021 Implemented
6400.186A Pairing knife was located in a kitchen drawer. According to Individual #1's Individual Support Plan (ISP) all "sharps" are to be kept locked. The agency failed to properly implement the storage of sharp objects as per the ISP On 10/8/21, at approximately 9:00am when the licensing representative arrived at the home for a monitoring visit Individual #1 only had 1 staff member providing supervision to him on the front porch of the home. Staff #1 informed the licensing representative that the second staff went to the main office. Staff #2 returned to the home and was gone for approximately one hour. As per Individual #1's ISP he is to receive 2:1 direct supervision from staff during awake hours. Individual #2 was being supervised by one staff for the entire monitoring on 10/8/21. As per the ISP Individual #2 is to be receiving 2:1 staff at all times, even when sleeping. Providence Home Care is not implementing both Individual #1 and Individual #2's supervision as per the ISP's.The home shall implement the individual plan, including revisions.During the monitoring visit, a paring knife was in a kitchen drawer. According to Individual #1's Individual Support Plan (ISP) all "sharps" are to be kept locked. The agency failed to properly implement the storage of sharp objects as per the ISP. Providence did not ensure the safety of Individual #1. The proper staffing ratios for individual #1 and individual #2 were not always observed per their ISPs of 2 to 1 necessary. Providence failed to provide the proper supervision on 10/8/21 at the time of the monitoring visit. Staff were not following the ISP by leaving a sharp knife unlocked; staff were most likely focused on providing supervision and support and accidentally placed the knife in the unlocked drawer while putting away dishes. Staff ratios were difficult to maintain due to call-outs from individual #1¿s frequent hospitalizations, and the COVID-19 pandemic. BSS Virshae Campbell updated RPP on 10/13/21 which is at the home for staff to review and sign; ZOOM training conducted on 10/18/21. 11/01/2021 Not Implemented
SIN-00164047 Renewal 10/08/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The license for this agency expires on 11/15/2019. A self-assessment wasn't completed until 10/5/2019 (Repeat Violation: 10/11/2018).The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The self-assessment for the residential home was not completed within the 3-6 month time period out from the license renewal date. Providence Program Specialist was under the impression that the assessment needed to be done within 3-6 months of the renewal date, but was incorrect as far as the time frame. Therefore, the Program Specialist instructed the Group Home Manager to complete the assessment in the incorrect timeframe. Now Providence Program Specialist has the correct assessment form and is aware of the correct time frame schedule. Providence will maintain a calendar that includes due dates of specific tasks, so that Program Specialist and Group Home Manager are aware of the required assessment completion time frame to ensure compliance. Regular updates and observation of the calendar will keep Providence compliant moving forward. 10/31/2019 Implemented
6400.62(d)At the top of the basement steps were shelves containing cleaning supplies. Also, on the shelves were a jar of peanut butter and canned goods (apples, beans, and sweet potato puree).Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.At the top of the basement steps there is shelving and cleaning supplies, peanut butter and canned goods were all found together on the same shelves. This is against regulations. Providence Group Home Manager was not aware that staff had stored these items together in the basement, as the basement is not utilized as a space for the individual or staff to spend time and is hardly ever entered for any reason. Now that Group Home Manager and Program Specialist are aware that these items were stored there, these items have been removed and moving forward a sign will be hung inside the basement explaining the storage/shelving space regulations. 10/31/2019 Implemented
6400.64(a)There was pink mildew around the entire shower where the wall met the tub. The bottom of the tub also had grime and mildew. The floor between the shower and sink had grime and mildew in the grout and corner.Clean and sanitary conditions shall be maintained in the home. The shower area, floor and sink area had signs of pink mildew and grime at the group home. Providence staff were not cleaning the bathroom details as often as necessary considering that the individual living at the group home showers multiple times per day due to incontinence. Providence Group Home Manager will regularly check the bathroom at the group home to ensure compliance with the regulation moving forward, and will purchase special cleaning products for mildew and grime that the staff can utilize regularly. 10/31/2019 Implemented
6400.82(d)There is no shower curtain in the bathroom where Individual #1 showers. There is also no curtain in the bathroom window next to the shower.Privacy shall be provided for toilets, showers and bathtubs by partitions or doors. Curtains are acceptable dividers if the bathroom is used only by one sex or only by individuals 9 years of age or younger. There was no shower curtain on the shower at the group home. Providence management was not aware that the shower curtain purchased by the Group Home Manager and given to staff had not been put up. Staff apparently did not want the individual to rip the curtain down and break it as he always has in the past, so instead they chose to not put the curtain up. Providence is now aware this is a complete violation of the regulation and privacy, so moving forward the Group Home Manager will regularly check the bathroom at this group home to ensure compliance with the regulation, and Program Specialist will supervise. 10/31/2019 Implemented
6400.82(f)Hand soap was not accessible in either bathrooms in this residence.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Handsoap was not visibly accessible in the kitchen or bathrooms at the group home during the audit. Providence locked up the handsoaps and chemicals to ensure safety of the group home individual residing there because he is unaware of chemicals and poisons and will ingest them unintentionally if left out. Whenever the individual uses the bathroom or needs to wash his hands in the kitchen, staff immediately unlock the handsoap and help him use it. Providence is now aware that chemical-free handsoap needs to be accessible at all times for the individuals, even if they are unaware of any dangers. Moving forward, Providence Group Home Manager will be purchasing Softsoap free and clear for the group home so that staff can safely leave handsoap out at all times and it will be very easily accessible for the individual. 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
6400.32(i)Providence Home Care's Cigarette, Cigar and Lighter Storage Policy is as follows: Every Group Home individual that smokes cigarettes or cigars will have all cigarette packs and/or cigars securely locked in a drawer, cabinet or lock box by staff at whatever group home he or she resides at. Any lighters or matches utilized with any cigarettes or cigars by group home individuals will also be securely locked in a drawer, cabinet, or lock box by staff at whatever home he or she resides at. Every group home individual who wants to smoke his or her cigarettes or cigars may ask staff for them at any time, and staff must unlock them along with the lighter or matches and allow the individual to use them. Immediately after use, the individual must return the items to the staff and the items must be placed back in locked drawer, cabinet, or lock box again. The policy as written restricts Individuals' ability to access their personal possessions, specifically cigarettes, cigars and lighters/matches for smoking.An individual has the right of access to and security of the individual's possessions.The cigarette, cigar, and lighter/match policy that Providence created restricts rights to the individuals¿ possessions according to the regulations. Program Specialist was not aware that this policy was restrictive when the policy was created. Providence wants to ensure the safety of all individuals, and in the past, an individual used lighters to attempt to set his dresser, mattress and end table on fire at the group home. This behavior caused the Providence team to create the policy, and while this policy was in place the individuals could ask for cigarettes, cigars and lighters/matches to smoke at any time and staff had to give them to the individual immediately. For the past several months, no individuals living in the Providence group homes actually smoke cigarettes or cigars. All who did smoke have quit or switched to vaping. Now that Providence is aware that this policy is considered restrictive, it is being removed immediately. Providence decided to terminate the policy and create a new policy that is not considered restrictive per regulations by the end of November. Program Specialist will ensure that this is put in place. 11/30/2019 Implemented
6400.52(a)(1)Staff #1 only had 17.75 training hours for the 2018 calendar training year (Repeat Violation: 10/11/2018).The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.Staff #1 did not have 24 hours of training in 2018. The staff person only had 17.75 hours of training. Program Specialist is aware of regulation, but previous HR person was disorganized and important components required of staff were not understood or completed. Now the new HR person is aware of the regulations, and after the audit on 10/8/19, Program Specialist gave HR the new regulations in order to understand and maintain compliance. Moving forward, new HR person is equipped with the proper knowledge of 6400 regulations and has already created a new organization system for the staff files to ensure compliance. HR will be going through all the group home staff files and re-organizing them. HR will coordinate with Program Specialist to make sure all staff that require 24 hours of training get it done. 10/31/2019 Implemented
SIN-00143549 Renewal 10/11/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)A self-assessment was not completed for the home located at 29 N 4th Street, Emmaus within 3 to 6 months of the expiration date of the agency's certificate of compliance. ((REPEAT VIOLATION 11-14-17))The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter.New Group Home Manager Jude Felix will ensure compliance moving forward with this goal. Jude will be notified by Program Specialist Sigrid Hurdle when the agency's certificate of compliance is within 3-6 months of expiring, and he will then complete the self-assessment of the site. Sigrid will ensure that this will not occur again by checking all site expiration dates and informing Jude, and then making sure Jude puts the prior to expiration 3-6 month window for each site in his calendar. Jude will correspond with Sigrid to make sure that all assessments are thoroughly completed. Sigrid will train Jude on how to complete the assessments, along with assistance from Behavioral Director Liz O'Connor. Jude will implement the new process with Sigrid and Liz's help as of January 1, 2019. 01/01/2019 Implemented
6400.31(b)A statement acknowledging the receipt of the information on rights was signed by Individual #1 upon admission on 8/31/17, but not annually thereafter.Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. Program Specialist Sigrid Hurdle will make sure that information on individual's rights will be provided to every individual in the program upon admission, and annually thereafter. Sigrid will also make sure that all individuals in the program sign the document acknowledging that they were informed upon admission, and annually thereafter. Sigrid will ensure compliance and consistency with this correction by setting up mandatory re-assessments and re-education of rights for every calendar year in the month of January. All individuals must be met with and re-sign all annual documents by the end of every January unless newly admitted into the program in a month after the calendar year month of January. No staff training to accomplish this correction, as Sigrid is responsible. 01/31/2019 Implemented
6400.46(a)Staff #1 did not receive orientation relevant to the responsibilities, daily operation of the home and policies and procedures of the home before working with individuals. Staff #3 did not receive orientation relevant to the responsibilities, daily operation of the home and policies and procedures of the home before working with individuals.The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. The Scheduling Manager will notify the Group Home Manager of all new staff going into a home for the first time. The manager will meet the new staff at the home and give the on-site orientation. If the Group Home Manager is not available, the Scheduling Manager will notify the staff member on the schedule to orient the new staff. HR will meet with the Scheduling Manager and the Group Home Manager to talk about the changes being made. The Group Home Manager will communicate it to the Group Home Staff during the monthly staff meeting held that is held in each home. HR will request that the Group Home Manager provide sign off sheets for all new orientees for the on-site orientations on a weekly basis. A memorandum will be sent to all staff outlining the change in procedure. All staff will be asked to sign off indicating that they have read and understand the process for new orientees. 01/01/2019 Implemented
6400.46(b)There was no training syllabus describing the orientation specified in subsection 46(a).The home shall have a training syllabus describing the orientation specified in subsection (a). HR Manager Eileen Confer will develop a training syllabus describing the orientation that utilized at each group home. Eileen will ensure that Jude Felix the group home manager distributes the syllabus of the orientation at each home to each home for reference. Eileen will ensure that the syllabus is utilized by including it within new hire packets for group home employees. Then the process will continue as described in violation of regulation 46 (a): The Scheduling Manager will notify the Group Home Manager of all new staff going into a home for the first time. The manager will meet the new staff at the home and give the on-site orientation. If the Group Home Manager is not available, the Scheduling Manager will notify the staff member on the schedule to orient the new staff.HR will meet with the Scheduling Manager and the Group Home Manager to talk about the changes being made. The Group Home Manager will communicate it to the Group Home Staff during the monthly staff meeting held that is held in each home.HR will request that the Group Home Manager provide sign off sheets for all new orientees for the on-site orientations on a weekly basis.A memorandum will be sent to all staff outlining the change in procedure. All staff will be asked to sign off indicating that they have read and understand the process for new orientees. 01/01/2019 Implemented
6400.46(c)The chief executive officer (CEO) did not have at least 24 hours of training relevant to human services or administration in the most recent complete training year (calendar year 2017). The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually.HR Manager Eileen Confer will make sure that the CEO Michael Frazer will complete his 24 hours of training every calendar year in order to stay in compliance. She will ensure that he completes his 24 hours of training yearly by sending him monthly memos reminding him to complete training hours and to update the number of training hours completed. Eileen will start the monthly reminders as of January 1st, 2019. No staff training regarding this violation is needed. This violation will be corrected by Eileen and Michael. 01/01/2019 Implemented
6400.46(d)Staff #4 (the Program Specialist) did not complete at least 24 hours of training relevant to the human services in the most recent complete training year (calendar year 2017)..Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. HR Manager Eileen Confer will make sure that the Program Specialist Sigrid Hurdle will complete her 24 hours of training every calendar year in order to stay in compliance. Eileen will ensure that she completes her 24 hours of training yearly by sending her monthly memos reminding her to complete training hours and to update the number of training hours completed. Eileen will start the monthly reminders as of January 1st, 2019. No staff training regarding this violation is needed. This violation will be corrected by Eileen and Sigrid. 01/01/2019 Implemented
6400.62(a)Poisons were found unlocked in the home. Individual #1 has been assessed as not safe with poisons. The unlocked poisons were found in the first floor bathroom and included two bottles of Equate brand antibacterial hand soap which was labeled "contact poison control if ingested," and one bottle of grout and tile cleaner which also was labeled "contact poison control if ingested."Poisonous materials shall be kept locked or made inaccessible to individuals. All cleaners and poisonous material are locked up according to the individual¿s ISP. They will be locked in the cabinet under the sink in the kitchen and also the locked closet. Jude the house manager will meet with the staff and re train staff on the importance of following an individual¿s ISP and the dangerous situations the individual could be subject to when an ISP is not followed. Jude will complete this task by the end of January. Jude will follow up weekly on inspecting the homes to ensure poisonous and hazardous material are being locked in their designated areas. 01/31/2019 Implemented
6400.64(a)The walls in the second floor hallway were covered with dirt from an unknown origin. The front bedroom (Individual #1) had a strong smell of urine.Clean and sanitary conditions shall be maintained in the home. The walls of the hallway on the second floor have been cleaned as of the beginning week of December. Jude the house manager will meet with the group home staff the first week of January and go over the importance of cleanliness including cleanliness of the walls of all homes. Staff at the group home will clean the walls with magic erasers weekly and from now on staff will always have cleaning supply on hand to clean any and all walls that have accumulated dirty. 01/04/2019 Implemented
6400.67(a)There was a ceiling tile missing in the living room, near the front door of the home. Three ceiling tiles in the living room, near the front window, were water-stained. There were holes in the wall in the second floor bathroom.Floors, walls, ceilings and other surfaces shall be in good repair. Liz O¿Connor will perform the maintenance needed to bring the home up to code. All missing ceiling tiles will be replaced, including the water stained tiles. The three holes in the wall of the bathroom will be patched, sanded and repainted. Policy will be put into effect by the first week of January. The policy will state that staff will let Liz know within 24 hours of any damaged property. This will be done by the end of the first month of 2019. No additional training is needed as Liz is currently up to date with the regulation. 01/31/2019 Implemented
6400.67(b)There was no sash over the transition from the second floor hallway floor to the hall bathroom floor, creating a potential tripping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.Liz will order the appropriate transition strip for where the floor meets in the hallway going into the bathroom. She will install the strip by the end of the second week in January. To prevent a repeat incident starting January first, Jude the house manager, will inspect any maintenance repairs done in the home to ensure it meets code. No additional training is needed as Jude and Liz are now up to date with the current regulation. 01/11/2019 Implemented
6400.110(a)The interconnected smoke detector located on the basement level of the home was not operable. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Liz O¿Connor will hire a professional alarm and smoke detector installation company to install smoke detectors to ensure proper function and installation. Practice fire drills preformed monthly will ensure the working condition of all detectors and routine maintenance will be preformed by the installation company. Moving forward we will always use a professional installation company to ensure we do not have a repeat of malfunction due to nonprofessional installation. This will be completed and implemented by the end of the first month of 2019. 01/31/2019 Implemented
6400.112(h)There was no documentation of an identified meeting place that individual(s) evacuated to during fire drills. ((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.Jude the house manager will update our current monthly fire drill sheet. This update will include a visual diagram of the meeting place where the consumers go to meet in the case of a fire. A signature page will be added for the consumers and all staff involved in the drill on shift. Included on the signature page will be an area to document the amount of time the drill took from start to finish and which exit was used during the fire drill. Staff will be trained on the new sheets they will be utilizing and what is expected of them during each drill preformed. The fire drill tracking sheets will be updated by the first week of the first month of 2019. Training will be done by Jude the house manager for all staff and will be completed at all sites by the end of the first calendar month of 2019. 01/31/2019 Implemented
6400.113(a)Individual #1 received initial fire safety training upon admission on 8/31/17, but not annually thereafter. 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. Jude the house manager will work with Elizabeth (Individual #1's behavioral specialist) to create a plan of general fire safety procedure including smoke safety, evacuation procedure and the meeting place. Elizabeth will help come up with a plan suitable to Individual #1's ability to comprehend, which will include pictures as he seems to learn better with visual prompts. Individual #1 will be taken thru the plan on a weekly basis acting out the necessary steps to follow until he has grasped the basic routine and is able to perform the procedure with minimal assist. Moving forward when having the monthly fire drills Individual #1 will be observe closely to ensure he has obtained the training and if need be will be taken thru his plan as often as needed. Individual #1 will sign off on the yearly training to the best of his writing ability, (which may consist of just scribble). This will be completed by the last week of February 2019. No further training is needed as the house manager is now up to date on the regulation and requirements. 02/28/2019 Implemented
6400.141(c)(3)There was no record that Individual#1 had a Diptheria /Tetanus immunization or booster within the past ten years, as recommended by the United States Public Health Service.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. Moving forward Immunization history will be received at time of admission by the Program Specialist for each individual. A spread sheet will be created by Katherine the Group Home Coordinator to track the dates of the immunizations and the dates they need to be updated. Those individuals already admitted to Providence that do not have existing immunization records or that can not be found will have blood work done to identify the immunizations they had in their lifetime. Additional training not needed as Katherine is now up to date on this regulation. The new process will be started by February 28, 2019 ((Individual #1 DT Immunization received 1/11/19 -CH 3/6/19)) 02/28/2019 Implemented
6400.141(c)(6)There was no record that Individual #1 had Tuberculin skin testing by Mantoux method.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Kathy the Group Home Coordinator will edit the physical examination form to include Tuberclin Skin Testing by Mantoux method so that every individual in the program moving forward has Tuberculin Skin Testing by Mantoux method consistently every 2 years. If the Tuberculin Skin Testing by Mantoux method is positive, then an initial chest x-ray will be scheduled. Kathy will ensure compliance with this plan of correction by editing the outdated form and replacing it in the electronic files with the new form that include the Tuberculin Skin Testing. No staff training is necessary to accomplish the plan, because Kathy Rodriques is responsible. Kathy will ensure implementation of the new form by the end of the first month of 2019. ((Individual #1 received TB testing 1/10/19 -CH 3/6/19)) 01/31/2019 Implemented
6400.141(c)(9)There was no record that Individual #1 has had a prostate examination.The physical examination shall include: A prostate examination for men 40 years of age or older. Katherine will implement a page thoroughly explaining what is expected of physicians when they complete the annual physical sheet and what is required by ODP. Katherine will thoroughly examine each physical form to ensure each physician has completed the form entirely. This will be implemented immediately. Katherine received a new physical form preferred by ODP from Jackeline via email. The form will be used for each consumer¿s upcoming physical exam. The new form was implemented November 2018 for a consumer at his yearly physical appointment. No additional training is needed for Katherine as she is now up to date on this regulation. ((Individual #1 was seen by his physician regarding a prostate examination and recommendations were given -CH 3/6/19)) 12/01/2018 Implemented
6400.141(c)(11)The annual physical examination dated 12/29/17 for Individual #1 did not document the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. .The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Katherine will implement a page thoroughly explaining what is expected of physicians when they complete the annual physical form and what is required by ODP. Katherine will thoroughly examine each physical form to ensure the physician has completed the form in its entirety. This will be implemented immediately. Katherine received the new physical form preferred by ODP from Jackeline via email. The form will be used for each consumer¿s upcoming physical exam, The new form was implemented November 2018 for a consumer at his yearly physical appointment. No additional training is needed for Katherine as she is now up to date on this regulation. 12/01/2018 Implemented
6400.141(c)(14)The annual physical examination dated 12/29/17 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Katherine will implement a page thoroughly explaining what is expected of physicians when they complete the annual physical form and what is required by ODP. Katherine will thoroughly examine each physical form to ensure the physician has completed the form in its entirety. This will be implemented immediately. Katherine received the new physical form preferred by ODP from Jackeline via email. The form will be used for each consumer¿s upcoming physical exam, The new form was implemented November 2018 for a consumer at his yearly physical appointment. No additional training is needed for Katherine as she is now up to date on this regulation. 12/01/2018 Implemented
6400.142(f)Individual #1's record did not include a written plan for dental hygiene, or documentation from the interdisciplinary team that the individual has achieved dental hygiene independence.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. Katherine the Group Home Coordinator will work with each individual¿s Behavioral Specialist to develop a dental hygiene plan. The plan will be completed by the end of the first month of 2019 calendar year and implemented immediately. This will also be included in each consumer¿s ISP moving forward and will be updated at the yearly ISP revision meeting. Staff will be trained according to each consumers ISP and implement the dental hygiene plan appropriate for that consumer. The dental hygiene plan will be completed by the end of the first month of 2019 calendar year. 01/31/2019 Implemented
6400.143(a)Individual #1 has refused medical and/or dental examinations and treatments, yet there was no documentation of the continued attempts to train the individual about the need for health care in the individual's record.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. A policy will be written addressing the refusal of medical and dental appointments and steps to be taken when that happens. This policy will be written by Katherine the Group Home Coordinator and implemented immediately upon completion of policy creation. Documentation of refusal will be written and kept in each chart upon each occurrence of refusal and education (no staff training, but individual will be trained) will be provided to the individual refusing treatment in terms the individual can understand and will be documented in the chart also. The policy will be written and implemented by the end of the first month of the calendar year 2019. 01/31/2019 Implemented
6400.151(c)(2)Staff #1's most recent Tuberculin skin testing by Mantoux method was 9/13/16.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner.HR Manager Eileen Confer will create an Excel spreadsheet that will track physical examinations and Tuberculin skin testing dates and results. Eileen will create the spreadsheet and implement the new system by January 1, 2019. The spreadsheet will ensure long-term compliance and consistency with physical examinations and the required Tuberculin skin testing and/or chest x-rays. No staff training required to fix this violation. Eileen is responsible and will ensure compliance. (Staff #1 received Mantoux 7/2018 -CH 3/6/19) 01/01/2019 Implemented
6400.151(c)(4)The physical examination dated 1/03/18 for Staff #1 did not include information of medical problems which might interfere with the health of the individuals.The physical examination shall include: Information of medical problems which might interfere with the health of the individuals.HR Manager Eileen Confer has revised the Health Assessment form to include a note to ¿Please complete all fields on this form.¿ The form will be given to all applicants who have been given a conditional offer of employment. HR has also added under ¿Please List any information regarding this individual¿s medical condition that might threaten the health of the clients or prohibit the individual from providing adequate care.¿ a box to check for ¿No medical conditions exist.¿ HR will review all physicals to ensure that all fields on the form are completed. If they are incomplete, HR will reach out the ¿Applicant/Employee¿ and ask them to contact their physician and ask them to complete all fields on the form. If something does not apply, write N/A. No staff training is required. HR is responsible for reviewing all applicant credentials. She will be more diligent in checking that all fields are completed on the Health Assessment. She is aware that if all fields are not completed, that she will reach out the ¿Applicant/Employee¿ and ask them to contact their physician and ask them to complete all fields on the form. If something does not apply, write N/A. 01/01/2019 Implemented
6400.163(c)Individual #1 is prescribed medication to treat the symptoms of a diagnosed psychiatric illness and reviews of the psychiatric medication did not occur every three months. The documentation in the record showed that psychiatric medication reviews occurred on 9/06/17, 4/05/18 and 7/23/18. 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.Katherine the group home coordinator will create a spread sheet to track the last date of each consumers last 90 day med review. Word excel will be used to create the tool to be used for tracking the dates. This will be created and implemented by the end of the calendar year. Reminders will be set in the computer system to go off one week prior to consumers appointment with the psych doctor to ensure the paper work has been prepared. Katherine will contact group home staff and give them reminders to have psych doctor fill out the paper work while consumer is at the appointment and have staff bring completed paper work back to the office immediately following appointments. Correction implemented as of 12/19/18. No staff training will be necessary regarding this violation. Kathy Rodriques is responsible for maintaining compliance. 12/19/2018 Implemented
6400.181(e)(4)The annual assessment dated 9/04/18 for Individual #1 did not include the individual's supervision needs. The assessment must include the following information: The individual's need for supervision. Program Specialist Sigrid Hurdle will edit the current Residential Individual Assessment packets to include the individual's need for supervision. Current assessment is compliant with requirements, therefore, an edit of the current packet should suffice. Program Specialist Sigrid Hurdle will edit the current assessment packet by January 31, 2019. Program Specialist Sigrid Hurdle will ensure consistent use of the updated packet by replacing the outdated version in electronic files so that it is not used again. The new packet will be utilized annually for all individuals in the program. No staff training is necessary for this 6400 regulation violation. Program Specialist is responsible. 01/31/2019 Implemented
6400.186(a)There was no three month review of the ISP for Individual #1 spanning the time period 1/01/18 to 3/31/18.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 Sigrid Hurdle will create a form that will be signed and dated by all individuals in the program on the date of their 3 month ISP meetings. The form will be created and implemented by January 31, 2019. Program Specialist Sigrid will also create a calendar to track the cycle of the 3 month ISP review meetings for every individual in the program to ensure compliance and consistency. No training of other staff regarding this 6400 regulation violation will be necessary. Program Specialist is responsible. 01/31/2019 Implemented
6400.186(b)The ISP reviews were not signed by Individual #1.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Program Specialist Sigrid Hurdle will observe all individuals in the program signing the !ISP review signature sheet after the team has had an ISP review meeting. Program Specialist will develop a document clearly stating that the ISP has been reviewed. All individuals in the program will sign and date the document after team discussion/meeting of the ISPs acknowledging that they agree with the decisions about their goals and the content within their ISPs. The document will be developed and implemented by January 31, 2019. Program Specialist will ensure compliance is maintained by remaining vigilant with checking the 3 month ISP review tracking calendar in correspondence with other violation of regulation 6400.186 (a). No staff training will be necessary regarding this plan of correction. Program Specialist is responsible. 01/31/2019 Implemented
SIN-00205756 Unannounced Monitoring 05/26/2022 Compliant - Finalized