Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00234423 Unannounced Monitoring 11/06/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)At time of inspection on 11/6/23 the "Personal Spending Log: for Individual #1 had one entry dated 10/31/23 for "Giant" in the amount of $60.03 with a current balance of $818.26. Additional receipts for Giant on 11/2/23 for $24.96 and 11/4/23 for $30.82 were in the home and not recorded on the "Personal Spending Log." Both receipts indicated that the "EBT/SNAP/FS card ending in 8098 belonging to Individual #1 had been used to make the purchases. Disbursements made to or for the individual shall be recorded and up to date. (REPEAT VIOLATION 1/10/23)(2) Disbursements made to or for the individual. An individual finance policy was updated. Staff training was conducted on 11/22/2023 on the Updated Policy 11/22/2023 Not Implemented
6400.64(a)The front top surface of the tub was lightly covered with what appeared to be dust and body hair. Approximately twenty hairs were found on the surface. A build up of dust and other debris was found along the edges of the floor and tub where the floor and wall meet. The surface of the kitchen counter under the microwave had an accumulation of food pieces and particles that consisted of elbow macaroni and other dried food particles. Surfaces were cleaned after notification onsite.Clean and sanitary conditions shall be maintained in the home. Surfaces were cleaned after notification onsite. The bathroom was cleaned 11/6/2023 to remove all body hair and debris. 12/31/2023 Implemented
6400.67(a)The paint on the baseboard heat extending from behind the couch and into the dining area showed section of great wear along the carpet as was evidenced by peeling paint and paint chips laying on the carpet.Floors, walls, ceilings and other surfaces shall be in good repair. The Property Management company of the apartment was notified immediately. A second request to Property Management was submitted via email on 12/11/2023. 12/31/2023 Implemented
6400.171At time of inspection a partially used jar of Ragu spaghetti sauce was found in the upper cupboard to the right of the stove. The manufacturer label indicated "Refrigerate after opening." The spaghetti sauce was stored improperly and not protected from contamination. (REPEAT VIOLATION 10/23)Food shall be protected from contamination while being stored, prepared, transported and served. The Spaghetti sauce was immediately discarded. 12/15/2023 Implemented
6400.214(b)At time of inspection on 11/6/23 the Assessment in the home was dated 5/6/22, and the physical in the home was dated 4/25/22. The most current copies of the documents were not located in the home and could not be accessed digitally. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. An updated copy of the Assessment from 5/1/23 and an updated physical from 4/26/23 were put in the home. 12/12/2023 Not Implemented
SIN-00232300 Unannounced Monitoring 10/02/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Clean and sanitary shall be maintained in the home. At the time of the inspection, located in the medication box with Individual #5's medications was an empty Great Value Purified Water bottle that was filled approximately ¼ of the way full with used Trueplus Safety Lancets.Clean and sanitary conditions shall be maintained in the home. The empty Great Value Purified Water bottle that was filled approximately ¼ of the way full with used Trueplus Safety Lancets was immediately removed from the medication box. This was replaced by a medical grade sharps container. 10/09/2023 Implemented
6400.144Individual #5 has a medication Hydroxyzine HCL 50mg, take one tablet by mouth every 8 hours as needed for anxiety, irritability to stay calm, aggression, hitting self, insomnia. 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. (Repeat Violations 8/31/23)Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Confirmation of psychiatric diagnosis and list of potential symptoms received by the physician. QuickMar was updated with this information and policy attached to MAR for reference. QuickMar updated to include area for staff to document what symptoms the individual was demonstrating and who gave approval to administer the PRN medication. 10/22/2023 Implemented
6400.32(r)An individual has the right to lock the individual's bedroom door. Individual #5's bedroom door lock is a "privacy lock". This type of lock can be opened with a tool or device that is not specific to the particular door or lock; such as, a screwdriver or coin. These types of locks do not provide the level of privacy and security of person and possessions as expected by this regulation.An individual has the right to lock the individual's bedroom door.The ¿privacy lock¿ in the individual¿s bedroom was replaced with a more secure lock which uses a unique key to open the lock which provides a greater level of privacy and security. The individual was given the keys to gain access to his bedroom. 10/18/2023 Implemented
6400.165(c)Individual #5 is prescribed Trueplus Safety 28g Lancets, use to test blood sugar twice daily. However, the Medication Administration Record (MAR) for Individual #5 stated Trueplus Safety 28g Lancets, use to test blood sugar once daily. Individual #5's MAR only had the medication being administered at 8am on 10/1 and 10/2. The medication is not being administered as prescribed. Individual #5 is prescribed Gababpentin 600mg, take one tablet by mouth three times a day in the morning, afternoon, and bedtime (9am, 2pm, 9pm). The licensing representative was completing the inspection and at 12:30pm the 2pm mediation administration had already been documented as being administered and it as confirmed by Staff #2 as being administered with Individual #5's 12 noon medication. The medication is not being administered as prescribed. Individual #5 is prescribed Divalproex Sod DR 500mg, take one tablet by mouth 3 times daily at 6am, 2pm, and 10pm for mood disorder. The licensing representative was completing the inspection and at 12:30pm the 2pm mediation administration had already been documented as being administered and it as confirmed by Staff #2 as being administered with Individual #5's 12 noon medication. The medication is not being administered as prescribed. (Repeat Violations 8/31/23)A prescription medication shall be administered as prescribed.Staff will be retrained on the importance of Medication administration as prescribed and proper documentation ensuring to follow the five rights of Medication administration: Right Time, Right person, Right route, Right medication, Right dose. This staff is currently on medical leave. Training will be completed upon his return. 12/15/2023 Implemented
SIN-00230305 Unannounced Monitoring 08/31/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(c)The kitchen of the home did not contain a fire extinguisher with a minimum 2A-10BC rating. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). WHAT HAPPENED & WHY? 6400.111(c) VIOLATION DESCRIPTION: The kitchen of the home did not contain a fire extinguisher with a minimum 2A-10BC rating. CORRECTION REQUIRED: A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection Non-compliant Fire Extinguisher that belonged to the apartment complex was tagged and utilized by the Field Supervisor in the home¿s kitchen. Field Supervisor did not realize it was a non-compliant type of extinguisher. WHAT ARE WE DOING NOW? On the day of inspection, the non-compliant type of fire extinguisher was replaced with the compliant type-2A-10BC. 10/31/2023 Implemented
6400.143(a)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. Individual #1 is prescribed Acne Medication 5% Gel. Individual #1 refused this medication on 8/1/23, 8/2/23, 8/3/23, 8/4/23, 8/7/23, 8/8/23 and 8/30/23.There is no documentation of continued attempts to train the individual about the need for health care documented 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. WHAT HAPPENED & WHY?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. Individual #1 is prescribed Acne Medication 5% Gel. Individual #1 refused this medication on 8/1/23, 8/2/23, 8/3/23, 8/4/23, 8/7/23, 8/8/23 and 8/30/23.There is no documentation of continued attempts to train the individual about the need for health care documented in the individual's record.Providence has gone through staffing changes and shortages within the homes and DSP staff have not executed all protocols and maintained compliance with regulations consistently. What are we doing right now? Immediately after the inspection, Providence Home Care implemented several correction measures right away. 1. Medical Care Coordinator contacted the physician and Hartzell¿s Pharmacy regarding the medications and missing or insufficient documents. Discontinued medications were properly discarded. A. Medical Care Coordinator developed a letter template that will be sent to the physicians for PRNs justification and symptom explanations. The letter template and direct contacts were made to the physicians and Hartzell¿s pharmacy to ensure compliance. The letter template will be used moving forward for every PRN. B. Any refusals by an individual were followed up on by Kathy with the physician and Hartzell¿s Pharmacy. Requests were made to transition frequent refusal medications to PRNs to reduce the frequency and number of formal refusals. 10/31/2023 Implemented
6400.144Individual #1 is prescribed the medication Hydroxyzine HCL 50mg tablet, take 1 tablet by mouth every 10hrs as needed for anxiety. The physician's order did not include written instructions listing the individual's specific symptoms of the psychiatric diagnosis that would warrant the use of an as needed psychotropic medication.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. WHAT HAPPENED & WHY?Individual #1 is prescribed the medication Hydroxyzine HCL 50mg tablet, take 1 tablet by mouth every 10hrs as needed for anxiety. The physician's order did not include written instructions listing the individual's specific symptoms of the psychiatric diagnosis that would warrant the use of an as needed psychotropic medication.Providence has gone through staffing changes and shortages within the homes and DSP staff have not executed all protocols and maintained compliance with regulations consistently. What are we doing right now? Immediately after the inspection, Providence Home Care implemented several correction measures right away. 1. Medical Care Coordinator contacted the physician and Hartzell¿s Pharmacy regarding the medications and missing or insufficient documents. Discontinued medications were properly discarded. A. Medical Care Coordinator developed a letter template that will be sent to the physicians for PRNs justification and symptom explanations. The letter template and direct contacts were made to the physicians and Hartzell¿s pharmacy to ensure compliance. The letter template will be used moving forward for every PRN. B. Any refusals by an individual were followed up on by Kathy with the physician and Hartzell¿s Pharmacy. Requests were made to transition frequent refusal medications to PRNs to reduce the frequency and number of formal refusals. 10/31/2023 Implemented
6400.165(c)Medications are not administered as prescribed. Individual #1 is prescribed Acne Medication 5% Gel; this medication is documented as omitted on 8/1/23. Clonidine HCL 0.2mg tablet by mouth twice daily at noon and bedtime. This medication was documented as omitted on 8/1/23 at 12pm. Divalproex Sodium Dr 500mg tab, take one tablet by mouth three times a day at 6am, 2pm and 10pm. This mediation is documented as omitted on 8/1/23 at 6am and 2pm. Flonase 50mcg at 8am, this medication was documented as omitted at 8am on 8/1/23. Gabapentin 600mg, Metformin HCL 500mg, Metoprolol Tartrate 50mg, Olanzapine 10mg tablet and Tradjenta 5mg tablet These medications are documented as omitted on 8/1/23 at 8am. (Repeat Violation 5/17/23)A prescription medication shall be administered as prescribed.WHAT HAPPENED & WHY? Medications are not administered as prescribed. Individual #1 is prescribed Acne Medication 5% Gel; this medication is documented as omitted on 8/1/23. Clonidine HCL 0.2mg tablet by mouth twice daily at noon and bedtime. This medication was documented as omitted on 8/1/23 at 12pm. Divalproex Sodium Dr 500mg tab, take one tablet by mouth three times a day at 6am, 2pm and 10pm. This mediation is documented as omitted on 8/1/23 at 6am and 2pm. Flonase 50mcg at 8am, this medication was documented as omitted at 8am on 8/1/23. Gabapentin 600mg, Metformin HCL 500mg, Metoprolol Tartrate 50mg, Olanzapine 10mg tablet and Tradjenta 5mg tablet These medications are documented as omitted on 8/1/23 at 8am. (Repeat Violation 5/17/23)Providence has gone through staffing changes and shortages within the homes and DSP staff have not executed all protocols and maintained compliance with regulations consistently. What are we doing right now? Immediately after the inspection, Providence Home Care implemented several correction measures right away. 1. Medical Care Coordinator contacted the physician and Hartzell¿s Pharmacy regarding the medications and missing or insufficient documents. Discontinued medications were properly discarded. A. Medical Care Coordinator developed a letter template that will be sent to the physicians for PRNs justification and symptom explanations. The letter template and direct contacts were made to the physicians and Hartzell¿s pharmacy to ensure compliance. The letter template will be used moving forward for every PRN. B. Any refusals by an individual were followed up on by Kathy with the physician and Hartzell¿s Pharmacy. Requests were made to transition frequent refusal medications to PRNs to reduce the frequency and number of formal refusals. 10/31/2023 Implemented
6400.166(c)If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication administration record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual. Individual #1 is prescribed Acne Medication 5% Gel. Individual #1 refused this medication on 8/2/23, 8/3/23, 8/4/23, 8/7/23, 8/8/23 and 8/30/23. The refusal was documented on the medication administration records, however there was not documentation that the prescriber was notified of the refusals. (Repeat Violation 5/17/23)If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual.WHAT HAPPENED & WHY? If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication administration record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual. Individual #1 is prescribed Acne Medication 5% Gel. Individual #1 refused this medication on 8/2/23, 8/3/23, 8/4/23, 8/7/23, 8/8/23 and 8/30/23. The refusal was documented on the medication administration records, however there was not documentation that the prescriber was notified of the refusals. (Repeat Violation 5/17/23) Providence has gone through staffing changes and shortages within the homes and DSP staff have not executed all protocols and maintained compliance with regulations consistently. What are we doing right now? Immediately after the inspection, Providence Home Care implemented several correction measures right away. 1. Medical Care Coordinator contacted the physician and Hartzell¿s Pharmacy regarding the medications and missing or insufficient documents. Discontinued medications were properly discarded. A. Medical Care Coordinator developed a letter template that will be sent to the physicians for PRNs justification and symptom explanations. The letter template and direct contacts were made to the physicians and Hartzell¿s pharmacy to ensure compliance. The letter template will be used moving forward for every PRN. B. Any refusals by an individual were followed up on by Kathy with the physician and Hartzell¿s Pharmacy. Requests were made to transition frequent refusal medications to PRNs to reduce the frequency and number of formal refusals. 10/31/2023 Implemented
SIN-00217639 Renewal 01/10/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)Individual #1 has an Electronic Benefit Transfer (EBT) card that was used to purchase essential food items for the home that are to be purchased by the provider as outlined in the 6100.684 regulation. EBT cards are to be used to purchase food items desired by the Individual that are in excess of the essential food items purchased by the provider. Grocery receipts for Individual #1 reviewed from 8/23/22 to date of inspection documented that Individual #1 has purchased items such as milk, mozzarella cheese, breadcrumbs, marinara sauce, ground beef. broccoli crowns, American cheese, olive oil spray, yellow rice, hot sausage, grapes, cucumbers, potatoes, chicken breast, macaroni and cheese, bagels, cream cheese, bottled water, hot dogs, hamburger buns, frozen pizza, bread, juice and ravioli. An Individual's funds shall be used for the Individual's benefit.Individual funds and property shall be used for the individual's benefit. An Individual's funds shall be used for the Individual's benefit. The individual utilized his EBT card for essential items that Providence should have purchased. The individual has the right to purchase what the individual wants, but Providence must provide the basic, essential items with the EBT card only being utilized for desired items beyond the essential items. Items purchased with the EBT card should be considered for the individual¿s personal consumption only. 04/20/2023 Implemented
6400.22(d)(1)The Autism/Acap plan with an effective begin date of 7/27/22 for Individual #1 records their financial "Budgeting and the payment of bills are done for him. Providence provides (Individual #1) with the $20 cash every week that * picks up at the office. * can manage only $20 per week." Assessment dated 5/6/22 for Individual #1 states that "gets $20 per week of spending money which * picks up at the Providence office every week in the form of cash." Neither the Autism plan nor the assessment for Individual #1 adequately defines their ability to make a purchase independently or identify dollar and coin amounts. The "6400 Residential Program Spending Log" also labeled as "Cash $" for Individual #1 with an initial log entry made on 8/30/22 records the initial starting amount as $40.00 Bal." The first transaction does not include the $40 that was initially recorded. The transaction entered as occurring on 8/30/22 is recorded as "$15.00-14.80= $.20" indicating that the balance of cash was now $.20. The $40 was not included in the balance moving forward. Additional deposits and transactions made from 8/30/22-10/13/22 are not accurate calculations. Deposits and transactions documented by the Provider during the timeframe would allow for a balance of $76.61 as of 10/18/22. Provider entry of "Balance as of 10/18/22 $25.00" is not accurate or up to date with their own entries. Additionally, balances after the Provider entry on 10/18/22 were recorded as "$13. + change," "$30. + change," and "10. = change" each entry indicating that the Provider was not properly accounting for the funds belonging to Individual #1 or ensuring that the documentation of funds was up to date as required.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. Since the inspection, the log has been reviewed in depth. Amounts of money have been given to individual from father, as well as accumulated amounts have occurred due to the individual not always spending the whole amount of money every week. 03/31/2023 Implemented
6400.112(c)Fire drills documented as being completed in 2022 did not provide an area for entry and documentation of any problems that may have been encountered during the fire drills. Documentation of any problems that may be encountered during a drill is required.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. At inspection, Fire drills documented as being completed in 2022 did not provide an area for entry and documentation of any problems that may have been encountered during the fire drills. Documentation of any problems that may be encountered during a drill is required. Providence did not realize that the fire drill log needed to contain a specific section for the problems encountered during the fire drill. Therefore, it was not specifically noted at the top of the logs. Since the inspection, Program Specialist updated the Residential Fire Drill Logs at all the homes to contain the section for any problems encountered during the drill-including examples to make it easier for staff. 02/10/2023 Implemented
6400.112(e)One sleep drill was documented as being conducted in 2022 at 3:30am on 9/20/22. No other asleep fire drills were documented as being conducted every six months as required.A fire drill shall be held during sleeping hours at least every 6 months. During the inspection, it was found that one sleep drill was documented as being conducted in 2022 at 3:30am on 9/20/22. No other asleep fire drills were documented as being conducted every six months as required. Providence staff lacked management staff to maintain proper fire drill oversight of the overnight drills conducted by staff during 2022 to ensure they were conducted during sleep hours every 6 months at Prospect Ave. Since the inspection, Providence has a new Residential Coordinator Assistant who is in every group home 5-7 days per week to provide oversight and to maintain compliance. 02/10/2023 Implemented
6400.112(h)Fire drills documented as being completed in 2022 did not indicate that individuals evacuated to the designated meeting place outside of the home. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.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)(10)Individual #1's physical was completed on 4/25/22. The yes/no boxes to indicate if Individual #1 was from communicable diseases was not checked on the physical form.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. During the inspection, Individual #1's physical was completed on 4/25/22. The yes/no boxes to indicate if Individual #1 was from communicable diseases was not checked on the physical form. Medical Coordinator accidentally missed this incomplete step on the form that was sent back from the doctor for individual #1. 04/25/2024 Implemented
6400.46(a)Staff #1 received fire safety training on 10/11/22. The certificate achieved indicates that it was awarded for "For successful completion of The Proper Handling of Portable Fire Extinguishers During Simulator Training." A syllabus for the training was requested to ensure that the documented training addressed all regulatory requirements. The syllabus submitted did not document that 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, smoke detectors and fire alarms and notification of the local fire department as soon as possible after a fire is discovered were areas covered in the fire safety training provided. The fire safety training for Staff #1 was not a complete fire safety training of all items as required.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.During the inspection, it was noticed that Staff #1 received fire safety training on 10/11/22 from Kistler O'Brien Fire Protection. The certificate achieved indicates that it was awarded for "For successful completion of The Proper Handling of Portable Fire Extinguishers During Simulator Training." A syllabus for the training was requested to ensure that the documented training addressed all regulatory requirements. The syllabus submitted did not document that 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, smoke detectors and fire alarms and notification of the local fire department as soon as possible after a fire is discovered were areas covered in the fire safety training provided. The fire safety training for Staff #1 was not a complete fire safety training of all items as required. Since the inspection, HR manager made contact multiple times with the fire safety expert to obtain syllabus containing specifics of what is addressed during the training. A full syllabus was put together through collaboration with the company and Providence. 02/10/2023 Implemented
6400.186The Autism/Acap plan with an effective begin date of 7/27/22 for Individual #1 records their financial ability as "Budgeting and the payment of bills are done for him. Providence provides * with the $20 cash every week that * picks up at the office. * can manage only $20 per week." Assessment dated 5/6/22 for Individual #1 states that "gets $20 per week of spending money which * picks up at the Providence office every week in the form of cash." The "6400 Residential Program Spending Log" also labeled as "Cash $" for Individual #1 with an initial log entry made on 8/30/22 records that deposits were made in excess of the amount outlined in both the Assessment and Autism/Acap Plan for Individual #1. On 8/30/22 a deposit in the amount of $40.00 is entered. On 9/14/22 $25.00 and on 10/10/22 $40.00. Documented amounts are in excess of the $20 outlined in both Assessment and Autism/Acap plans. The Individual plan shall be implemented as written.The home shall implement the individual plan, including revisions.Since the inspection, the log has been reviewed in depth. Amounts of money have been given to individual from father, as well as accumulated amounts have occurred due to the individual not always spending the whole amount of money every week. 03/31/2023 Implemented
SIN-00204499 Unannounced Monitoring 04/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(a)When tested the hot water in the bathroom sink reached a temperature of 131 degrees then flow slowed to a trickle that then reached 134 degrees. Staff explained that a device was attached to the faucet which prevented water flow after 120 degrees was reached. Hot water temperature exceeded the allowed 120 degrees prior to tapering to a trickle. The home shall have adequate hot running water under pressure.A home shall have hot and cold running water under pressure. 1) When tested the hot water in the bathroom sink reached a temperature of 131 degrees then flow slowed to a trickle that then reached 134 degrees. Staff explained that a device was attached to the faucet which prevented water flow after 120 degrees was reached. Hot water temperature exceeded the allowed 120 degrees prior to tapering to a trickle. The home shall have adequate hot running water under pressure. Providence¿s contractors installed water temperature regulators prior to inspection to attempt to control the temperature of the water being utilized in the bathroom and kitchen sinks at the South Mountain Apartments group homes. However, the regulators installed were not effective in controlling the temperature and also reduced the pressure. Upon inspection this was discovered. Providence removed the regulators from the sinks and purchased new mixing valves from Ferguson that will be installed by Providence¿s contractors (please see evidence email of receipt). 06/10/2022 Implemented
6400.166(b)Individual #6 is prescribed "Melatonin 5mg Take 1 tablet by mouth at bedtime as needed for sleep." The blister pack of Melatonin in use at the home was filled on 4/14/22. Notations and popped blisters on the blister pack indicate that the medication was given on 4/17- 4/28. The April 2022 Medication Administration Record (MAR) for Individual #6 record the medication being administered on 4/17, 4/18, 4/19, 4/20, 4/22, 4/24, 4/26, 4/27 and 4/28. Melatonin administered on 4/21, 4/23 and 4/25 was not properly recorded with the date, time nor initials of the person administering on the April 2022 MAR at time of administration.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.2) Individual #6 is prescribed "Melatonin 5mg Take 1 tablet by mouth at bedtime as needed for sleep." The blister pack of Melatonin in use at the home was filled on 4/14/22. Notations and popped blisters on the blister pack indicate that the medication was given on 4/17- 4/28. The April 2022 Medication Administration Record (MAR) for Individual #6 record the medication being administered on 4/17, 4/18, 4/19, 4/20, 4/22, 4/24, 4/26, 4/27 and 4/28. Melatonin administered on 4/21, 4/23 and 4/25 was not properly recorded with the date, time nor initials of the person administering on the April 2022 MAR at time of administration. Staff on shift administering medications must initial the MAR in the designated slot with their initials to document accurately that the medication was given. For Individual #6, staff failed to record the medication being administered on 4/17, 4/18, 4/19, 4/20, 4/22, 4/24, 4/26, 4/27 and 4/28. Melatonin administered on 4/21, 4/23 and 4/25 was not properly recorded with the date, time nor initials of the person administering on the April 2022 MAR at time of administration. Pharmaceutical Nurse Manager/RN from Providence reviews the medications at every home every day to ensure consistency and accuracy. 06/10/2022 Implemented
6400.186Individual# 6's Individual Autism Acap plan, effective date 4/15/22, states that all staff are to "Ensure that all target objects (such as knives, scissors, batteries, cords, clothes' straps and strings, shoelaces, anything that can be swallowed that is smaller than a tennis ball are all out or reach and locked up." During monitoring on 4/29/22 Licensing Representative noted a small remote in front of the television that contained two AAA batteries and a plastic toothbrush cover measuring approximately one inch by one half inch on the bathroom counter. Both items were clearly visible and within reach of Individual #6. Additionally, provider entered twelve separate incidents into the Enterprise Incident Management (EIM) from 3/1/2021-4/1/22, in response to swallowing incidents that required medical treatment ranging from observation to hospitalization. Two of the described incidents resulted from swallowing AAA batteries. The home shall implement the individual plan as written.The home shall implement the individual plan, including revisions.3) Individual# 6's Individual Autism ACAP plan, effective date 4/15/22, states that all staff are to "Ensure that all target objects (such as knives, scissors, batteries, cords, clothes' straps and strings, shoelaces, anything that can be swallowed that is smaller than a tennis ball are all out or reach and locked up." During monitoring on 4/29/22 Licensing Representative noted a small remote in front of the television that contained two AAA batteries and a plastic toothbrush cover measuring approximately one inch by one half inch on the bathroom counter. Both items were clearly visible and within reach of Individual #6. Additionally, provider entered twelve separate incidents into the Enterprise Incident Management (EIM) from 3/1/2021-4/1/22, in response to swallowing incidents that required medical treatment ranging from observation to hospitalization. Two of the described incidents resulted from swallowing AAA batteries. The home shall implement the individual plan as written. Upon inspection, staff on shift were not following all of the aspects of the BSP/ISP and Restricted Plan in the BSP. Individual #6 moved to the South Mountain Apartments group homes recently and has been doing very well; and showing increased progress and no incidents. Due to her progress, staff became too comfortable and loose with following the strict aspects of the plan and failed to ensure safety. The toothbrush holder was thrown in the garbage per individual #6¿s approval by the Program Specialist while the inspector was present, and the remote control for the television was locked up by the direct support staff person during the inspection. The staff person present was given disciplinary action after the inspection, and BSS for the individual #6 continued regular trainings with staff on the BSP to ensure understanding. 06/10/2022 Implemented
6400.193(b)(2)The restrictive plan for Individual #6 updated on 2/17/22 does not outline nor describe the less restrictive techniques and resources appropriate to the behavior have been tried but have failed.For each incident requiring restrictive procedures: A restrictive procedure may not be used unless less restrictive techniques and resources appropriate to the behavior have been tried but have failed.4) Upon inspection, it was discovered that the restrictive plan for Individual #6 updated on 2/17/22 does not outline nor describe the less restrictive techniques and resources appropriate to the behavior have been tried but have failed. BSS for individual #6 has several resources at the home that are there to assist staff with supporting the complex and difficult behaviors as well as coping skills and strategies. However, this information was not in the binder with the ISP and BSP for the inspector to see. After the inspection, Program Specialist and BSS discussed what was needed and placed the documents in the binder with the BSP and ISP for easier access for staff and anyone else coming into the home that needs to reference the documents. 05/13/2022 Implemented
6400.195(c)(4)The restrictive plan for Individual #6 updated on 2/17/22 does not list a target date to achieve the outcome.The behavior support component of the individual plan shall include: A target date to achieve the outcome.5) Upon inspection, it was discovered that the restrictive plan for Individual #6 updated on 2/17/22 does not list a target date to achieve the outcome. Program Specialist and BSS were not aware a target date needed to be on the plan. During the initial human rights meeting it was determined that her status and progress with the plan would be reviewed after approximately 3 months (end of May/beginning of June). It would be determined by the Human Rights Committee if the restricted plan should be removed, edited, or kept at that time. 06/10/2022 Implemented
6400.195(c)(8)The restrictive plan for Individual #6 updated on 2/17/22 does not name the staff person responsible for monitoring and documenting progress with the behavior support component of the individual plan.The behavior support component of the individual plan shall include: The name of the staff person responsible for monitoring and documenting progress with the behavior support component of the individual plan.6) The restrictive plan for Individual #6 updated on 2/17/22 does not name the staff person responsible for monitoring and documenting progress with the behavior support component of the individual plan. Program Specialist and BSS were not aware these aspects needed to be on the plan. After the inspection, BSS signed the plan in the binder at the group home, and other relevant documents (restricted plan, data, information on less restrictive strategies for staff) designating herself as the responsible person. 06/10/2022 Implemented
SIN-00199712 Add an Addendum 02/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The handle to the hot water in the bathtub was broken and was easily removed from the faucet.Floors, walls, ceilings and other surfaces shall be in good repair. During inspection, the handle to the hot water in the bathtub was broken and was easily removed from the faucet. Floors, walls, ceilings and other surfaces shall be in good repair. Providence did not know the handle in the bathtub was broken- perhaps it was pulled at just the right angle during inspection to come loose. Residential Coordinator contacted the maintenance at the South Mountain Apartment complex to repair the handle on the bathtub. (see evidence email) 02/11/2022 Implemented
6400.68(b)The hot water temperature in the bathtub was in excess of 120 degrees at 147.5F. Hot water temperatures in bathtubs and showers may not exceed 120°F. 2. At the time of inspection, the hot water temperature in the bathtub was in excess of 120 degrees at 147.5F. The water temperature in the home should not exceed 120f degrees. This group home location is in an apartment complex, and the water in the building is for the whole building; so the temperature is at the level the apartment management wants it to be. Providence purchased faucet attachments to regulate the water temperature by shutting off the water when it reaches 120f (see evidence email). ((Providence installed a water mixer in the home -CH 3/15/2022)) 02/16/2022 Implemented
6400.82(e)The bathtub did not contain a nonslip surface or mat. Bathtubs and showers shall have a nonslip surface or mat. During inspection, it was discovered that the bathtub did not have a nonslip surface or mat. Bathtubs and showers shall have a nonslip surface or mat. The surface in the tub/shower seemed to be rough enough to not require a non-slip surface or mat; however, it does per inspection observation. Immediately after inspection, Residential Coordinator purchased non-slip adhesive for the floor of the tub/shower and it was installed. 02/23/2022 Implemented
6400.110(a)The smoke detector in the main living area of the home was inoperable. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. During inspection, the smoke detector in the main living area of the home was inoperable. When Providence acquired the apartment, the smoke detectors were all functional. The battery was dead in the detector and needed to be replaced. Residential Coordinator contacted Apartment maintenance for replacement (please see evidence email). 02/11/2022 Implemented
SIN-00235185 Unannounced Monitoring 11/06/2023 Compliant - Finalized
SIN-00207983 Renewal 07/13/2022 Compliant - Finalized
SIN-00205752 Unannounced Monitoring 05/26/2022 Compliant - Finalized