Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.71 | There were no emergency numbers posted on or by the telephone. | 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.
| WHAT HAPPENED & WHY?
6400.71 VIOLATION DESCRIPTION: There were no emergency numbers posted on or by the telephone. CORRECTION REQUIRED: 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. Individual #1 frequently uses the house phone to make personal calls and rips down the Emergency Contact List from the wall. There is a backup list of numbers on the bulletin board near the kitchen that can be referenced.
WHAT ARE WE DOING NOW? Immediately after inspection, one of the Team Leads put a new Emergency Contact list on the wall near the house phone. |
10/31/2023
| Implemented |
6400.110(a) | The home did not have a minimum of one operable automatic smoke detector on each floor. The home is an apartment and contained one smoke detector that was inoperable. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | WHAT HAPPENED & WHY? The home did not have a minimum of one operable automatic smoke detector on each floor. The home is an apartment and contained one smoke detector that was inoperable.
The battery in the smoke detector had just been replaced by the Field Supervisor but he forgot to take the plastic off the battery.
WHAT ARE WE DOING NOW? During the inspection the Field Supervisor removed the smoke detector and took out the battery and discovered this in front of the inspector. He removed the plastic in front of the inspector and removed it and reset the detector to show the inspector it was operable. |
10/31/2023
| Implemented |
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) | Individual #1 is prescribed Ammonium Lactate 12% cr, apply to affected area once daily. This medication was refused on 8/11/23, 8/12/23, 8/16/23, 8/18/23, 8/19/23 and 8/24/23. There is no documentation of continued attempts to train Individual #1 about the need for health care documented in Individual #1'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 and why? Individual #1 is prescribed Ammonium Lactate 12% cr, apply to affected area once daily. This medication was refused on 8/11/23, 8/12/23, 8/16/23, 8/18/23, 8/19/23 and 8/24/23. There is no documentation of continued attempts to train Individual #1 about the need for health care documented in Individual #1'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 |
6400.144 | Health Services including pharmaceuticals are not being planned for or arranged for Individual #1. Individual #1 is prescribed Individual #1 is prescribed Hydroxyzine HCL 25mg tablet, this medication is documented on the Medication Administration Record (MAR) as "awaiting order from pharmacy on 8/20/23, 8/21/23 and 8/22/23." This medication is also documented on the MAR on 8/20/23 stating "pending provider review." The medication is documented as discontinued on 8/22/23. The medication was not available to Individual #1 from 8/20through 8/22/23 until it was discontinued. There was no doctor's order available with the discontinuation information.
Individual #1 is prescribed Nasal Decongestant 30mg tab; Melatonin 5mg tablet; Guaifenesin 100mg. These medications were not available in the home. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| What happened and why? 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 has gone through staffing changes and shortages within the homes and DSP staff have not executed all protocols and maintained compliance with regulations consistently.
What are we doing right now?
Immediately after the inspection, Providence Home Care implemented several correction measures right away. 1. Medical Care Coordinator contacted the physician and Hartzell¿s Pharmacy regarding the medications and missing or insufficient documents. Discontinued medications were properly discarded.
A. Medical Care Coordinator developed a letter template that will be sent to the physicians for PRNs justification and symptom explanations. The letter template and direct contacts were made to the physicians and Hartzell¿s pharmacy to ensure compliance. The letter template will be used moving forward for every PRN.
B. Any refusals by an individual were followed up on by Kathy with the physician and Hartzell¿s Pharmacy. Requests were made to transition frequent refusal medications to PRNs to reduce the frequency and number of formal refusals. |
10/31/2023
| Implemented |
6400.163(h) | Prescription medications that are expired are not destroyed in a safe manner. Individual #1 is prescribed Melatonin 5mg Tablet, take one tablet by mouth nightly as needed. This medication is expired and is not destroyed according to applicable Federal and State statutes and regulations. Individual #1 is prescribed Miconazole 2% topical cream for 7 days. This mediation was prescribed on 6/9/23 for 7 days and remained in the home. This medication was not destroyed according to applicable Federal and State statutes and regulations. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | What happened and why? Prescription medications that are expired are not destroyed in a safe manner. Individual #1 is prescribed Melatonin 5mg Tablet, take one tablet by mouth nightly as needed. This medication is expired and is not destroyed according to applicable Federal and State statutes and regulations. Individual #1 is prescribed Miconazole 2% topical cream for 7 days. This mediation was prescribed on 6/9/23 for 7 days and remained in the home. This medication was not destroyed according to applicable Federal and State statutes and regulations.
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 Junel-Fe 1mg/20mcg tablet. This medication was filled on 7/3/23 and is a 28-day supply. The packet of medication contained 19 pills and has not been refilled since 7/2/23. The medication is documented on the Medication Administration Record as administered as prescribed. (Repeat Violation 5/17/23) | A prescription medication shall be administered as prescribed. | What happened and why? Medications are not administered as prescribed. Individual #1 is prescribed Junel-Fe 1mg/20mcg tablet. This medication was filled on 7/3/23 and is a 28-day supply. The packet of medication contained 19 pills and has not been refilled since 7/2/23. The medication is documented on the Medication Administration Record as administered as prescribed. (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) | Individual #1 is prescribed Ammonium Lactate 12% cr, apply to affected area once daily. This medication was refused on 8/11/23, 8/12/23, 8/16/23, 8/18/23, 8/19/23 and 8/24/23. 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 and why? Individual #1 is prescribed Ammonium Lactate 12% cr, apply to affected area once daily. This medication was refused on 8/11/23, 8/12/23, 8/16/23, 8/18/23, 8/19/23 and 8/24/23. 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 |