Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00234431 Unannounced Monitoring 11/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(e)The trash can in the home's kitchen was lacking a functional lid. The swinging lid was missing from the trash can's top portion, leaving it open and unprotected.Trash receptacles over 18 inches high shall have lids. Additional trash cans with lids were purchased to adequately accommodate the volume of trash generated in the home. 12/31/2023 Implemented
6400.67(a)At time of inspection, the home's bathroom floor was missing approximately 14 small tiles. The tiles surrounding these missing tiles were loosening as well. This bathroom floor was in a state of disrepair.Floors, walls, ceilings and other surfaces shall be in good repair. The Property Management company of the apartment was notified immediately. Apartment maintenance replaced tile in bathroom. 12/31/2023 Implemented
6400.71There were no emergency telephone numbers on or by the telephone located in the home's living room. Repeat violation -- 05/17/23, 8/31/23)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. Phone numbers for nearest hospital, police department, fire department, ambulance and poison control center were placed on a sticker label and stuck to the back of each phone. 12/31/2023 Implemented
SIN-00230306 Unannounced Monitoring 08/31/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71There 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
6400.144Health 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
SIN-00217640 Renewal 01/10/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The bathroom tub had what appeared to be buildup of soap scum around the tub.Clean and sanitary conditions shall be maintained in the home. During the time of inspection, the bathroom tub had what appeared to be buildup of soap scum around the tub. All surfaces should be clean and sanitary. The individual residing in the home showers frequently and there may have been residual soap scum after the morning shower right before inspection. After the inspection, Program Specialist spoke with the individual about the soap scum build up. 02/10/2023 Implemented
6400.67(a)At the time of inspection, the thermostat attached to the electric heat baseboard was not attached and hanging off the side of the baseboard. Also, the bathroom light switch was not securely attached to the wall.Floors, walls, ceilings and other surfaces shall be in good repair. At the time of inspection, the thermostat attached to the electric heat baseboard was not attached and hanging off the side of the baseboard. Also, the bathroom light switch was not securely attached to the wall. Prior to the inspection, the baseboard was attached and the bathroom light switch was securely attached in the bathroom on the wall. This was during the Agency¿s recent self-inspection. However, at the time of the licensing inspection, there was a loose thermostat in the corner that was not noticed during self-inspection or by staff due to its location on the baseboard area near the floor, and the bathroom light switch was not loose. After inspection, a maintenance request at the apartment complex was submitted and the light switch and baseboard thermostat were tightened. 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. At the time of inspection, 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(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, it was observed that 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
6400.171There was a container with a yellow liquid in the cupboard stored among the glass drinkware. When asked what the liquid was, it was reported to be cooking oil. This was not in the original container. Due to the said oil being placed in a previously used container without identifying dates or labels it is not able to be determined if it was protected from contamination.Food shall be protected from contamination while being stored, prepared, transported and served. At the time of inspection, there was a container with a yellow liquid in the cupboard stored among the glass drinkware. When asked what the liquid was, it was reported to be cooking oil. This was not in the original container. Due to the said oil being placed in a previously used container without identifying dates or labels it is not able to be determined if it was protected from contamination. While the inspector was present, the individual residing in the home said that the oil could be disposed of, and so his staff threw the container filled with the oil into the garbage can (which the inspector witnessed). The violation was explained to the individual. Since the inspection, the Residential Coordinator Assistant has ensured that the individual and the staff have not utilized containers for anything other than the original substance (no transfer of substances to other containers from the originals). Now 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
SIN-00207235 Unannounced Monitoring 06/24/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)Individual #2's Individual Service Plan indicated that the individual struggles with budgeting money appropriately and does not identify any amount of money that the individual is able to manage. Receipts are not maintained in the home for Individual #2. A purchase in the amount of $40 was documented on the individuals financial record, however there were no receipts for the purchase. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. Individual #2's Individual Service Plan indicated that the individual struggles with budgeting money appropriately and does not identify any amount of money that the individual is able to manage. Receipts are not maintained in the home for Individual #2. A purchase in the amount of $40 was documented on the individuals financial record, however there were no receipts for the purchase. Individual #2's father is his repayee and he has a financial record log at the home since the last inspection. Individual #2's father loads spending money directly onto his spending debit card, which Individual #2 checks and tracks through his online login. Individual#2's father sends him $100 per month of spending money directly deposited onto his spending debit card at the beginning of the month. Individual #2 is able to manage independently up to $100. He will not allow Providence Home Care DSPs or Management to see his account or provide the login info to verify. His CS and BSS are from another agency- Opportunity Behavioral Health. If you ask Individual #2 how much spending money he has remaining at any time, he is able to tell you. Since the inspection, Program Specialist asked Individual #2 simple math questions as well as his balance and he was able to provide answers quickly and correctly. 08/16/2022 Implemented
SIN-00199713 Add an Addendum 02/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The vent in the ceiling in the bathroom was not clean and sanitary, it was covered in a layer of dust.Clean and sanitary conditions shall be maintained in the home. 1. The vent in the ceiling in the bathroom was not clean and sanitary, it was covered in a layer of dust. All surfaces should be clean and sanitary. Residential Coordinator did not see the vent dust accumulation prior to the inspection. After inspection, 6 foot extender dusters with replaceable heads by Swiffer were purchased for Fernor Street group home and all of the other homes. 02/23/2022 Implemented
6400.68(b)The hot water temperature in the bathtub was 151 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. 2. The hot water temperature in the bathtub was 151 degrees. 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 contractor installed them after instructed by Residential Coordinator to do so. This will ensure the water remains within safe range. ((Providence added water mixes to the home -CH 3/15/22)) 02/16/2022 Implemented
6400.82(e)The bathtub did not have 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 installed (see evidence email photo). 02/23/2022 Implemented
SIN-00235192 Unannounced Monitoring 11/06/2023 Compliant - Finalized
SIN-00207973 Renewal 07/13/2022 Compliant - Finalized