| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment, dated 12/21/21, is incomplete. The fire safety and physical site sections are blank. | 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.
| During the inspection, it was discovered that The self-assessment, dated 12/21/21, is incomplete. The fire safety and physical site sections are blank.
Program Specialist missed those pages at the King Street site during one of the self-assessments for the property.
Since the inspection, Program specialist has inspected the property for compliance with regulations under fire safety and physical site again to ensure compliance. |
01/04/2023
| Implemented |
| 6400.43(b)(1) | The agency's Poisonous Chemicals and Sharp Objects Policy is overly broad and, in practice, is a restrictive procedure. It indicates all poisonous materials and sharp objects must be kept locked in all properties. Poisonous chemicals and sharp objects, however, need only be locked up in homes where individuals have documented safety concerns---not as a blanket policy. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | At the time of the inspection, it was noted that The agency's Poisonous Chemicals and Sharp Objects Policy is overly broad and, in practice, is a restrictive procedure. It indicates all poisonous materials and sharp objects must be kept locked in all properties. Poisonous chemicals and sharp objects, however, need only be locked up in homes where individuals have documented safety concerns---not as a blanket policy.
Providence put the policy in place back in November/December of 2021 as part of a POC and as the result of a provisional license in the Northeast region (no longer in effect as of June 2022). Providence has since had a meeting with BSASP, ODP and Licensing on 10/28/22 via Microsoft Teams about the policy and it¿s corresponding documents, and has received feedback, advice and guidance on how to edit the policy. Program Specialist is waiting for another response from BSASP, ODP and Licensing reps who were involved in the meeting to give advice on whether the edited policy and documents are now compliant or if further editing is needed. |
03/01/2023
| Implemented |
| 6400.112(c) | Fire drills do not include if any problems occurred on the drills | 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, within the Providence fire drill log it was discovered that ¿Fire drills do not include if any problems occurred on the drills¿. Program Specialist was not aware that this category needed to be mentioned and included on the Providence fire drill log to maintain compliance.
Immediately after inspection, Program Specialist updated the Providence fire drill log template to include a section for any problems experienced during the fire drills- with space to explain. |
02/01/2023
| Implemented |
| 6400.113(c) | Individual 1's 12/27/21 and 1/14/22 fire safety trainings do not specify what was covered during the training. It indicates general fire safety was covered, but does not indicate that evacuation procedures, responsibilities during fire drills, or the designated meeting place outside the building or within the fire safe area in the event of an actual fire was also covered. | A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. | Upon inspection, Individual 1's 12/27/21 and 1/14/22 fire safety trainings do not specify what was covered during the training. It indicates general fire safety was covered, but does not indicate that evacuation procedures, responsibilities during fire drills, or the designated meeting place outside the building or within the fire safe area in the event of an actual fire was also covered.
Program Specialist did not realize that all of the topics covered had to be listed on the signed form utilized for the residential individuals for intake and annual fire safety training.
Since the inspection, Program Specialist has updated the form to include the topics covered and not just the length of evacuation, but the length of time of the training as well. |
01/04/2023
| Implemented |
| 6400.141(c)(3) | Individual 1's file does not contain documentation showing they have received all recommended immunizations. An immunization record provided only covers information up until the end of the 1990s; a COVID vaccine record card was also provided, but no documentation of routine immunizations such as yearly flu shots. Additional documentation was requested but not provided. | 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. | Upon inspection, Individual 1's file does not contain documentation showing they have received all recommended immunizations. An immunization record provided only covers information up until the end of the 1990s; a COVID vaccine record card was also provided, but no documentation of routine immunizations such as yearly flu shots. Additional documentation was requested but not provided.
Residential Medical Coordinator was not able to obtain vaccine information post 1990s from the legal guardian or physicians of individual #1; Medical coordinator also didn¿t realize that the flu vaccination section was blank.
Since the inspection, Medical Coordinator has made and will continue to make further attempts to obtain vaccination records post 1990s for individual #1. |
02/01/2023
| Implemented |
| 6400.141(c)(6) | Individual 1's TB test is out of date, with a period greater than two years between their last test and now. Their 10/27/21 physical indicates their last TB test was on 10/29/20. | 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. | Individual 1's TB test is out of date, with a period greater than two years between their last test and now. Their 10/27/21 physical indicates their last TB test was on 10/29/20. The 2022 TB test was given and was 7 days out of compliance from 2020 (2 years later). Medical Coordinator will ensure the next test is on or before the date the TB was given in 2022. |
01/04/2023
| Implemented |
| 6400.181(e)(10) | Individual 1's file does not contain a lifetime medical document. | The assessment must include the following information: A lifetime medical history. | At the time of inspection, it was found that Individual 1's file does not contain a lifetime medical document. Residential Medical Coordinator did not receive a lifetime medical document from team of individual #1 upon her transition and move into the Providence Residential program.
Since the inspection, Medical Coordinator is working with Providence Skilled Nursing Department to obtain a lifetime medical produced through the HRST and through coordination with the family. |
03/01/2023
| Implemented |
| 6400.217 | Individual 1's file does not contain a signed consent for the release of information. The document was requested but not received. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| During the inspection, it was observed that Individual 1's file does not contain a signed consent for the release of information. Documentation was requested but not received. Program Specialist has record of consent for release of information on file for individual #1 since transition and move into the Providence Residential program. Program Specialist misplaced original record at the office during the time of inspection, but since the inspection the document has been recovered in individual #1¿s paper file.
Program Specialist uploaded paper document to the computer for electronic filing and to prevent reoccurrence. |
01/04/2023
| Implemented |
| 6400.24 | Controlled Substance Count for Individual 1's Clonazepam 0.5mg tablet was inconsistent between the record kept in the EMAR system and the quantity present at site. The EMAR system stated that there were 44 tablets at site however there were 45 tablets present at site. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | 9) During the inspection, it was discovered that Controlled Substance Count for Individual 1's Clonazepam 0.5mg tablet was inconsistent between the record kept in the EMAR system and the quantity present at site. The EMAR system stated that there were 44 tablets at site however there were 45 tablets present at site.
Medical Coordinator followed up with Newhard¿s Pharmacy (utilized by Providence for all medications for group homes for many years) who explained after the inspection that 2 pills were deducted automatically in the system (overall) and that threw off the count. When the AM dose was administered, the system took out that dose and the previous day. This left the count incorrect on the day of inspection. |
01/04/2023
| Implemented |
| 6400.46(b) | Staff Member 1: Fire safety training/expert credentials-10/28/21- listed as instructor on certificates-requested, not provided. Staff 2's credentials provided. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | During the inspection, Staff Member 1: Fire safety training/expert credentials-10/28/21- listed as instructor on certificates-requested, not provided. Staff 2's credentials provided. Human Resources (HR) Manager was confused about which years credentials to provide and mixed up the fire safety training experts from Kistler O¿Brien. Providence utilized 2 different fire safety training experts from Kistler O¿Brien to train all staff annually on fire safety over the past couple of years. Staff Member #2 was the trainer in 2021 for Fire Safety.
After inspection, HR Manager reached out to the manager at Kistler O¿Brien to obtain credentials for 2021 fire safety training expert and provided the documents to the licensing inspector too late. |
01/04/2023
| Implemented |
| 6400.46(b) | Staff Member 2: fire safety training expert credentials requested, but not provided. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | At the inspection, Staff Member 2: fire safety training expert credentials requested, but not provided. Human Resources (HR) Manager was confused about which years credentials to provide and mixed up the fire safety training experts from Kistler O¿Brien.
After inspection, HR Manager reached out to the manager at Kistler O¿Brien to obtain credentials for Staff Member #2 and provided the documents to the licensing inspector too late. |
01/04/2023
| Implemented |
| 6400.52(a)(1) | Staff Member 1: A total of 14 hours of annual training completed, does not meet the 24-hour required annual training hours. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Staff Member 1-Program Specialist: A total of 14 hours of annual training completed, does not meet the 24-hour required annual training hours. Program specialist completed over 24 training hours, but not the designated required category and subject matter training hours.
Program Specialist met with HR Manager to see which hours were completed and still needed to be that are required. |
01/04/2023
| Implemented |
| 6400.52(a)(3) | Staff Member 2: A total of 10 hours of annual training completed for the training year. | The following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists. | During the inspection, it was discovered that Staff Member 2: A total of 10 hours of annual training completed for the training year. Staff Member 2 reported to HR that there was not enough time to complete required trainings due to busy schedule working at the group homes. Staff Member 2 will be given a training by BS Supervisor on ¿Importance of Professionalism and Training on Individuals¿ Support Plans¿ no later than February 1st, 2022. |
01/04/2023
| Implemented |
| 6400.169(a) | Staff Members 1 and 2: It could not be determined if the staff members successfully completed the annual med admin training course as the score to pass is a total of 90 points and all staff members attained a total score of 80 points according to the annual practicums provided. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | At the time of inspection, Staff Members 1 and 2: It could not be determined if the staff members successfully completed the annual med admin training course as the score to pass is a total of 90 points and all staff members attained a total score of 80 points according to the annual practicums provided.
After the inspection, Providence Residential management reviewed the medication administration training documents and there was an error on the PDF¿the total score was incorrect and miscalculated by the computer or previous medication administration trainer. This information was relayed to licensing.
However, Providence Residential Medical Coordinator and contracted Medication Administration Trainer re-trained staff, including Staff Member #1 and #2. |
01/04/2023
| Implemented |