Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00268485 Renewal 06/10/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.18(b)(2)Medication audit for Individual #1 - 1 Levothyroxine 50mg Tab was observed in the blister pack dated for the 8th. The MAR was signed off for all dates of administration including the date medication was not administered.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person: A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner.An internal incident report was completed and an EIM report was submitted on 6/10/2025. The medication certified staff that was responsible to administer the medication was re-trained by the House Manager on 6/11/2025 on the procedure of administering the prescribed medication prior to completing the documentation on the e-MAR. All other resident's MAR's were reviewed on 6/11/2025 and were found to be compliant. 08/08/2025 Implemented
6400.167(a)(4)Medication audit for Individual #1 - 1 Levothyroxine 50mg Tab was observed in the blister pack dated for the 8th. MARS was signed off for all dates of administration including the date medication was not administered.Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time.The medication certified staff that was responsible to administer the medication was re-trained by the House Manager on 6/11/2025. The training included logging into the e-MAR and carefully administering the medication prior to completing the documentation. The protocols of medication administration was reviewed in it's entirety (see attachment #4). All other resident's MAR's were reviewed on 6/11/2025 and were found to be compliant. 08/08/2025 Implemented
SIN-00205639 Renewal 05/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)Handrail on exterior balcony is loose from the left and right side and is in need of repair. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. On Thursday May 26, 2022 a maintenance request was submitted through our Worxhub computer maintenance system by the Residential Coordinator to strengthen the deck railing to make it sturdier and prevent it from shaking. The work was completed 6/6/2022 (see attachments A & B). 06/09/2022 Implemented
SIN-00141715 Renewal 08/21/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(1)Individual #1 was disbursed $380.86 dollars, however there was no separate up to date record of the money disbursed. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. Individual #1 financial record was reviewed for the $380.86 outing that occurred on 4/19/2018. All receipts were reviewed and reconciled for individual #1 and all other individuals for the outing on 4/19/2018. There were separate records developed of how the money was disbursed for Individual #1 and all other individuals for the outing on 4/19/2018. The Management of Clients Funds Policy was reviewed and revised on 9/1/2018 for Individual #1 and all other individual¿s that reside at the Divine Providence Village Community Living Arrangement Program. The Community Living Arrangement Management team including fiscal personnel were trained to the new policy and procedure on 9/17/2018. Starting October 2018, the Client funds manager reviews monthly ledgers for Individual #1 and all other individual¿s that reside in the program with the House Managers. The monthly ledgers are forwarded to the Director of Finance for approval and forwarded to the Director of Operations as well as the Director of Community Programs to ensure separate records of financial resources, including dates and amounts of deposits and withdrawals are kept for individual #1 and all other individual¿s that reside in the program. Parties responsible; House Manager, Client Fund Manager, Director of Finance, Director of Operations and Director of Community Programs. 11/29/2018 Implemented
SIN-00162724 Renewal 09/17/2019 Compliant - Finalized
SIN-00091921 Renewal 04/07/2016 Compliant - Finalized
SIN-00061587 Renewal 03/13/2014 Compliant - Finalized
SIN-00047483 Renewal 03/01/2013 Compliant - Finalized