Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00225313 Renewal 05/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)There was no Previous Fire Safety training for individual #1 An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. Individual #1 had a new Fire Safety Training completed on 1/7/2023. Going forward, all indivduals that reside in the program will have a new Fire Safety Training completed by 7/1/2023 by the Program Specialist/House Manager. Beginning on 9/1/2023 all indivduals will have an annual Fire Safety Training completed at their annual Individual Service Plan (ISP) which includes; being instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. The Program Specialist will ensure the training is completed, documented and included in the ISP. 07/01/2022 Implemented
6400.141(c)(14)The most recent annual physical for individual #1 was missing information pertinent to diagnosis and treatment in case of emergency. The section designated for this information on the form was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The current annual physical for indivduals #1 was sent to the primary care physician office on 5/24/2023 for completion of the section; Information pertinent to diagnosis and treatment in case of emergency. A follow up notification was made on 6/9/2023 to gather the revised document. The primary care physician¿s office faxed the completed revised physical with all information completed on 6/15/2023. 06/15/2023 Implemented
6400.144The following medications prescribed to individual #1 were not present at the time of inspection: Blistex PRN Diazepam 10 MG tab PRN Triamcinolone .1% ointment PRNHealth 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. The Health Care Coordinator reorder the missing PRN medications (Diazepam and Triamcinolone) for indivdual #1 on 5/23/2023. The Blistex PRN was discontinued by the Primary Physician on 5/23/2023. The two other medications were received in the home on 5/23/2023. 05/23/2023 Implemented
6400.166(b)On 5/23/23 the prescription Clonidine .2mg 8 AM for individual #1 was logged as "Medication not available" however the medication was given.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.After review of individual #1 medication record on 5/23/2023, the Medication Observer according to the Office of Developmental Programs Medication Training Course determined the logging of the medication for indivdual #1 was a documentation error. The medication was given and the logging of the medication was in error (logging a 1 is defined as the medication given, logging 11 is defined as the medication was not available in the facility). Facility documentation error forms were completed for individual #1 and sent to the Quality Management Coordinator for review. 05/24/2024 Implemented
SIN-00162731 Renewal 09/17/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1's disbursement Check #4043 in the amount of $100.00 for purchase of $91.83 no proof of balance provided on personal account ledger until 3 months after the check was cashed. Financial records were not kept up to date.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. Individual #1 financial record was reviewed for the $100.00 request in 4/2019 and the purchase receipt that was returned in 7/2019. The Management of Clients Funds Policy was reviewed and revised on 11/7/2019 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 will be trained to the new policy and procedure by 11/18/2019. Starting December 2019, the Client funds manager reviews monthly ledgers for Individual #1 and all other individual's that reside in the program with the House Managers by appointment. The monthly ledgers are forwarded to the Director of Finance for approval to ensure the receipts of monthly spending are documented on the day the expense occurred or within 24 hours of the receipt. 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. The financial records/receipts will be reviewed from January 2019 to present for all indivduals and grouped by monthly dates. Completion Date 1/31/2020. The Director of Community Programs will audit financial ledgers of 1 home monthly for the next year. Any discrepancies will be forwarded to the Director of Finance and Administrator. The Director of Finance will audit 3 group homes quarterly and any discrepancies will be forwarded to the Director of Community Programs and Administrator. Completion Date: Ongoing, Monthly Parties responsible; House Manager, Client Fund Manager, Director of Finance, Director of Community Programs and Administrator. 11/18/2019 Implemented
6400.67(a)The hot water handle in the bathtub of the main level bathroom was broken and the drain was not in good repair. The handle leaked hot water when turned on and the drain was slow to drain water.Floors, walls, ceilings and other surfaces shall be in good repair. The Director of Maintenance evaluated the bathtub faucet that was leaking hot water. He determined that the hot water value was in dis-repair and he replaced the hot water valve packing nut washer on 9/18/2019. The faucet was tested again and the bathtub facet was in good repair. All other faucets in the home were evaluated and were determined in good repair. Going forward the House Manager will complete their routine Community Programs Home Monitoring/Audit Checklist on a monthly basis and floors, walls, ceiling and other surfaces in relation to good repair was added. The House Manager will hand the monthly audit into the residential Coordinator and any items in dis-repair will be forwarded to the maintenance department for correction through the electronic WorxHub maintenance system. The Direction of Operations will complete a quarterly audit of 3 homes per quarter. She will complete the Community Programs Home Monitoring/Audit Checklist for each home and forward to the Director of Community Programs for review. Any items in dis-repair will be forwarded to the maintenance department for correction through the electronic WorxHub maintenance system. The Quality Management team will conduct semi-annual audits of each home. The documentation will be forwarded to the Director of Community programs for review. Any items in dis-repair will be forwarded to the maintenance department for correction through the electronic WorxHub maintenance system. Completion Date: Ongoing, Monthly Parties responsible; House Manager, Residential Coordinator, Director of Operations, Director of Community Programs, Maintenance Department and Quality Management Team. 09/18/2019 Implemented
6400.142(a)There was no Dental Examination performed by a licensed dentist annually. Appointment was made 8/26/19 but the agency failed to submit the paperwork on time to ensure a year did not lapse between dental appointments.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Individual #1 was admitted to the facility on 10/5/2018 from another program. His dental prior to admission was 8/26/2018. The admission committee and nursing did not document the dental should have been due in August 2019. The appointment was scheduled and completed on 10/9/2019. All other admissions for the year were reviewed and remained in compliance for dental services. Completion Date: 11/8/2019. Going forward upon admission, the HealthCare Coordinator will document the last dental appointment of the individual, within 365 days. If dental information is not available upon admission, the individual will be scheduled for a current dental appointment within 45 days of admission. The Quality Management team will complete reviews of the medical files of all individual's on a semiannual basis and provide documentation to the Director of Community Programs. If any non-compliance is noted, the team will meet to discuss and develop a plan for the individual to receive dental services. The Quality Management team will conduct semi-annual audits of each individual's medical file. The documentation will be forwarded to the Director of Community programs for review. If Discrepancies occur, a team meeting will be held to discuss and develop a plan for the individual to receive dental services in a timely manner. Completion Date: 7/31/2020 Parties responsible; Admissions Committee, Healthcare Coordinator, Director of Community Programs and Quality Management Team. 10/09/2019 Implemented
SIN-00075329 Renewal 03/30/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Tilex Mold and Mildew cleaner was stored under the sink in the hall bathroom. Poisonous materials shall be kept locked or made inaccessible to individuals. It is the responsibility of the Site Manager to ensure that poisonous materials in the home are kept locked daily. The Site Manager will document that all poisonous materials are secured on the daily shift report. (The house supervisor will conduct weekly physical site inspections to ensure all poisonous materials are locked. The house manager will use a checklist to ensure the home is compliant with all physical site regulations. the spreadsheet will be sent to the program specialist after each inspection. Any physical site issues should be noted on the checklist. The home supervisor and program specialist are responsible to report any physical site issues immediately to the director and maintenance. The program specialist will conduct a monthly physical site inspections to ensure all poisonous materials are locked. All staff will be trained on the physical site regulations within 30 days of receipt of this plan. AH 10.29.2015) 04/01/2015 Implemented
6400.164(b)Divaloproex Sod 500mg was not logged on the medication administration record on 3/3/15. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. Individuals receiving medication while at day program now have their own blister packs of medications to be administered along with a separate Medication Administration Record. (A record review of all individuals in the agency will be completed within 30 days of receipt of this plan to identify any other medications logs not in compliance with this regulation. The house manager or designee is responsible to review the medication logs daily to ensure all medication is administered and the person administering the medication has signed off. The program specialist will review the medication logs on a monthly basis to ensure all medications are being administered and all med trained staff have signed off after administering. Quarterly audits of the medication logs will be conducted by the director. AH 10.29.2015) 04/30/2015 Implemented
SIN-00120225 Renewal 08/14/2017 Compliant - Finalized
SIN-00091928 Renewal 04/07/2016 Compliant - Finalized
SIN-00061594 Renewal 03/13/2014 Compliant - Finalized