Providence House

• Service and Service Coordination Requirements - Emergency Response
• EOEA reviewed response times and tests of the emergency response system from the calendar year 2024 to determine compliance with Service Coordination requirements.
• In the month of July 2024 there were 74 e-call response times over the eight minutes required by the Residence policy.
• In the month of February 2024 there were 66 e-call response times over the eight minutes required by the Residence policy.
• The Residence is not consistently monitoring the reasons for late e-call response times to meet the service needs of Residents.
• The Residence has chosen to manually document hourly safety checks of Residents living in the Special Care Residence (SCR) to comply with the regulation to provide timely assistance to a Resident in the event of an emergency needs situation.
• Documentation of hourly safety checks for July 2024 through the date of compliance review had multiple instances where staff failed to document the hourly safety checks of the SCR Residents during the hours of 7:00 p.m. and 7:00 a.m.
• Service and Service Coordination - Special Care
• EOEA reviewed the Special Care Residence (SCR) operations review for calendar year 2023 through the date of the Compliance Review to verify that the SCR is being administered with all the required safeguards:
• Although the Residence documented that it reviewed its provisions for entry and exit doors and policies and procedures to assess and reduce the risk of potential hazards in the physical environment related to the special characteristics of the population, EOEA observed the laundry room door located in the SCR unit, that was not secured in accordance with the Residence safety procedures.
• General Requirements for an Assisted Living Residence (ALR)
• EOEA reviewed six Resident Records to determine compliance with requirements for the Screening and Assessment, Service Plan Development and Service Plan Requirements.

Service Plan Development and Requirements

• Two records were missing documentation of a Service Plan reassessment required within 30-days after the commencement of residency.
• Two records were missing documentation of a reassessment and service plan review being completed every six months.
• Quality Assurance and Performance Improvement
• EOEA reviewed documentation to ensure the Residence has established an effective, ongoing quality improvement and assurance program for Service Planning, Resident Safety Assurances and Medication Quality for the calendar years 2023 and 2024.

Medication administration observation

• EOEA observed three Personal Care (PC) staff providing medication assistance to six Residents to ensure the Residence has developed and implemented systems that suppo1t and promote safe SAMM.
• During medication observations, EOEA noted that when PC staff and nursing staff were asked about the Residence's SAMM policies and procedures, each of the three staff were unfamiliar with those policies and did not know how to reference the SAMM policies for clarification.

SAMM

• One Resident had one medication in their medication storage unit previously marked for disposal that was not removed and recorded per the Residence's medication disposal policy.
• One Resident's pharmacy blister pack had one medication that had not been administered from a previous day without explanation by the PCA on the SAMM observation sheet.
• Reporting Resident-specific Emergencies - Incident Reports
• EOEA reviewed the Residence records and submitted incident reports from December 5, 2023 through August 1, 2024 for evidence that all occurrences of an incident or accident that has or may have a Significant Negative Effect on a Resident's health, safety or welfare were reported to EOEA within 24 hours after the occurrence of the incident or accident.
• The Residence filed 47 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.
• EOEA was made aware of incidents involving Resident that occurred on and for one

. The incidents were not

• reported to EOEA, and the Residence's internal investigations were not completed as confirmed by the Executive Director and Resident Care Director.
• Resident Records- Progress notes
• EOEA reviewed six Resident records to determine compliance with record requirements.
• Inconsistent documentation of significant occurrences in the Progress Notes for two Residents.
• Record Requirements - Correspondence Log
• EOEA reviewed the current 90-day Correspondence Logs for the Traditional and Special Care Residence required to communicate information necessary to maintain the continuity of care for all Residents.
• The Residence did not use the Correspondence Logs to communicate all significant or pertinent information necessary to maintain the continuity of care for all Residents.
• The Residence did not consistently document for each 24-hour period in each Correspondence Log.
• Training Requirements Introductory Visit and Review
• EOEA reviewed the records of six Residents to determine compliance with the requirements that a nurse review the Resident's service plan with all relevant personal care workers within the 48 hours after the provision of service or with any change of condition for the Resident.
• Two records were missing signature documentation to support that Introductory Visits have been conducted with all applicable staff prior to or within 48 hours after the provision of Personal Care services.

Supervision

• EOEA reviewed the records of three PCA personnel to verify a qualified nurse shall, at least once every six months, evaluate the Personal Care Services and his or her awareness of SAMM regulations and applicable policies and verifies his or her demonstrated ability to comply with SAMM regulations and related Residence policies and procedure provided by personal care staff of the Residence or by [...]
• Documentation of current PCA skills evaluations for the first six months of calendar year 2024 were missing for three PCA records reviewed.
• Documentation of current SAMM skills evaluations for the first six months of calendar year 2024 were missing for three PCA records reviewed.
• Compliance Reviews of Assisted Living Residences - Record Review
• EOEA reviewed the Residence's records including all documents that should be maintained in relation to the operations of the Residence.
• The Residence's records to determine compliance with requirements with (SAMM) documentation from the date of Resident move-in through the date of compliance review were not made available for review for six Residents.