| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1 was neglected in that the individual began exhibiting signs of illness on or around Saturday 12/18/21 and was not provided appropriate medical care. Individual #1 continued to exhibit signs of illness up to and including Wednesday 12/22/21, the day of the individual's passing. Individual's #1's primary care physician (PCP) was contacted on 12/20/21 and staff was instructed to take Individual #1 to a CVS or Rite Aid for Covid-19 testing. No attempts to take Individual #1 for Covid-19 testing were made after speaking with the PCP. Individual #1 was taken out into the community to complete banking, shop and out to eat while the individual was ill and not provided any medical care the day prior to the individual's passing. On the date of passing, Individual #1 continued to show signs of illness and was more lethargic and did not eat well. Individual #1 was asked if the individual would like to go to urgent care or the hospital and the individual declined. No additional attempts were made on this day to obtain medical treatment. Individual #1 passed away on 12/22/21 at 8:10PM due to Acute Respiratory Failure due to Covid-19. Individual #2 and Individual #3 were neglected in that Individual #1, a housemate had passed away on 12/22/21 from Acute Respiratory Failure due to Covid-19. Individual #2 and Individual #3 were exposed to Individual #1 while the Individual was positive for Covid-19. The provider was made aware of Individual #1's positive Covid-19 test results on 12/26/21 with instructions to have Individual #2 and Individual #3 tested for Covid-19. Individual #2 and Individual #3 were not tested for Covid-19 until 8 days later on 1/4/22. Results of Individual #2 and Individual #3's Covid testing were not obtained until 1/28/22. Individual #2's Covid-19 testing was inconclusive as not enough sample was given and it was recommended that Individual #2 be retested. Individual #2 was not retested based on the results of the inconclusive Covid-19 testing because the Individual was hospitalized prior to the results of the Covid-19 testing from 1/4/22 being received. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | As of 1/1/22, staff who failed to seek appropriate medical care and to follow the primary physician¿s instructions to take the individual to Rite Aid for COVID testing was no longer with Spectrum Community Services.
On 2/10/22, upon learning details of the citations, management had a meeting with program supervisors to discuss Health and Safety Protocols including training and updating processes for handling individual illness to ensure prompt attention for health and safety.
On 2/10/22, we retrained Program Managers on Health and Safety protocols including seeking medical attention for residents on a timely manner. On 2/25/2022, all Berks SCS employees received training on Health and Safety protocols. |
02/25/2022
| Implemented |
| 6400.67(a) | The basement ceiling is has water stains and missing ceiling blocks at the bottom of the stairs.
The molding along the bathroom floor next to the toilet is dirty, falling off the wall.
There is what appears to be a burn mark on the wall above the bathroom sink.
The wall next to the left side of the shower has what appears to be water damage and the wall is crumbling.
There is a hole approximately 4x3 inches in the right wall in the third bedroom.
(REPEAT VIOLATION FROM 10/5/21) | Floors, walls, ceilings and other surfaces shall be in good repair. | On 2/25/22, the basement ceiling, and the molding along the bathroom floor were repaired.
On 2/28/22, burn mark on the wall above the bathroom sink and the wall next to the left side of the shower were repaired. |
02/28/2022
| Implemented |
| 6400.144 | Individual #1 was not provided with medical health services. Individual #1 began experiencing signs of illness on approximately 12/18/21. Individual #1's Primary Care Physician (PSP) was not contacted until 12/20/21 for guidance on Individual #1's symptoms. Individual #1's PCP instructed staff to take Individual #1 to CVS or Rite Aide for Covid-19 testing and vaccination as PCP did not provide these services in the office. Individual #1 was not taken for Covid-19 testing or to receive the vaccination as directed by the PCP and Individual #1 passed away on 12/22/21 from Acute Respiratory Failure due to Covid-19. (REPEAT VIOLATION FROM 5/12/21 and 10/5/21) | 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.
| As of 1/1/22, staff who failed to seek appropriate medical care and to follow the primary physician¿s instructions to take the individual to Rite Aid for COVID testing was no longer with Spectrum Community Services.
On 2/10/22, upon learning details of the citations, management had a meeting with program supervisors to discuss Health and Safety Protocols including training and updating processes for handling individual illness to ensure prompt attention for health and safety.
On 2/10/22, we retrained Program Managers on Health and Safety protocols including seeking medical attention for residents on a timely manner. On 2/25/2022, all Berks SCS employees received training on Health and Safety protocols. |
02/25/2022
| Implemented |
| 6400.52(a)(1) | Staff #1, Staff #2 and Staff #3 did not complete 24 hours of annual training in 2021. Staff #1 completed 19.25 hours, Staff #2 completed 17.5 hours and Staff #3 completed 17.5 hours. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Effective 1/10/22, all SCS employee files were reviewed to ensure compliance with 24 hours of annual training guidelines. |
02/08/2022
| Implemented |
| 6400.52(c)(1) | Staff #3 and Staff #4 did not receive annual training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. (REPEAT VIOLATION FROM 11/15/21) | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | On 2/18/22, Staff #3 and Staff #4 received annual training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. A review of all Spectrum Community Services staff files will occur and staff will be trained in all areas required by the regulation by 3/16/22. |
02/18/2022
| Implemented |
| 6400.52(c)(2) | Staff #3 did not receive annual training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101---10210.704) and applicable protective services regulations. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | On 2/18/22, Staff #3 received annual training in the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse. A review of all Spectrum Community Services staff files will occur and staff will be trained in all areas required by the regulation by 3/16/22. |
02/18/2022
| Implemented |
| 6400.52(c)(3) | Staff #3 did not receive annual training in individual rights. (REPEAT VIOLATION FROM 11/15/21) | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | On 2/18/22, Staff #3 received annual training on individual rights. A review of all Spectrum Community Services staff files will occur and staff will be trained in all areas required by the regulation by 3/16/22. |
02/18/2022
| Implemented |
| 6400.52(c)(4) | Staff #3 did not receive annual training in recognizing and reporting incidents. (REPEAT VIOLATION FROM 11/15/21) | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | On 2/18/22, Staff #3 received annual training in recognizing and reporting incidents. A review of all Spectrum Community Services staff files will occur and staff will be trained in all areas required by the regulation by 3/16/22. |
02/18/2022
| Implemented |
| 6400.52(c)(5) | Staff #1, Staff #2, Staff #3, Staff #4, Staff #5 and Staff #6 did not receive annual training in the safe and appropriate use of behavior supports if the person works directly with an individual. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Staff #1 is no longer with agency.
On 2/21/22, Staff #2, Staff #4, and Staff #6 received annual training in the safe and appropriate use of behavior support.
On 2/22/22, staff #3 received annual training in the safe and appropriate use of behavior support.
On 2/28/22, Staff #5 received annual training in the safe and appropriate use of behavior support.
A review of all Spectrum Community Services staff files will occur and staff will be trained in all areas required by the regulation by 3/16/22. |
02/28/2022
| Implemented |
| 6400.52(c)(6) | Staff #1, Staff #2, Staff #3, Staff #4, Staff #5 and Staff #6 did not receive annual training in the Implementation of the individual plan if the person works directly with an individual. (REPEAT VIOLATION FROM 11/15/21) | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Staff #1 is no longer with agency.
On 2/21/22, Staff #2, Staff #4, and Staff #6 received annual training in the safe and appropriate use of behavior support.
On 2/22/22, staff #3 received annual training in the safe and appropriate use of behavior support.
On 2/28/22, Staff #5 received annual training in the safe and appropriate use of behavior support.
A review of all Spectrum Community Services staff files will occur and staff will be trained in all areas required by the regulation by 3/16/22. |
02/28/2022
| Implemented |
| 6400.165(c) | Individual #3 is prescribed Artificial tears admin 3x daily, This medication is not signed out as administer since 1/4/21. The prescription label indicated that it was last filled on 2/9/21 with a 15-day supply. This medication would have needed to be refilled at least 23 refills since last refill date if being administered as prescribed.
(REPEAT VIOLATION FROM 5/12,21, 10/5/21 and11/15/21) | A prescription medication shall be administered as prescribed. | Artificial Tears was refilled on 2/9/21, 2/11/21, 3/10/21, 6/24/21, 7/20/21, 9/7/21, 11/12/21, 12/8/21, 12/16/21, 1/25/22, and 2/15/22. On 3/1/2022, staff working with individual had medication administration refresher training. Training document was placed in their respective file. |
03/01/2022
| Implemented |
| 6400.166(a)(13) | Individual #3 is prescribed Alfusozin 10mg take 1 tablet daily. The medication record did not include the name and initials of the person administering the medication on 1/23/22. Individual #3 is prescribed Melatonin 3mg, take two tablets by mouth daily, and Trazadone 50mg take two tablets by mouth at bedtime, the medication record did not include the name and initials of the person administering the medication on 1/22/22.
(REPEAT VIOLATION FROM 5/12/21) | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | On 3/1/2022, staff working with individual had medication administration refresher training. Training document was placed in their respective files. |
03/01/2022
| Implemented |