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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | There was a bottle of cleaning liquid that was not in its originally labeled bottle located in the bathroom, under the sink on the right side. | There was a bottle of cleaning liquid that was not in its originally labeled bottle located in the bathroom, under the sink on the right side. | House Managers and DSPs are responsible for assuring that all poisonous materials are kept safely away from individuals as required by their ISPs including the chemicals staying in their original containers. Residential Supervisors are responsible for checking on this during their weekly visits to assure this is true.
This container was immediately removed on 10/8/21 after citation was noted. The unmarked container was completely removed from facility and all poisonous chemicals locked according to ISPs.
The existence of unmarked chemical bottles was checked in remaining homes across the region on 10/8/21 and none were present, but staff were trained across the region.
House staff and management staff were trained on this requirement again on 10/12/2020. |
10/08/2021
| Implemented |
| 6400.64(a) | At the time of the inspection there were dead bugs, dirt, and cobwebs in the front walkway of the home and leading all the way up the stairs to the second floor where the living room is located. The windowsills in the home, specifically seen in the living room, were thick with dust and there were also dead bugs.
The downstairs/basement apartment, although unoccupied, contained many dead bugs/flies, filthy toilets, counters, floors, walls, ceilings, windows, broken glass on the floor, etc. The stairwell leading down to this apartment was accessible at the time of the inspection. | Clean and sanitary conditions shall be maintained in the home. | The House Manager and staff cleaned mentioned areas the evening of inspection on 10/5/21 to meet expected standards.
House Managers and DSPs are responsible for assuring the cleanliness of each residence. There is a daily/weekly cleaning list in each home to be followed by staff. The House Manager bears the front-line responsibility to make sure it is initialed off and followed by each shift.
The Residential Supervisor is responsible for checking on this during their weekly visits to assure facility remains clean and safe.
The Regional Director is responsible to inspect facility for cleanliness on a weekly basis. |
10/05/2021
| Implemented |
| 6400.66 | At the time of the inspection, the light outside of the basement door was inoperable. | At the time of the inspection, the light outside of the basement door was inoperable. | House Managers are responsible for informing the Residential Supervisor of any maintenance items as they occur. Updated maintenance concerns are to be reported daily by EOPs on the proper maintenance form located on Extended Reach, our current Electronic Management System.
Residential Supervisors are to verify that items are entered in our electronic maintenance request system and inform Regional Director within 24 hours.
The Regional Director keeps a running list of all outstanding maintenance items to discuss with maintenance and have resolved if they linger for more than a week. Maintenance issue are to be addressed in a timely manner. This item was reported to maintenance on 10/16/21.
All outstanding items were addressed with maintenance on 10/16/21 across the region. All staff were retrained on the procedure to file maintenance issue on 10/15/21. |
11/28/2021
| Implemented |
| 6400.67(a) | The walls in the downstairs/basement apartment, although unoccupied, had holes in multiple locations. | The walls in the downstairs/basement apartment, although unoccupied, had holes in multiple locations. | House Managers are responsible for informing the Residential Supervisor of any maintenance items as they occur. Updated maintenance concerns are to be reported daily by EOPs on the proper maintenance form located on Extended Reach, our current Electronic Management System.
Residential Supervisors are to verify that items are entered in our electronic maintenance request system and inform Regional Director within 24 hours.
The Regional Director keeps a running list of all outstanding maintenance items to discuss with maintenance and have resolved if they linger for more than a week. Maintenance issue are to be addressed in a timely manner. This item was reported to maintenance on 10/16/21.
All outstanding items were addressed with maintenance on 10/16/21 across the region. All staff were retrained on the procedure to file maintenance issue on 10/15/21. |
11/28/2021
| Implemented |
| 6400.71 | There was a cordless phone sitting on its charging dock in the office. The emergency numbers were posted beside the phone however they were not listed on the back of the phone. Best practice and recommendation is to post the numbers on the back of the phone to remain in compliance should staff take the phone out of the office and leave it laying at another location within the home. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| The landline phone in this facility is only used be staff ¿ and that is for incoming calls. The individuals that use a phone have a personal phone to use, so this landline is not used outside of the office by staff or individuals.
A sticker with emergency numbers was put on the back of the phone by the House Manager regardless of the Emergency Contact List seen in the office to eliminate any possibility of this occurring.
This was completed by House Manager on 10/22/21. This correction shall be made if needed in every home across the region by 10/29/21 as per direction of Regional Director and checked by the Residential Supervisor for compliance.
The Residential Supervisor will make sure this list is present on every landline in every home across the region by 10/29/21. |
10/22/2021
| Implemented |
| 6400.72(c) | At the time of the inspection, the exit door located in the lower-level apartment/basement that opens up to the driveway (in front of the home) was unlocked and accessible to anyone from the outside. The stairwell door leading from the basement to the upstairs of the home was also unlocked and accessible. This creates a health and safety risk as anyone from the outside would have access to the home without staff being aware of an outsider intrusion. | At the time of the inspection, the exit door located in the lower-level apartment/basement that opens up to the driveway (in front of the home) was unlocked and accessible to anyone from the outside. The stairwell door leading from the basement to the upstairs of the home was also unlocked and accessible. This creates a health and safety risk as anyone from the outside would have access to the home without staff being aware of an outsider intrusion. | The doors were locked and secured the day of the surprise inspection, 10/5/21.
All new and current EOPs will be trained/retrained on the importance of constant and persistent safety measures within the home. The House Manager will instruct staff that, at all times, access to the unused portion of the establishment should be locked and inaccessible to individuals, no matter the entrance point. |
10/25/2021
| Implemented |
| 6400.74 | At the time of the inspection, the last 3 steps leading to the basement level did not have non-skid surfaces on them. This stairwell is open, and the individuals have access to this staircase. | Interior stairs and outside steps shall have a nonskid surface.
| Regional Director provided non-skid material for steps on 10/20/21 at 8am.
The House Manager will be responsible for putting down non skid tape on 10/20/21 and the Residential Supervisor and Regional Director will be responsible for assuring this is done on all interior and exterior steps during their weekly visits.
The deck steps were redone with non skid tape on 10/20/2021 as verified by pictures sent to Regional Director.
All homes were inspected for the need of non-skid strips the week of 10/11/21 and those home requiring any repair were provided the material to do so by the Regional Director. House Managers are responsible to see task to completion by 10/20/21 as per verification by the Residential Supervisor. |
10/20/2021
| Implemented |
| 6400.77(b) | At the time of the inspection, there were no scissors or tweezers in the first aid kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The House Manager is responsible for needed items being inside the first aid kits in each home. They are responsible to check these for use of contents and replenish. At the time of inspection, the needed scissors and tweezers were inside the desk drawer and replaced into the first aid kit the same day, 10/5/21.
The House Manager will notify the Residential Supervisor if they are in need of restocking the First Aid Kit or replacing any that are broken or in disrepair for any reason.
The Residential Supervisor is responsible to make sure needed items reported missing or entire kits are replaced when items are reported from the House Manager as needing replaced. |
10/05/2021
| Implemented |
| 6400.80(b) | At the time of inspection, the deck directly outside of individual #1's bedroom was covered with wet leaves. This poses a safety hazard/fall risk. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The leaves were removed from the mentioned deck on 10/6/21 by EOP staff as per House Manager.
The House Manager is responsible for notifying the Residential Supervisor when there are leaves on the property that need to be removed.
The Residential Supervisor will be responsible or notifying landscaping when there are leaves on the property in between regular maintenance.
Landscaping is responsible for removing leaves on a regular schedule plus when notified that there is an abundance of leaves.
The Regional Director will be responsible for assuring that there is not an abundance of leaves at any property during their weekly visits. The Regional Director will also implement a weekly checklist starting on 12/1/21 to include making sure no exits/sidewalks at any property could cause an unsafe situation for individuals or staff.
All facilities checked across the region by Regional Director, and none had this particular issue as of 10/20/21. |
10/06/2021
| Implemented |
| 6400.81(k)(6) | At the time of the inspection, there were no mirrors in any of the 3 individuals' bedrooms who live in this home. There were no notations in any of the individuals' ISPs to indicate that the individuals requested to not have a mirror or omitted for health and safety reasons. | In bedrooms, each individual shall have the following: A mirror. | Mirrors have been placed in each individual¿s room as of 10/20/21 by Regional Director. Individual #1 refused to have one or he would break it on purpose, but he did agree to allow one to hang inside his closet.
The House Manager is responsible for maintaining the bedrooms with basic necessities, including a mirror, unless an ISP states a contradiction to this regulation, in which case it will be noted clearly in the ISP. In the case that anything is in need of being purchased for a bedroom, the House Manager would contact the Residential Supervisor.
Bedroom essentials were checked across the region by the Regional Director and mirrors put in all rooms without one unless the ISP stipulated differently. This was completed 10/20/21 |
10/20/2021
| Implemented |
| 6400.83(c) | At the time of the inspection, there was a crock of cooking spoons located on the bottom shelf of the cabinet located on the right of the stove. It had serving spoons that were not clean. There were visible grease stains on them, indicating that they were not properly washed after use. | Utensils used for eating, drinking and preparation of food or drink shall be washed and rinsed after each use. | The dirty utensils were removed and rewashed by staff on 10/5/21 after inspection team left.
It is the responsibility of each staff and House Manager to ensure the dishes they do are clean, dry, and put away in a timely manner.
The Residential Supervisor and House Manager should assure clean and organized dishes and utensils during their weekly site checks beginning 12/1/21.
As of 10/20/21, this was addressed in every home to be checked and put on daily list to be checked by all staff.
The Regional Director will be responsible for assuring that there is oversight via weekly checklist of Residential Supervisor beginning 12/1/21 during weekly visits. |
10/05/2021
| Implemented |
| 6400.171 | At the time of inspection there were boxes of food in the cabinet and lazy susan (rice, pancake mix, and a bag of cereal) that were left open and not properly closed/sealed prior to storage. | Food shall be protected from contamination while being stored, prepared, transported and served.
| The open food containers found on 10/5/21 during the inspection were discarded the same day.
It is the responsibility of the House Manager and EOPs to ensure the boxed food is stored in a way that prevents contamination or early staleness. The process of storing food in labeled containers that are dated or closing the original container to airtight is part of the shadowing process for new staff. Current staff were retrained by Regional Director on 10/20/21on proper food storage.
The Residential Supervisor and House Manager should assure proper training of new staff as they go through the shadowing process for 24 hours upon hire.
The Residential Supervisor will sign off on shadowing of all new staff hired. |
10/05/2021
| Implemented |
| 6400.166(a)(4) | The Medication administration record for individual #2 was missing all the information on the prescribed medication "Magnesium Oxide 400mg 1 Tablet by mouth one time per day at 8am". | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Medication was added to the MAR by corporate contact on 10/20/21.
All EOPS and House Managers are trained and responsible for adding new medications prescribed to the MAR and sending the label information to our corporate contact to be added to the MAR permanently until discontinued so the MAR will show correct and current medication information.
The Residential Supervisor has final sign off on shadowing and preparedness of staff to work in the home.
All staff, regardless of position, are required to be undergo Medication Administration Training before working in the home alone during a medication administration time.
All staff are trained by a licensed Medication Administration Trainer within the company, including two onsite observations, before administering any medication to individuals. |
10/20/2021
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The providers license expires 8/6 and the self-inspections for each of the homes were completed within the last two months, October and November of 2020, instead of 3-6 months prior to their license expiring and/or 3-6 months after their last annual licensing inspection, as required by this regulation. | 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.
| . A plan to fix the immediate problem
a. WHO.(job title) will be responsible for correcting the problem (each step of the process) in the future. The Program Specialist is responsible for completing the self assessment in a timely manner, the Regional Director is responsible for confirming that the self assessments are completed
b. WHAT will be corrected. Self assessments will be completed 3-6 months prior to the license expiring and/or 3-6 months after their last annual licensing inspection
c. WHEN and HOW (usually attached as procedure)
Self assessments will be uploaded into our electronic filing system and reminder notifications done for the Program Specialist and Regional Director three months prior to our license expiring.
The Program Specialist will complete the self assessments within 30 days of the notification, or two months prior to the expiration of our license
The Regional Director will review all self assessments to assure they are completed and accurate within the next 30 days, so that all self assessments are completed, accurate and uploaded into the electronic file system by one month prior to our license being due.
2. A plan to prevent future occurrences
By the licensing date Regional Directors will report to the Vice President a list of all completed self assessments and any that have not been completed. If any are not completed they will be completed within a week
3. Note of each plan of correction that you trained the staff responsible for that plan. They are to be trained in their responsibilities. Since the plans are new since licensing was there, the training date needs to be since licensing was there. Program Specialists and Regional Directors will be trained on this process in a training to be scheduled for 2/18/2021
4. Send documents that will enable us to validate that the new plan is up and running. Ex: if one plan includes a new form to be used for all future quarterly reviews, send a quarterly review completed on that new form. Dont send blank forms. Please send the current year and past years documentation when correcting a violation that requires an annual timeframe. The agenda and attendance list will be sent to the Central Region Licensing Director by 2/19/2021.
5. Label every attachment and refer to that label on the plan of correction that it applies to. Ex: attachment #1, attachment #2, etc. |
02/19/2021
| Implemented |
| 6400.66 | At the time of the inspection, the staff did not know how to turn on the entrance lights on either side of the front door; therefore, it could not be verified if the lights were operational. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| . A plan to fix the immediate problem
a. WHO (job title) will be responsible for correcting the problem (each step of the process) in the future. The Residential Supervisor reviewed the location of all light switches with staff. The Regional Director informed maintenance that the lights needed to be replaced. Maintenance replaced the lights.
b. WHAT will be corrected. Lights needed to be replaced. Staff needed to be retrained on the location of all light switches.
c. WHEN and HOW (usually attached as procedure)
Staff were retrained by the Residential Supervisor on the location of all light switches on 11/18/2020.
Maintenance was notified by Regional Director that the lights needed to be replaced on 11/19/2020
Maintenance replaced lights on 12/18/2020
2. A plan to prevent future occurrences
All lights will be checked on weekly inspections by Residential Supervisor and Regional Director
3. Note of each plan of correction that you trained the staff responsible for that plan. They are to be trained in their responsibilities. Since the plans are new since licensing was there, the training date needs to be since licensing was there. House staff were trained on the location of light switches on 11/18/2020. Residential Supervisors and Regional Directors we informed on the process on 11/20/2020.
4. Send documents that will enable us to validate that the new plan is up and running. Ex: if one plan includes a new form to be used for all future quarterly reviews, send a quarterly review completed on that new form. Dont send blank forms. Please send the current year and past years documentation when correcting a violation that requires an annual timeframe.
5. Label every attachment and refer to that label on the plan of correction that it applies to. Ex: attachment #1, attachment #2, etc. |
12/18/2020
| Implemented |
| 6400.74 | REPEAT 07/11/19- The outside steps off of the back deck did not have a nonskid surface on each step, and some of the non-skid surfaces were peeling off and needed replaced. | Interior stairs and outside steps shall have a nonskid surface.
| 1. A plan to fix the immediate problem
a. WHO (job title) will be responsible for correcting the problem (each step of the process) in the future. The house manager will be responsible for putting down non skid tape and the Residential Supervisor and Regional Director will be responsible for assuring this is done on all interior and exterior steps during their weekly visits.
b. WHAT will be corrected. All interior and exterior steps will have non skid surfaces as required.
c. WHEN and HOW (usually attached as procedure)
The deck steps were redone with non skid tape on 11/20/2020. All homes were inspected from 11/23-25/2020 by the Residential Supervisor and non skid strips were put down to replace any worn or missing strips
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. All homes were instructed to buy a roll of non skid tape by 11/30/2020 and maintain a supply thereafter. House managers of each home are to replace any missing or worn non skid strips they identify in their daily inspection of the home. Residential Supervisors are to have a roll of non skid tape in their tool boxes for emergencies. They are to check for missing or worn non skid strips during their weekly inspection of each home and assure they are replaced before they leave.
3. Note of each plan of correction that you trained the staff responsible for that plan. They are to be trained in their responsibilities. Since the plans are new since licensing was there, the training date needs to be since licensing was there. House managers were trained in this procedure on 11/25/2020
4. Send documents that will enable us to validate that the new plan is up and running. Ex: if one plan includes a new form to be used for all future quarterly reviews, send a quarterly review completed on that new form. Dont send blank forms. Please send the current year and past years documentation when correcting a violation that requires an annual timeframe. Please see attached picture of non skid strips on the deck labeled Euclid Back Porch Steps
5. Label every attachment and refer to that label on the plan of correction that it applies to. Ex: attachment #1, attachment #2, etc. |
11/30/2020
| Implemented |
| 6400.80(b) | At the time of the inspection, there was a build up of leaves on the back deck by the entrance door and on the stairs, and leaves covering the entirety of the deck off of individual #1 bedroom, to which this individual has access | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | 1. A plan to fix the immediate problem
a. WHO (job title) will be responsible for correcting the problem (each step of the process) in the future. The House Manager is responsible for notifying the Residential Supervisor when there are leaves on the property that need to be removed. The Residential Supervisor will be responsible or notifying landscaping when there are leaves on the property in between regular maintenance. Landscaping is responsible for removing leaves on a regular schedule plus when notified that there is an abundance of leaves. The Regional Director will be responsible for assuring that there is not an abundance of leaves at any property during their weekly visits.
b. WHAT will be corrected. There must never be an abundance of leaves on any house property as this is a safety hazard.
c. WHEN and HOW (usually attached as procedure)
Landscaping removed leaves from all properties during the week of 11/30/2020.
Going forward, the House Manager will notify the Residential Supervisor when there are leaves on the property that need to be removed.
The Residential Supervisor will notify landscaping when there are leaves on the property in between regular maintenance.
Landscaping will remove leaves on a regular schedule plus when notified that there is an abundance of leaves, within 48 hours of notification.
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. The Regional Director will assure that there is not an abundance of leaves at any property during their weekly visits, and that the above procedure is adhered to at all times.
3. Note of each plan of correction that you trained the staff responsible for that plan. They are to be trained in their responsibilities. Since the plans are new since licensing was there, the training date needs to be since licensing was there. House Managers and Residential Supervisors will be trained on this procedure on 3/18/2021 when its time for landscaping to clear the grounds from any remaining leaves, branches, etc. from over the winter. They will be trained again on 9/16/2021 at the beginning of the fall season.
4. Send documents that will enable us to validate that the new plan is up and running. Ex: if one plan includes a new form to be used for all future quarterly reviews, send a quarterly review completed on that new form. Dont send blank forms. Please send the current year and past years documentation when correcting a violation that requires an annual timeframe. See attached picture of property labelled Euclid Back Porch
5. Label every attachment and refer to that label on the plan of correction that it applies to. Ex: attachment #1, attachment #2, etc. |
09/16/2021
| Implemented |
| 6400.80(b) | At the time of the inspection, there was a build up of leaves on the back deck by the entrance door and on the stairs, and leaves covering the entirety of the deck off of individual #1 bedroom, to which this individual has access. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | . A plan to fix the immediate problem
a. WHO (job title) will be responsible for correcting the problem (each step of the process) in the future. If the leaves are on a deck or balcony, the House Manager is responsible for assuring they or a DSP rakes and removes the leaves. If the leaves are on the grass/property, the House Manager is responsible for notifying the Residential Supervisor when there are leaves on the property that need to be removed. The Residential Supervisor will be responsible or notifying landscaping when there are leaves on the property in between regular maintenance. Landscaping is responsible for removing leaves on a regular schedule plus when notified that there is an abundance of leaves. The Regional Director will be responsible for assuring that there is not an abundance of leaves at any property during their weekly visits.
b. WHAT will be corrected. There must never be an abundance of leaves on any house property as this is a safety hazard.
c. WHEN and HOW (usually attached as procedure)
House staff removed the leaves on 11/18/2020. Landscaping removed leaves from all properties during the week of 11/30/2020.
Going forward, the House Manager have leaves removed or will notify the Residential Supervisor when there are leaves on the property that need to be removed.
The Residential Supervisor will notify landscaping when there are leaves on the property in between regular maintenance.
Landscaping will remove leaves on a regular schedule plus when notified that there is an abundance of leaves, within 48 hours of notification.
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. The Regional Director will assure that there is not an abundance of leaves at any property during their weekly visits, and that the above procedure is adhered to at all times. Procedures will be updated to reflect this change in procedures.
3. Note of each plan of correction that you trained the staff responsible for that plan. They are to be trained in their responsibilities. Since the plans are new since licensing was there, the training date needs to be since licensing was there. House Managers and Residential Supervisors will be trained on this procedure on 3/18/2021 when its time for landscaping to clear the grounds from any remaining leaves, branches, etc. from over the winter. They will be trained again on 9/16/2021 at the beginning of the fall season.
4. Send documents that will enable us to validate that the new plan is up and running. Ex: if one plan includes a new form to be used for all future quarterly reviews, send a quarterly review completed on that new form. Dont send blank forms. Please send the current year and past years documentation when correcting a violation that requires an annual timeframe. See attached picture of property labelled Euclid Back Porch Steps
5. Label every attachment and refer to that label on the plan of correction that it applies to. Ex: attachment #1, attachment #2, etc. |
09/16/2021
| Implemented |
| 6400.104 | The notification letter to the fire department does not include the exact location of the individual's bedrooms that need assistance to evacuate and the notification letter is not current. The fire evacuation plan dated 7/27/2020 indicates that there are two individuals at this home, however the notification letter to the fire department is dated 12/16/2019 and indicates that there is only one individual in the home. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| . A plan to fix the immediate problem
a. WHO (job title) will be responsible for correcting the problem (each step of the process) in the future. The Residential Supervisor has updated and sent a letter to the local fire department indicating who is in which bedroom and who needs assistance evacuating.
b. WHAT will be corrected As Spectrum receives new admissions, locations of individuals change, and/or the physical capacity of individuals change, updated letters will be sent to the local fire department indicating who in in which bedroom and who needs assistance evacuating. This will be completed by the Residential Supervisor as changes occur and annually.
c. WHEN and HOW (usually attached as procedure)
Fire letter for this location was updated and submitted on 11/16/2020
Fire letters will be reviewed for all homes in all regions by 1/8/2020 and updated as necessary to assure they are in compliance.
Fire letters in the future will be completed and sent to the local fire department within 48 hours or any change requiring an updated letter.
Regional Directors will review and approve all letters before they are sent to the local fire department
2. A plan to prevent future occurrences
Spectrum will develop a move in and change of location checklist for Residential Supervisors to assure that new fire letters are completed as required, by 1/20/2020.
3. All Program Specialists, Residential Supervisors and Regional Directors will be trained on how and when to do local fire department letters on 1/7/2020. This training element will be incorporated into their annual training requirements and new hire training requirements by 1/15/2020
4. Send documents that will enable us to validate that the new plan is up and running. Please see updated fire letter for this location labeled Euclid Fire Letter
5. Label every attachment and refer to that label on the plan of correction that it applies to. Ex: attachment #1, attachment #2, etc. |
01/20/2021
| Implemented |
| 6400.106 | At the time of inspection, there was no written documentation of the furnace cleaning from 2019 to verify the date of the inspection, however current inspection is scheduled for 11/16/2020. Due to not having the documentation from 2019, licensing staff can't qualify that the inspection was being held in the time frame as required by this regulation | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| 1. A plan to fix the immediate problem
a. WHO (job title) will be responsible for correcting the problem (each step of the process) in the future
The Regional Director is responsible for assuring that all records for individuals and staff are complete and available. The vice president is responsible for assuring that all records are available both in hard copy in the vice presidents secured files, and in our electronic filing system.
b. WHAT will be corrected. Spectrum could not locate the 2019 furnace inspection record and therefore could not demonstrate that the 2020 furnace inspection was done within the 12 month annual requirement. To correct this, files will be redundant and kept in both electronic and hard copy form.
c. WHEN and HOW (usually attached as procedure)
The redundant system will begin on 1/4/2021. Regional Directors will be trained on how this will be operationalized on 12/23/2020.
A review of all hard copy and electronic records will be conducted by 1/4/2021 to determine which files contain the 2019 furnace inspections documentation, and will be duplicated to be included in both electronic and hard copy format.
The electronic files will be reviewed to ensure that every document for individuals, homes and staff have a home so they can be easily retrieved, by 1/8/2021.
Once we are sure there are no bugs in the process, it will be codified in our procedures by 1/22/2021.
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. Program Specialists, one per region, will be assigned to do quality assurance checks between hard and electronic copies at random, monthly, to assure all files are included. This will commence on 2/1/2021.
3. Note of each plan of correction that you trained the staff responsible for that plan. They are to be trained in their responsibilities. Since the plans are new since licensing was there, the training date needs to be since licensing was there. Regional Directors will be trained on this system on 12/23/2020. Program Specialists will be trained on this system on 1/4/2021.
4. Send documents that will enable us to validate that the new plan is up and running. Ex: if one plan includes a new form to be used for all future quarterly reviews, send a quarterly review completed on that new form. Dont send blank forms. Please send the current year and past years documentation when correcting a violation that requires an annual timeframe. The procedure will be finalized by 1/22/2021 and sent to the Central Region Licensing Director
5. Label every attachment and refer to that label on the plan of correction that it applies to. Ex: attachment #1, attachment #2, etc. |
02/01/2021
| Implemented |
| 6400.111(a) | At the time of the inspection, there was no fire extinguisher located in the basement of the home. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | 1. A plan to fix the immediate problem
a. WHO (job title) will be responsible for correcting the problem (each step of the process) in the future. The Residential Supervisor is responsible for assuring working fire extinguisher is on each floor or each home. Regional Director is responsible for confirming during their weekly home visits that each fire extinguisher is in place.
b. WHAT will be corrected. There needs to be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic.
c. WHEN and HOW (usually attached as procedure)
A fire extinguisher that meets requirements was put in the basement of this home on 11/20/2020
All homes were inspected on 11/23/2020 to assure there were no other missing fire extinguishers, and there were not.
2. A plan to prevent future occurrences
Fire extinguishers will be included in the checklist for weekly home visits to assure that this is checked every week, not only the presence of fire extinguishers but that they are inspected and fully charged.
3. Note of each plan of correction that you trained the staff responsible for that plan. They are to be trained in their responsibilities. Since the plans are new since licensing was there, the training date needs to be since licensing was there.
4. Send documents that will enable us to validate that the new plan is up and running. Ex: if one plan includes a new form to be used for all future quarterly reviews, send a quarterly review completed on that new form. Dont send blank forms. Please send the current year and past years documentation when correcting a violation that requires an annual timeframe. Please see picture labeled Fire Ext
5. Label every attachment and refer to that label on the plan of correction that it applies to. Ex: attachment #1, attachment #2, etc. |
11/23/2020
| Implemented |
| 6400.113(a) | Individual #1 had fire safety training on 8/13/20. There was no documentation of when this individual had his 2019 fire safety training thus licensing staff were unable to verify that the individual had his yearly fire safety training as required by this regulation. | 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. | 1. A plan to fix the immediate problem
a. WHO (job title) will be responsible for correcting the problem (each step of the process) in the future
The Regional Director is responsible for assuring that all records for individuals and staff are complete and available. The vice president is responsible for assuring that all records are available both in hard copy in the vice presidents secured files, and in our electronic filing system.
b. WHAT will be corrected. Spectrum could not locate the 2019 fire safety training records and therefore could not demonstrate that the 2020 fire safety trainings were done within the 12 month annual requirement. To correct this, files will be redundant and kept in both electronic and hard copy form.
c. WHEN and HOW (usually attached as procedure)
The redundant system will begin on 1/4/2021. Regional Directors will be trained on how this will be operationalized on 12/23/2020.
A review of all hard copy and electronic records will be conducted by 1/4/2021 to determine which individual and staff files contain the 2019 fire safety documentation, and will be duplicated to be included in both electronic and hard copy format.
The electronic files will be reviewed to ensure that every document for individuals and staff have a home so they can be easily retrieved, by 1/8/2021.
Once we are sure there are no bugs in the process, it will be codified in our procedures by 1/22/2021.
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. Program Specialists, one per region, will be assigned to do quality assurance checks between hard and electronic copies at random, monthly, to assure all files are included. This will commence on 2/1/2021.
3. Note of each plan of correction that you trained the staff responsible for that plan. They are to be trained in their responsibilities. Since the plans are new since licensing was there, the training date needs to be since licensing was there. Regional Directors will be trained on this system on 12/23/2020. Program Specialists will be trained on this system on 1/4/2021.
4. Send documents that will enable us to validate that the new plan is up and running. Ex: if one plan includes a new form to be used for all future quarterly reviews, send a quarterly review completed on that new form. Dont send blank forms. Please send the current year and past years documentation when correcting a violation that requires an annual timeframe. The procedure will be finalized by 1/22/2021 and sent to the Central Region Licensing Director
5. Label every attachment and refer to that label on the plan of correction that it applies to. Ex: attachment #1, attachment #2, etc. |
02/01/2021
| Implemented |
| 6400.113(c) | The agency could not provide a written record of fire safety training for Individual #1 from his 2019 training. He had fire safety training on 12/17/18, which would indicate that he should have had it again in December of 2019. Licensing was held in August of 2019 last year; thus, this documentation would have been needed to qualify the individual's yearly training. | A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. | 1. A plan to fix the immediate problem
a. WHO (job title) will be responsible for correcting the problem (each step of the process) in the future
The Regional Director is responsible for assuring that all records for individuals and staff are complete and available. The vice president is responsible for assuring that all records are available both in hard copy in the vice presidents secured files, and in our electronic filing system.
b. WHAT will be corrected. Spectrum could not locate the 2019 fire safety training records and therefore could not demonstrate that the 2020 fire safety trainings were done within the 12 month annual requirement. To correct this, files will be redundant and kept in both electronic and hard copy form.
c. WHEN and HOW (usually attached as procedure)
The redundant system will begin on 1/4/2021. Regional Directors will be trained on how this will be operationalized on 12/23/2020.
A review of all hard copy and electronic records will be conducted by 1/4/2021 to determine which individual and staff files contain the 2019 fire safety documentation, and will be duplicated to be included in both electronic and hard copy format.
The electronic files will be reviewed to ensure that every document for individuals and staff have a ¿home¿ so they can be easily retrieved, by 1/8/2021.
Once we are sure there are no bugs in the process, it will be codified in our procedures by 1/22/2021.
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. Program Specialists, one per region, will be assigned to do quality assurance checks between hard and electronic copies at random, monthly, to assure all files are included. This will commence on 2/1/2021.
3. Note of each plan of correction that you trained the staff responsible for that plan. They are to be trained in their responsibilities. Since the plans are new since licensing was there, the training date needs to be since licensing was there. Regional Directors will be trained on this system on 12/23/2020. Program Specialists will be trained on this system on 1/4/2021.
4. Send documents that will enable us to validate that the new plan is up and running. Ex: if one plan includes a new form to be used for all future quarterly reviews, send a quarterly review completed on that new form. Dont send blank forms. Please send the current year and past years documentation when correcting a violation that requires an annual timeframe. The procedure will be finalized by 1/22/2021 and sent to the Central Region Licensing Director
5. Label every attachment and refer to that label on the plan of correction that it applies to. Ex: attachment #1, attachment #2, etc. |
02/01/2021
| Implemented |
| 6400.174 | At the time of the inspection, the staff at this home did not have the individual's menus posted and the staff was also unable to find the menu in order to verify that the individuals are offered foods from each food group. | At least one meal each day shall contain at least one item from the dairy, protein, fruits and vegetables and grain food groups, unless otherwise recommended in writing by a licensed physician for individuals.
| 1. A plan to fix the immediate problem
a. WHO (job title) will be responsible for correcting the problem (each step of the process) in the future. It is the Program Specialists responsibility to assure weekly menus are done and accessible in each home to assure that individuals are offered foods from each food group. It is the Regional Directors job to confirm this during their weekly visits to each home
b. WHAT will be corrected. Menus for each home will be done weekly and be accessible to assure that individuals are offered foods from each food group.
c. WHEN and HOW (usually attached as procedure)
House Managers will develop menus weekly, get them approved by the Program Specialist, and develop shopping lists to support the weekly menu. Program Specialists and Regional Directors will assure these menus are present and accessible through their weekly visits to each home
Menus were developed during the week of 11/23/2020 and every week thereafter, approved and made accessible
Menus will be incorporated into the site visit checklists by 12/28/2020.
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. Central Region House Managers, Residential Supervisors and the Regional Director were trained in this procedure during the week of 11/23/2020 during home site visits. All regions will be trained by 12/28/2020. This will be added to site visit checklist to assure compliance.
3. Note of each plan of correction that you trained the staff responsible for that plan. They are to be trained in their responsibilities. Since the plans are new since licensing was there, the training date needs to be since licensing was there. Central Region staff were trained on this during weekly home visits during the week of 11/23/2020.
4. Send documents that will enable us to validate that the new plan is up and running. Ex: if one plan includes a new form to be used for all future quarterly reviews, send a quarterly review completed on that new form. Dont send blank forms. Please send the current year and past years documentation when correcting a violation that requires an annual timeframe. See sample menu labeled Sample Menu
5. Label every attachment and refer to that label on the plan of correction that it applies to. Ex: attachment #1, attachment #2, etc. |
12/28/2020
| Implemented |
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