Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00238779 Renewal 02/13/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The light outside the back door of the garage was not operable at the time of the inspection.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. On 2/14/24, during the inspection, the bulb in the light was replaced and working. 02/14/2024 Implemented
6400.67(b)At the time of the inspection a golf ball size amount of lint was located in the lint trap of the dryer. Floors, walls, ceilings and other surfaces shall be free of hazards.On 2/14/24, the lint was removed during the inspection. 02/14/2024 Implemented
6400.68(b)The water temp measured 129.4 at the time of the inspection. Hot water temperatures in bathtubs and showers may not exceed 120°F. On 2/14/24, the water temperature was turned down in the home and tested over a 24 hour period. The temperature was registering 119 consistently. 02/14/2024 Implemented
SIN-00217217 Renewal 01/10/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101The door in the garage was not able to be opened at the time of the inspection.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. On 1/11/23 a maintenance request was put into the corporate office to repair the storm door On 1/13/23 maintenance arrived on site and completely repaired the storm door in the garage 01/13/2023 Implemented
6400.106The furnace inspection for the home was completed on 8/13/21 and then again on 9/20/22.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. This cannot be corrected for this inspection cycle 01/11/2023 Implemented
SIN-00197114 Technical Assistance 12/07/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At the time of the inspection the cabinet in the garage was not locked. The cabinet contained several cleaners that stated contact poison control if ingested.Poisonous materials shall be kept locked or made inaccessible to individuals. House Managers and DSPs are responsible for assuring that all poisonous materials are kept safely away from individuals as required by their ISPs. Residential Supervisors are responsible for checking on this during their weekly visits to assure poisons are always inaccessible to the individuals in the home. These containers were under lock, however the lock was not latched properly at time of inspection. Staff are responsible to ensure the proper locking system for poisons. The existence of unlocked chemical bottles was checked in remaining homes across the region on 12/7/21 and any that were unlocked, regardless of ISP stipulations were locked, but staff were retrained across the region. House staff and management staff were trained on this requirement again on 12/7/21. 12/07/2021 Implemented
6400.167(a)(1)Individual #1's dose of melatonin 5mg was not administered on December 6th at bedtime.Medication errors include the following: Failure to administer a medication.The individual¿s medication was not delivered by the pharmacy on time. The Senior of the home called the doctor for written instructions of missed dose and called pharmacy for delivery that same day 12/7/21. Medication Error was filed in HCSIS system. 12/07/2021 Implemented
SIN-00195254 Renewal 11/09/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)At the time of the inspection, there was an unmarked bottle under the kitchen sink with and unidentified liquid inside.Poisonous materials shall be stored in their original, labeled containers. 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 11/10/21 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 addressed in a House Manager training on 11/22/21 with Regional Director to ensure understanding of the regulation and further verification that this does not exist in any other home in the region. 12/01/2021 Implemented
6400.181(c)The most recent assessment for individual #1, dated 11/01/2021, did not indicate that the assessment was based on assessment instruments, interviews, progress notes and observations. This is a repeat violationThe assessment shall be based on assessment instruments, interviews, progress notes and observations. The Program Specialist is responsible for writing a complete and specific assessment. Due to the lack of a Program Specialist at this time, the Regional Director will go back and check each and every Annual Assessment to make sure they contain the proper verbiage on the development of the assessment in an opening statement on the actual assessment. 12/10/2021 Implemented
6400.181(e)(13)(iv)The most recent assessment dated 11/01/2021 for individual #1, stated, "Individual #1 displays aggression toward staff as well as oneself. This has resulted in hospitalizations and ER visits to be checked for injury." These statements do not indicate the individual's progress, growth, or performance over the past 365 days. It fails to detail if these behaviors are a decline, improvement, or non-changing over the past year and there was no documented baseline behavior detailed in the assessment in order to assess yearly change.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. The Program Specialist is responsible for writing a complete and specific assessment which includes the progress in each area for the individual being assessed. Due to the lack of a Program Specialist at this time, the Regional Director will monitor all assessments being done until the new Program Specialist starts to monitor for correctness and thoroughness of the assessment before it goes to the Service Coordinator, including language including the detail if these behaviors are a decline, improvement, or non-changing over the past year and that there is documented baseline behavior detailed in the assessment in order to assess yearly change.. 12/10/2021 Implemented
6400.181(e)(13)(v)The most recent assessment dated 11/01/2021 for individual #1, stated, "Individual #1 does recognize [ones] mother and will verbally ask for her. Individual #1 has no awareness of strangers". The assessment did not assess the individual's progress, growth, or performance over the past 365 days.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. The Program Specialist is responsible for writing a complete and specific assessment which includes the progress in each area for the individual being assessed. Due to the lack of a Program Specialist at this time, the Regional Director will monitor all assessments being done until the new Program Specialist starts to monitor for correctness and thoroughness of the assessment before it goes to the Service Coordinator. 12/10/2021 Implemented
6400.165(g)Individual #1's psychiatric appointments did not include documentation of the reason for prescribing the medications or documentation for the need to continue the medication, nor did it include the necessary dosage amount. This documentation was not seen for any of the tele-visits that were completed and the form from 11/11/21 visit was not properly completed. There were blank spaces left on the form where this information was to be indicated and only notate was the current change in one of the medications only (Risperidone).If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Spectrum is requesting from the psychiatrist a completed form that includes for all medications documentation for the reason for prescribing the medication, the need to continue the medication and the necessary dosage. We will continue to follow up, including with another appointment if necessary, to get this information. Spectrum has also reviewed all psychiatric medications prescribed for all individuals and is assuring that this information is available for them as well. 12/07/2021 Implemented
SIN-00177562 Renewal 11/10/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)According to staff, the individual living in this home is unsafe with poisons and poisons should be locked. At the time of inspection, there was a bottle of scrubbing bubbles bathroom cleaner being stored in an unlocked cabinet below the bathroom sink, it did state to "call poison control" on the back which denotes it is a poisonous material.Poisonous materials shall be kept locked or made inaccessible to 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 House Managers and DSPs are responsible for assuring that all poisonous materials are kept safely away from individuals as required by their ISPs. Residential Supervisors are responsible for checking on this during their weekly visits to assure this is true. b. WHAT will be corrected. All poisonous materials are to be kept safely away from individuals as required by their ISPs. c. WHEN and HOW (usually attached as procedure) The Scrubbing Bubbles were immediately removed and returned to the locked location of the other poisonous materials. All homes were reviewed on 11/23/2020 to assure that all poisons were locked away in a home where any individuals ISP indicated that this is required. ¿ House staff and management staff were trained on this requirement again on 11/24/2020. 2. A plan to prevent future occurrences This requirement will also be added to the site visit checklist for Residential Supervisors and Regional Directors for use during their weekly home visits. This will also be added to the House Managers daily checklist by 12/1/2020.. 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 and management staff were trained on this requirement again on 11/24/2020. 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. 12/01/2020 Implemented
6400.113(a)Individual #1 had fire safety training on 11/7/2020. There is no documentation from fire drill training conducted in 2019 to verify that fire safety training was completed yearly 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
SIN-00159413 Initial review 07/15/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)Hot water temperature was measured at 136 degrees F in the bathroom sink (there was no tub to be measured -- a stall type shower is present in the bathroom). Hot water temperature was measured at 138 degrees F in the kitchen sink. Hot water temperatures in bathtubs and showers may not exceed 120°F. Hot water tank was turned down. Temperature will be checked with a thermometer 1 time per week until temperature steadily does not exceed 120°F. Then the temperature will be recorded during monthly fire drills. Staff will be trained on this regulation. All home licensed by spectrum will be checked to assure compliance agency wide - JR 07/15/2019 Implemented
SIN-00194069 Unannounced Monitoring 10/05/2021 Compliant - Finalized
SIN-00161708 Unannounced Monitoring 08/21/2019 Compliant - Finalized