| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Good repair:
The white wire shelf in the entryway hall closet was broken and falling down at the time of inspection.
The entryway hall closet door was a slider door and it was very difficult to open and shut.
The Left closet door in Individual #1's bedroom wouldn't open.
The blinds in the living room on the far-right window were broken and in need of repair. | Floors, walls, ceilings and other surfaces shall be in good repair. | 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 are responsible for informing Residential Supervisor of any maintenance items as they occur. Residential Supervisors enter the item in our electronic maintenance request system and inform Regional Director within 24 hours, who keeps a running list of all outstanding maintenance items to discuss with maintenance and have resolved if they linger for more than a week.
b. WHAT will be corrected. Maintenance items are to be addressed in a timely manner
c. WHEN and HOW (usually attached as procedure)
All maintenance items were corrected on 12/18/2020
All homes were reviewed in detail for any outstanding maintenance items, which were then placed in the electronic maintenance request system and added to the Regional Directors list. All maintenance items in the region were addressed by 12/18/2020.
All items were assessed at all homes by 12/8/2020 and corrected by 12/18/2020.
All staff were trained on this procedure again on 12/8/2020
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. House Managers are responsible for informing Residential Supervisor of any maintenance items as they occur. Residential Supervisors enter the item in our electronic maintenance request system and inform Regional Director within 24 hours, who keeps a running list of all outstanding maintenance items to discuss with maintenance and have resolved if they linger for more than 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. All staff were trained on this procedure again on 12/8/2020
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 picture labeled Huffman Shelf, Huffman Vent, Huffman Blinds.
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 |
| 6400.68(b) | At the time of the inspection, the water temperature was measured at 122.2 degree's Fahrenheit, which exceeds the 120 degree plus 2-degree variance as required by this regulation. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | 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 are responsible for taking daily water temperatures at their home and recording it on the electronic file system that tracks daily water temperatures at each home. The system puts out notices daily of any water temperature that is out of range and the Residential Supervisor assures that a correction is made.
b. WHAT will be corrected. Water temperatures will be within required regulatory range.
c. WHEN and HOW (usually attached as procedure)
In this case the water heater was turned down the same day as inspection and an appointment was made with a water heater company to inspect and make any corrections to the water heater. The water heater was working fine. Water temperatures were taken daily and continue to be taken daily and the water temperature remains within range.
Water temperatures in all homes were and continue to be taken daily and reported out and corrected as indicated above.
Water temperature was corrected on 11/17/2020. All water temperatures for each home have been taken daily and reported and corrected same day for about a year.
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. House Managers are responsible for taking daily water temperatures at their home and recording it on the electronic file system that tracks daily water temperatures at each home. The system puts out notices daily of any water temperature that is out of range and the Residential Supervisor assures that a correction is made.
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 reminded to continue taking daily water temperatures on 11/19/2020.
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. |
11/19/2020
| Implemented |
| 6400.81(k)(6) | REPEAT 08/21/19- Individual #2 doesn't have a mirror in her room and because she was an emergency placement on 10-01-2020 she still doesn't have a SEEN plan to address the behaviors associated with why she doesn't have a mirror nor is this in her ISP. There was also no documentation from the PS to the SC indicating that not having a mirror should be added to the individual plan due to behaviors and safety concerns. | In bedrooms, each individual shall have the following: A mirror. | 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. Program Specialists are responsible for making sure Supports Coordinators have updated information to update individuals¿ ISPs. Regional Directors supervise the work of Program Specialists.
b. WHAT will be corrected. Individuals are to have a mirror in their room unless otherwise indicated in their ISP/behavioral plan.
c. WHEN and HOW (usually attached as procedure)
Program Specialist provided information about mirror restriction for this individual on 11/16/2020, to be included in a revised ISP.
All ISPs/behavioral plans for each individual were reviewed by 11/27/2020 to assure all necessary information was included for any restrictions that must apply to an individual. All were in compliance.
All Program Specialists and Regional Directors were retrained on 11/30/2020 on working with individual¿s teams and assuring that any restriction is immediately indicated to the SC so that it can be reflected in the ISP
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring All Program Specialists and Regional Directors were retrained on 11/30/2020 on working with individuals teams and assuring that any restriction is immediately indicated to the SC so that it can be reflected in the ISP. Regional Directors will spot check ISPs where s/he knows there are restrictions to assure they are reflected in the ISP.
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. All Program Specialists and Regional Directors were retrained on 11/30/2020 on working with individuals teams and assuring that any restriction is immediately indicated to the SC so that it can be reflected in the ISP.
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. |
11/30/2020
| Implemented |
| 6400.81(k)(6) | Mirror in bedroom
Individual #2 doesn't have a mirror in her room and because she was an emergency placement on 10-01-2020 she still doesn't have a SEEN plan to address the behaviors associated with why she doesn't have a mirror nor is this in her ISP. There was also no documentation from the PS to the SC indicating that not having a mirror should be added to the individual plan due to behaviors and safety concerns. | In bedrooms, each individual shall have the following: A mirror. | 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. Program Specialists are responsible for making sure Supports Coordinators have updated information to update individuals¿ ISPs. Regional Directors supervise the work of Program Specialists.
b. WHAT will be corrected. Individuals are to have a mirror in their room unless otherwise indicated in their ISP/behavioral plan.
c. WHEN and HOW (usually attached as procedure)
Program Specialist provided information about mirror restriction for this individual on 11/16/2020, to be included in a revised ISP.
All ISPs/behavioral plans for each individual were reviewed by 11/27/2020 to assure all necessary information was included for any restrictions that must apply to an individual. All were in compliance.
All Program Specialists and Regional Directors were retrained on 11/30/2020 on working with individual¿s teams and assuring that any restriction is immediately indicated to the SC so that it can be reflected in the ISP
2. A plan to prevent future occurrences
¿ Long-term plans often include changing practice, teaching, and ongoing monitoring All Program Specialists and Regional Directors were retrained on 11/30/2020 on working with individuals teams and assuring that any restriction is immediately indicated to the SC so that it can be reflected in the ISP. Regional Directors will spot check ISPs where s/he knows there are restrictions to assure they are reflected in the ISP.
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. All Program Specialists and Regional Directors were retrained on 11/30/2020 on working with individuals teams and assuring that any restriction is immediately indicated to the SC so that it can be reflected in the ISP.
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. |
11/30/2020
| Implemented |
| 6400.83(c) | At the time of inspection, there was a blender cup/container and a baking cookie sheet both appearing unwashed but stored in the cabinets. | Utensils used for eating, drinking and preparation of food or drink shall be washed and rinsed after each use. | 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 Manager and DSPs
b. WHAT will be corrected Dishes will be properly cleaned and stored in a timely manner
c. WHEN and HOW (usually attached as procedure)
Dishes are to be thoroughly cleaned after use, dried and put away or put into dishwasher to be properly cleaned.
Residential Supervisor and Regional Director are to assure that this is occurring through their weekly site visits.
All house staff were trained in this procedure 11/23/2020
All other homes were inspected for dirty dishes during the weekly site visits of the week of 11/23/2020 and none were found
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring Proper cleaning procedures are added to the shadowing portion of new hire training that occurs after new hire 24 hours of training. Clean dishes are confirmed during weekly site visits of the Residential Supervisor
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. All house staff were trained in this procedure 11/23/2020. Proper cleaning procedures are added to the shadowing portion of new hire training that occurs after new hire 24 hours of training
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. |
11/27/2020
| Implemented |
| 6400.103 | The Emergency Evacuation Plan (Fire Evacuation Plan) does not include means of transportation and the emergency shelter location. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| . A plan to fix the immediate problem
a. WHO (job title) The Program Specialist is responsible for maintaining the Emergency Evacuation Plan under the supervision of the Regional Director. The plan will be written by the Program Specialist and reviewed by the Regional Director
b. WHAT will be corrected. The Emergency Evacuation Plan (Fire Evacuation Plan) does will include means of transportation and the emergency shelter location.
c. WHEN and HOW (usually attached as procedure)
The emergency evacuation plan was rewritten to include means of transportation and emergency shelter location on 11/19/2020
The Program Specialist was trained to include all necessary data elements on 11/19/2020
All emergency evacuation plans were rewritten to include means of transportation and emergency shelter location on 11/20/2020
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. The emergency evacuation plans will be modified as necessary as any data elements change and reviewed at least annually every January to assure accuracy
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. The Program Specialist is responsible for maintaining and updating the emergency evacuation plan and was retrained on this task on 11/19/2020
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 copy of revised emergency evacuation plan (attachment XX)
5. Label every attachment and refer to that label on the plan of correction that it applies to. Ex: attachment #1, attachment #2, etc. |
11/20/2020
| Implemented |
| 6400.104 | The notification letter to the local fire department dated 10/02/2020 does not include the exact location of the individual's bedrooms that need assistance to evacuate and the fire letter is not "current" as it incorrectly states that there are 2 exits but the home has 3 exits as evidenced by the fire drill records. | 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 XX
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 XX
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 |
| 6400.113(a) | REPEAT 08/21/19- Individual # 2 was admitted to the home on 10/02/2020. The individual did not receive any of the fire-safety training required by this regulation upon admission or at any time up until the date of this inspection on 11/12/2020. | 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 Program Specialist is responsible for instructing the individual on fire safety on the day of admission, and reviewed and confirmed by Regional Director
b. WHAT will be corrected. Individual must receive fire safety training upon admission and annually thereafter
c. WHEN and HOW (usually attached as procedure)
The Program Specialist instructed the individual on fire safety on 11/18/2020
The Program Specialist reviewed all individuals files and assured all other individuals were trained in fire safety and other required trainings that were missing, during the week of 11/23/2020
All trainings were completed by 11/27/2020
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. Required trainings including fire safety trainings are included in the new admissions checklist. Trainings are completed upon admission and then in the upcoming January, and then every January thereafter.
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. The Program Specialist was retrained in providing fire safety training on 11/18/2020
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. |
11/27/2020
| Implemented |
| 6400.144 | Letter from UPMC Family Medicine at Montoursville, dated 7/29/2020, requested that Individual #1 "change to a provider that is part of another practice" due to, "consistently being late or no-showing appointments".
According to staff #1 there was a history of this when the individual was with another agency, however, she was late on one appointment which did cause the individual to have to find another medical provider. This caused difficulty coordinating care for the individual after she had a hospital stay on 8/9/2020-8/10/2020 and was instructed to seek PCP follow up within 10 days post discharge. Had they not been late to the appointment, the individual would not have lost her PCP provider. | 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.
| 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 are responsible, in coordination with the Program Specialist, for scheduling all medical appointments and making arrangements for the individual to attend the appointment
b. WHAT will be corrected Staff must assure individuals have medical appointments scheduled and attend the appointments in a timely manner
c. WHEN and HOW (usually attached as procedure)
House Managers were trained on 12/10/2020 on how to review appointment requirements and referrals, to make appointments, and to assure that the individual arrives at the appointment 20 minutes before the appointment is scheduled for. Program Specialist will review individual files at least every six months to assure individuals are making their appointments on time, and if not corrective action will be taken.
Appointment reminders were put into our electronic file system to give notices of all appointments for individuals. This was completed on 12/14/2020.
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. This procedure will be added to the trainings for staff who are promoted to House Managers. Program Specialist will review individual files at least every six months to assure individuals are making their appointments on time, and if not corrective action will be taken.
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 on 12/10/2020 on how to review appointment requirements and referrals, to make appointments, and to assure that the individual arrives at the appointment 20 minutes before the appointment is scheduled for. This procedure will be added to the trainings for staff who are promoted to House Managers.
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. |
12/14/2020
| Implemented |
| 6400.145(2) | The Emergency Medical Plan information contained within the face sheet document does not include the method of transportation to be used in the event of an emergency as required by regulation 6400.145.2. | The home shall have a written emergency medical plan listing the following: The method of transportation to be used. | A plan to fix the immediate problem
a. WHO (job title) The Program Specialist is responsible for maintaining the Emergency Medical Plan under the supervision of the Regional Director. The plan will be written by the Program Specialist and reviewed by the Regional Director
b. WHAT will be corrected. The Emergency Medical Plan will include means of transportation.
c. WHEN and HOW (usually attached as procedure)
The emergency medical plan was rewritten to include means of transportation on 11/19/2020
The Program Specialist was trained to include all necessary data elements on 11/19/2020
All emergency medical plans were rewritten to include means of transportation on 11/20/2020
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. The emergency medical plans will be modified as necessary as any data elements change and reviewed at least annually every January to assure accuracy
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. The Program Specialist is responsible for maintaining and updating the emergency medical plan and was retrained on this task on 11/19/2020
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 copy of revised emergency evacuation plan (attachment XX)
5. Label every attachment and refer to that label on the plan of correction that it applies to. Ex: attachment #1, attachment #2, etc. |
11/20/2020
| Implemented |
| 6400.145(3) | The Emergency Medical Plan information contained within the face sheet document does not include an emergency staffing plan as required by regulation 6400.145.3. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | 1. A plan to fix the immediate problem
a. WHO (job title) The Program Specialist is responsible for maintaining the Emergency Medical Plan under the supervision of the Regional Director. The plan will be written by the Program Specialist and reviewed by the Regional Director
b. WHAT will be corrected. The Emergency Medical Plan will include emergency staffing plan.
c. WHEN and HOW (usually attached as procedure)
The emergency medical plan was rewritten to include emergency staffing plan on 11/19/2020
The Program Specialist was trained to include all necessary data elements on 11/19/2020
All emergency medical plans were rewritten to emergency staffing plan on 11/20/2020
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. The emergency medical plans will be modified as necessary as any data elements change and reviewed at least annually every January to assure accuracy
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. The Program Specialist is responsible for maintaining and updating the emergency medical plan and was retrained on this task on 11/19/2020
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.
5. Label every attachment and refer to that label on the plan of correction that it applies to. Ex: attachment #1, attachment #2, etc. |
11/20/2020
| Implemented |
| 6400.171 | At the time of the inspection, there were approximately 10 boxes of food that were stored in the pantry but were open and not being stored in a manner that would avoid contamination. | Food shall be protected from contamination while being stored, prepared, transported and served.
| 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 food is handled and stored in an appropriate manner.
b. WHAT will be corrected. Food will be protected from contamination during handling and storage.
c. WHEN and HOW (usually attached as procedure)
These boxes of food were removed and disposed of properly on 11/18/2020
Staff at this home were trained in proper food handling and storage by the Residential Supervisor on 11/24/2020.
All staff were trained in proper food handling and storage by the Residential Supervisor on 11/30/2020.
During weekly visits starting 11/30/2020 each home was reviewed to assure all food was stored appropriately
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. Proper food handling and storage will be observed during weekly site visits by the Residential Supervisor. Training in proper food handling and storage was added to annual training requirements for front line staff.
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. All staff were trained in proper food handling and storage by the Residential Supervisor on 11/30/2020. Training in proper food handling and storage was added to annual training requirements for front line staff.
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. |
11/30/2020
| 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 for licensing staff 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.
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 |
| 6400.181(a) | Individual #1 was admitted into the program on 2-3-2020; regulation 6400.181a requires that an assessment be completed within 60 days of admission to the program. At the time of the inspection on 11/10/2020, there was no assessment in the individual's chart. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential 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 Program Specialist under the supervision of the Regional Director is responsible for the writing and maintenance of all assessments.
b. WHAT will be corrected. The individual assessments will be written within 60 days of admission and annually thereafter.
c. WHEN and HOW (usually attached as procedure)
The assessment was written on 12/2/2020
All individuals files were checked on 12/3/2020 to assure that assessments were completed and current for each individual
The due date of each individuals assessment was placed in our electronic file system so that the Program Specialist will get a notification of an upcoming due date for an individuals assessment.
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. The due date of each individuals assessment was placed in our electronic file system so that the Program Specialist will get a notification of an upcoming due date for an individuals assessment
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 Specialist was retrained on the due dates of assessments on 11/19/2020
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 attachment labeled XX
5. Label every attachment and refer to that label on the plan of correction that it applies to. Ex: attachment #1, attachment #2, etc. |
12/03/2020
| Implemented |
| 6400.182(d)(1) | At the time of the inspection, Individual #1's chart did not contain the most recent ISP based off of the individuals most recent assessment because the individual has not had an assessment since admission on 2-3-2020. | The plan lead shall develop, update and revise the ISP according to the following: The ISP shall be initially developed, updated annually and revised based upon the individual's current assessment as required under § § 2380.181, 2390.151, 6400.181 and 6500.151 (relating to assessment). | 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 Program Specialist under the supervision of the Regional Director is responsible for the writing and maintenance of all assessments and sending the assessment to the SC so that the ISP can be updated.
b. WHAT will be corrected. The assessment was written and sent to the Supports Coordinator so that the ISP can be updated.
c. WHEN and HOW (usually attached as procedure)
The assessment was written on 12/2/2020 and sent to the SC on the same day to update the ISP
All individuals files were checked on 12/3/2020 to assure that assessments were completed and current for each individual and sent to the SC as appropriate to update the ISP
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. The due date of each individuals assessment was placed in our electronic file system so that the Program Specialist will get a notification of an upcoming due date for an individuals assessment. When assessments are updated they will be sent to the SC so that ISPs can be updated.
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. The Program Specialist was retrained on the due dates of assessments and need to send them to the SC on 11/19/2020
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. |
12/03/2020
| Implemented |
| 6400.211(b)(1) | Individual #1's chart did not contain the address of the emergency contact. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| 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 Program Specialist is responsible for assuring complete cover sheets including all emergency contact information.
b. WHAT will be corrected. Individuals cover sheets are to be completed including all emergency contact information.
c. WHEN and HOW (usually attached as procedure)
The individuals cover sheet was updated on 11/21/2020 to include all emergency contact information.
All individuals cover sheets were reviewed and updated on 11/21/2020 to include all emergency contact information.
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. Cover sheets will be reviewed at least every 6 months to assure the information is accurate, and also changed as new information becomes available.
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 Specialist was retrained on 11/20/2020 on all data elements necessary to be included on individuals cover sheets.
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 attachment labeled XX
5. Label every attachment and refer to that label on the plan of correction that it applies to. Ex: attachment #1, attachment #2, etc. |
11/21/2020
| Implemented |
| 6400.214(b) | At the time of the inspection, individual #1's chart did not contain the most recent ISP. The full ISP that was in the file was dated 12/19/19, which was the ISP that was written prior to the individual being admitted with Spectrum Community Services on 2-3-2020. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| 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 notifying the Supports Coordinator of any relevant changes, and the SC modifies the ISP as necessary.
b. WHAT will be corrected. The ISP will be modified to reflect changes including Spectrum being the CLA Provider
c. WHEN and HOW (usually attached as procedure)
The Program Specialist notified the SC of the changes needed however the changes were not made
The Program Specialist must follow up to assure changes are made, and if not notify the SC again
The Program Specialist did notify the SC again on 11/20/2020, and changes will be made.
All ISPs are being reviewed to assure they are completely current, and all reviews will be done by 12/30/2020 and SCs notified as appropriate
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. Program Specialist was retrained to follow up to assure that critical revisions are made to the ISP when needed and to remind the SC when they are not.
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 Specialist was retrained to follow up to assure that critical revisions are made to the ISP when needed and to remind the SC when they are not.
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. |
12/30/2020
| Implemented |
| 6400.31(b) | Individual #1's signed form on individual rights did not include the most recent and updated list of individual rights under 6400.31; including but not limited to 6400.32r- the right to locks doors. | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | 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 Program Specialist is responsible for assuring that the rights list is updated and signed by all individuals.
b. WHAT will be corrected. The rights list was updated on 11/23/2020 and signed by each individual by 11/30/2020
c. WHEN and HOW (usually attached as procedure)
Individual #1 is both nonverbal and cannot physically use a lock. However she was read the rights list, and we ordered a lock for her door to be installed which will remain unlocked.
All individuals signed the new rights list after being discussed with them, and those who would like a lock had a lock ordered for them and will be installed upon arrival.
Any future changes in rights will be monitored by the Regional Director and changes made to the rights document and signed by individuals as changes are made and annually
2. A plan to prevent future occurrences
Regional Director and Program Specialist were retrained on their roles in updating documents and having them signed as necessary. Any future changes in rights will be monitored by the Regional Director and changes made to the rights document and signed by individuals as changes are made and annually
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 Director and Program Specialist were retrained on their roles in updating documents and having them signed as necessary.
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. |
11/30/2020
| Implemented |
| 6400.181(f) | The assessment for individual #1 was not sent to the individual plan team members at least 30 calendar days prior to an individual plan meeting because the individual's assessment has not yet been completed to date. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | 1. A plan to fix the immediate problem
a. WHO (job title) The Program Specialist is responsible for writing assessments and forwarding them to team members at least 30 days prior to the individual plan meeting
b. WHAT will be corrected. Assessments will be written and forwarded to team members at least 30 days prior to individual plan meetings.
c. WHEN and HOW (usually attached as procedure)
The assessment for this individual was written on 12/3/2020
All assessments will be reviewed to assure their completeness, accuracy and timeliness by 1/4/2021
Program Specialist was retrained on this requirement with a focus on the timeline requirements.
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. Regional Director will spot check assessments every month to assure they are being updated and sent to the team prior to any individual plan meeting.
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 Specialist was retrained on this requirement with a focus on the timeline requirements.
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. |
01/04/2021
| Implemented |
| 6400.182(b) | Individual #1 was admitted to the program on 2-3-2020; the ISP in individual #1's chart was dated 12/19/2019 with a critical revision not completed until 5/20/2020, which was more than the 90 days as required by regulation 6400.182b. | The initial individual plan shall be developed based on the individual assessment within 90 days of the individual's date of admission to the home. | . 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 notifying the Supports Coordinator of any relevant changes, and the SC modifies the ISP as necessary. The Program Specialist is responsible for updating assessment upon arrival of a new individual at Spectrum.
b. WHAT will be corrected. The ISP will be modified to reflect changes including Spectrum being the CLA Provider, and based on an updated assessment
c. WHEN and HOW (usually attached as procedure)
The Program Specialist notified the SC of the changes needed however the changes were not made. However, the assessment was not done at that point
The Program Specialist must follow up to assure changes are made, and if not notify the SC again. The Program Specialist must update assessments when new individuals are admitted to Spectrum
The Program Specialist did notify the SC again on 11/20/2020, and changes will be made. The assessment has been updated.
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. Program Specialist was retrained to follow up to assure that critical revisions are made to the ISP when needed, to remind the SC when they are not, and to update assessments when a new individual is admitted to Spectrum (or any other time there is a critical revision needed and at least annually).
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 Specialist was retrained to follow up to assure that critical revisions are made to the ISP when needed, to remind the SC when they are not, and to update assessments when a new individual is admitted to Spectrum (or any other time there is a critical revision needed and at least annually).
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. |
11/20/2020
| Implemented |
| 6400.186 | An individual living in this home is to have sharps locked per the individual's ISP. Upon inspection of the home, there were two knives found in the kitchen drawers that were not locked up. | The home shall implement the individual plan, including revisions. | 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, House Manager and DSPs are responsible for assuring sharps are always locked up when not in use.
b. WHAT will be corrected. Sharps will always be placed in a locked cabinet/drawer when not in use
c. WHEN and HOW (usually attached as procedure)
The sharps were placed in a locked drawer.
As all of the sites were visited the next week by the Residential Supervisor they were specifically checked to assure no sharps were out in homes where that is restricted.
The House Managers and DSPs were all retrained on 11/25/2020 on the requirement of sharps not in use to be immediately secured if indicated in the ISP or behavioral plan.
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. Checking to assure sharps are secured when required will be added to the site visit checklist for Residential Supervisors and the daily checklist for House Managers and DSPs by 12/30/2020.
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. The House Managers and DSPs were all retrained on 11/25/2020 on the requirement of sharps not in use to be immediately secured if indicated in the ISP or behavioral plan.
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. |
12/30/2020
| Implemented |
| 6400.213(1)(i) | Individual #1's chart did not contain her Social Security number. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | 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. Program Specialists under the supervision of Regional Directors are responsible for making sure all data elements are present in an individuals file
b. WHAT will be corrected. Social security numbers are to be included in all individuals files
c. WHEN and HOW (usually attached as procedure)
The social security number was added to this individuals file on 11/16/2020
All files were reviewed and social security numbers added where necessary. This was completed on 11/21/2020.
The Program Specialist was retrained on all of the data elements that are necessary to be included in each individuals file on 11/17/2020
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. When face sheets are updated at least annually files will be checked to assure all necessary data elements are still contained in the file.
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. The Program Specialist was retrained on all of the data elements that are necessary to be included in each individuals file on 11/17/2020
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. |
11/21/2020
| Implemented |