| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | REPEAT 07/15/19- During the on-site inspection on 11/13/20, the temperature of the kitchen sink was 128.3 degrees. | 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)
The water temperature on the hot 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 |
| 6400.103 | The Emergency Evacuation information contained on the face sheet does not include the type of transportation to be used. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| 1. 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.
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 |
| 6400.141(c)(15) | Individual # 1's physical examination dated 01/24/20 does not include dietary information, the space was left blank. | The physical examination shall include:Special instructions for the individual's diet. | 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 all medical examinations forms are complete with all data elements.
b. WHAT will be corrected. Special dietary instructions (or lack thereof) are to be specified on the medical examination form.
c. WHEN and HOW (usually attached as procedure)
An appointment for the individual will be had or scheduled to be had by 1/4/2021
All PCP medical examination forms have been reviewed for each individual by 12/11/2020 and where there are any missing data elements new appointments have been scheduled to rectify this situation.
The Residential Supervisor was retrained on 12/1/2020 on assuring all data elements are completed during a medical visit.
Medical forms are to be prepopulated where possible for the doctors review and signature to assist the doctor in completing all data elements.
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. The Residential Supervisor was retrained on 12/1/2020 on assuring all data elements are completed during a medical visit. Medical forms are to be prepopulated where possible for the doctors review and signature to assist the doctor in completing all data elements.
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 Residential Supervisor was retrained on 12/1/2020 on assuring all data elements are completed during a medical visit.
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 |
| 6400.144 | Individual # 1 is recommended a 1600 calorie diet. The physical examination dated 01/24/20 reads Prescribed Diet as ADA 1600 Cal. The ISP last updated 06/11/20 indicates that she should have 45 grams of carbohydrates at each meal, 15 grams of carbohydrates at each snack. A review of the Calorie tracking records demonstrate that the agency did not track total calories for the day nor for each meal and snack during the month of November 2020. Records were provided for November 01-November 12, respectively. | 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. The Program Specialist, House Manager and DSPs are responsible for assuring the dietary tracking form is completed and diet is adhered to.
b. WHAT will be corrected. The dietary tracking form is to be completed and the diet adhered to.
c. WHEN and HOW (usually attached as procedure)
The Program Specialist, House Managers and the DSPs for all homes were trained on 11/19/2020 on using and completing a dietary tracking form, and assuring that the prescribed diet for the individual is followed.
The Program Specialist during their weekly site visit assures that the dietary tracking sheet is being completed for all data elements.
The Regional Director during their weekly site visits also checks the dietary tracking sheet to assure that it is being completed accurately
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. The Program Specialist during their weekly site visit assures that the dietary tracking sheet is being completed for all data elements. The Regional Director during their weekly site visits also checks the dietary tracking sheet to assure that it is being completed accurately
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, House Managers and the DSPs for all homes were trained on 11/19/2020 on using and completing a dietary tracking form, and assuring that the prescribed diet for the individual is followed.
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 |
| 6400.145(3) | The Emergency Medical Plan contained on the face sheet does not include the emergency staffing plan. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | 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. |
11/19/2020
| Implemented |
| 6400.181(e)(5) | Individual # 1's Assessment dated 12/27/19 does not include her ability to self medicate. The document response to the skill "self-medicating" reads "Not Applicable". | The assessment must include the following information: The individual's ability to self-administer medications. | 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 writing a complete and specific assessment
b. WHAT will be corrected. The Program Specialist will write assessments that are complete and specific, and not write `N/A for self medication, the answer is either yes or no.
c. WHEN and HOW (usually attached as procedure)
The assessment for this individual was rewritten on 12/4/2020 to reflect a yes/no answer as to whether the individual can self medicate.
The Program Specialist was retrained on writing an assessment to be specific in all answers in the assessment on 12/4/2020.
The Regional Director checks assessments every six months to assure this type of error does not happen again.
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. The Program Specialist was retrained on writing an assessment to be specific in all answers in the assessment on 12/4/2020. The Regional Director checks assessments every six months to assure this type of error does not happen again.
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 writing an assessment to be specific in all answers in the assessment on 12/4/2020.
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. |
12/04/2020
| Implemented |
| 6400.181(e)(6) | Individual # 1's Assessment dated 12/27/19 does not assess her ability to use poisons. The document responds "No Opportunity" to Safely uses ALL poisonous materials, Safely Avoids All poisonous materials, Safely uses some poisonous materials. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | .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 writing a complete and specific assessment
b. WHAT will be corrected. The Program Specialist will write assessments that are complete and specific, and not write no opportunity for use of poisons, the answer is either yes or no.
c. WHEN and HOW (usually attached as procedure)
The assessment for this individual was rewritten on 12/4/2020 to reflect a yes/no answer as to whether the individual can safely use poisons.
The Program Specialist was retrained on writing an assessment to be specific in all answers in the assessment on 12/4/2020.
The Regional Director checks assessments every six months to assure this type of error does not happen again.
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. The Program Specialist was retrained on writing an assessment to be specific in all answers in the assessment on 12/4/2020. The Regional Director checks assessments every six months to assure this type of error does not happen again.
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 writing an assessment to be specific in all answers in the assessment on 12/4/2020.
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. |
12/04/2020
| Implemented |
| 6400.181(e)(9) | Individual # 1 takes insulin twice per day and uses a glucometer to test her blood sugars. The Lifetime medical history does not include diabetes as a diagnosis | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | . 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 the lifetime medical includes all necessary information including all diagnosis.
b. WHAT will be corrected. The lifetime medical will be updated to include all diagnosis.
c. WHEN and HOW (usually attached as procedure)
The lifetime medical was updated to include all diagnosis on 12/7/2020.
All lifetime medicals were reviewed and when necessary updated to include any missing diagnosis on 12/9/2020
The Program Specialist was retrained on assuring the lifetime medical includes all diagnosis on 12/7/2020
Specific dates by which correction tasks will be completed are required in order to effectively monitor plan completion
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. In addition to the Program Specialist being retrained, the Regional Director revies lifetime medicals randomly every six months to assure that all diagnosis included in the medical forms are included in the lifetime medical
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 assuring the lifetime medical includes all diagnosis on 12/7/2020
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. |
12/09/2020
| Implemented |
| 6400.52(c)(3) | The CEO training record does not include the annual individual rights training for the years 2019 and 2020. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual 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 HR, Training and Program Services Vice Presidents are responsible for assuring that all training requirements are met by all staff.
b. WHAT will be corrected. The CEO will be trained in all required trainings annually including individual rights
c. WHEN and HOW (usually attached as procedure)
The CEO will be trained in individual rights on 1/6/2021.
All staff training records are being reviewed to ensure they have all trainings, and any missing trainings will be conducted by 2/1/2021
The vice presidents have convened a series of meetings to revamp trainings so that all regulatorily required trainings are conducted at the regional level for new hires before their shadowing, and for ongoing employees throughout the year.
The new training process will be initiated on 2/1/2021
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. The vice presidents have convened a series of meetings to revamp trainings so that all regulatorily required trainings are conducted at the regional level for new hires before their shadowing, and for ongoing employees throughout the year. The new training process will be initiated 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. The CEO will be trained in individual rights on 1/6/2021
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.
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 |
| 6400.169(a) | Staff # 1's initial medication training packet was not dated as being completed. The date was left blank on the training form. Staff # 2's Annual Practicum was dated by the trainer as 10/19. An additional annual practicum was dated as completed on 08/2020. The documents list a date range within a month instead of the specific date of completion. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | 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 Training Vice President and med administration trainers are responsible for assuring that all med administration training requirements are met by all front line staff.
b. WHAT will be corrected. All front line staff with any paperwork issues at all will be retrained in med administration.
c. WHEN and HOW (usually attached as procedure)
All of the front line staff with any paperwork issues in med administration were retrained on 11/17-18/2020.
The vice presidents have convened a series of meetings to revamp trainings so that all regulatorily required trainings are conducted at the regional level for new hires before their shadowing, and for ongoing employees throughout the year. This review and revamping will include fixing any paperwork issues so we can document all trainings accurately.
The new training process will be initiated on 2/1/2021
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. The vice presidents have convened a series of meetings to revamp trainings so that all regulatorily required trainings are conducted at the regional level for new hires before their shadowing, and for ongoing employees throughout the year. The new training process will be initiated 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. All of the front line staff with any paperwork issues in med administration were retrained on 11/17-18/2020.
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. |
02/01/2021
| Implemented |
| 6400.169(d) | Staff # 2's training record indicates that she completed a medication training on 04/18/19, however, there is no documentation of a medication training having been completed on that date. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | 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 Training Vice President and med administration trainers are responsible for assuring that all med administration training requirements are met by all front line staff.
b. WHAT will be corrected. All front line staff with any paperwork issues at all will be retrained in med administration.
c. WHEN and HOW (usually attached as procedure)
All of the front line staff with any paperwork issues in med administration were retrained on 11/17-18/2020.
The vice presidents have convened a series of meetings to revamp trainings so that all regulatorily required trainings are conducted at the regional level for new hires before their shadowing, and for ongoing employees throughout the year. This review and revamping will include fixing any paperwork issues so we can document all trainings accurately.
The new training process will be initiated on 2/1/2021
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. The vice presidents have convened a series of meetings to revamp trainings so that all regulatorily required trainings are conducted at the regional level for new hires before their shadowing, and for ongoing employees throughout the year. The new training process will be initiated 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. All of the front line staff with any paperwork issues in med administration were retrained on 11/17-18/2020.
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. |
02/01/2021
| Implemented |
| 6400.182(c) | Individual # 1 is diagnosed with Diabetes type II as listed on the Physical Exam dated 01/24/20 completed by Hope Enterprises. (The Physical Examination completed on the same date by Spectrum does not include diabetes as a diagnosis). Additionally, the physical exam completed 01/24/20 by Spectrum does not include the diagnosis of Inhibitive RAD Syndrome, Mild ID, ADD, Anxiety, Bipolar Disorder, Mood Disorder, Intermittent Explosive Disorder, Scoliosis, Obesity, Nocturnal Enuresis and Sleep Disorder. The Spectrum diagnosis lists only Mood Disorder, ADHD and DM2. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current 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 is responsible for assuring all medical examinations forms are complete with all data elements.
b. WHAT will be corrected. All diagnosis are to be specified on the medical examination form.
c. WHEN and HOW (usually attached as procedure)
An appointment for the individual will be had or scheduled to be had by 1/15/2021
All PCP medical examination forms have been reviewed for each individual by 12/11/2020 and where there are any missing data elements new appointments have been scheduled to rectify this situation.
The Residential Supervisor was retrained on 12/1/2020 on assuring all data elements are completed during a medical visit.
Medical forms are to be prepopulated where possible for the doctors review and signature to assist the doctor in completing all data elements.
2. A plan to prevent future occurrences
Long-term plans often include changing practice, teaching, and ongoing monitoring. The Residential Supervisor was retrained on 12/1/2020 on assuring all data elements are completed during a medical visit. Medical forms are to be prepopulated where possible for the doctors review and signature to assist the doctor in completing all data elements.
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 Residential Supervisor was retrained on 12/1/2020 on assuring all data elements are completed during a medical visit.
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. |
01/15/2021
| Implemented |