| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(3) | Staff #13 did not assure the safety and protection of individual #1 based upon the violations listed in this LIS. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | On 4/14/23 staff #13 was retrained both in conversation with the EIM Coordinator for Spectrum and by reading the training materials provided by ODP. |
04/14/2023
| Implemented |
| 6400.171 | There was a uncovered pasta dish in the refrigerator was a fork still in the dish at the time of the inspection. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Upon discovery the refrigerator was checked for any food not being stored correctly in the home (both cupboards and refrigerator) and corrected if needed. |
04/24/2023
| Implemented |
| 6400.18(a)(4) | Staff #8 failed to report the incident that occurred on 3/25/2023 regarding individual #1 and staff# 7 physical and verbal altercation. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Abuse, including abuse to a individual by another client.
| Staff #8 was retrained on several instances including 4/8, 4/14, and 4/19 during both private meetings and a management meeting held by the Deputy CEO to address the filing and reporting of incidents to both her supervisor, the PSL, and the EIM system. |
04/19/2023
| Implemented |
| 6400.18(f) | Staff #8 failed to take immediate action to protect the health, safety, and well-being of individual #1. | The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident. | Staff #8 was retrained on several instances including 4/8, 4/14, and 4/19 during both private meetings and a management meeting held by the Deputy CEO to address the filing and reporting of incidents to both her supervisor, the PSL, and the EIM system. |
04/14/2023
| Implemented |
| 6400.18(g) | Staff #8 did not initiate an investigation into the verbal and physical abuse of individual #1 within 24 hours of discovery. | The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person. | Staff #8 was retrained on several instances including 4/8, 4/14, and 4/19 during both private meetings and a management meeting held by the Deputy CEO to address the filing and reporting of incidents to both her supervisor, the PSL, and the EIM system in a timely manner. The meeting included all EOCs and the PSL. |
04/19/2023
| Implemented |
| 6400.18(i) | Spectrum did not finalize the incident report within 30 days of discovery. | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | Staff #8 was retrained on several instances including 4/8, 4/14, and 4/19 during both private meetings and a management meeting held by the Deputy CEO to address the filing and reporting of incidents to both her supervisor, the PSL, and the EIM system in a timely manner. The meeting included all EOCs and the PSL on 4/14.
Due to not filing the report until 4/7/23 when the RON was issued, there was no way for us to meet a deadline that started 3/26. From the time of filing, all deadlines were met well before the due dates. |
04/19/2023
| Implemented |
| 6400.192 | The home is restricting the number of cigarettes the individual can have during the day, but this is not stated in the restrictive plan for individual #1 dated 2/15/2023. | The home shall develop and implement a written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the staff persons who may authorize the use of restrictive procedures and a mechanism to monitor and control the use of restrictive procedures. | On 4/18/23 the PSL spoke to and retrained the Lenape staff about how to better word the notes being put in around the individuals smoking. This is not and has never been a restrictive procedure for her. The plan is just a normal part of her behavior which is to try redirection and after ample efforts to educate and redirect, allow her to have the cigarette. It is a health and safety concern. This is what was in her behavior plan, but it was not restrictive.
Desirea has agreed to adhere to a smoking/vaping schedule that is aligned with her medication regimen each day. The schedule is:
- 8:00AM Medication
- 12:00PM Medication
- 3:30PM Flex Time
- 8:00PM Medication
Desirea may smoke within 1 hour of any of these times, before or after. The session does not have to be exactly what the schedule presents.
Staff should strongly encourage Desirea to stick with her schedule and to remind her of natural consequences that could result from increasing the number of times she smokes each day. These consequences may include:
- Spending all of her money on the cigarettes/cigars and not having enough for other things.
- Running out of cigarettes/cigars.
- Negative impact on her physical and mental health (i.e. lung cancer, dependency, withdrawal).
If Desirea continues to fixate on smoking, make attempts to redirect her to activities she enjoys. If she persists on smoking after 3 attempts to redirect, she may proceed to smoke. |
05/01/2023
| Implemented |