Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00274059 Renewal 10/17/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(c)Coliform Water testing is to be completed quarterly. Testing was completed 3/7/25 and 9/15/25. June 2025 was missed for testing.A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.There is no immediate correction as this can't be made up from four months ago. 10/27/2025 Implemented
SIN-00238777 Renewal 02/13/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.61(a)The front sidewalk does not extend to the driveway. Individual # 1 utilizes a scooter and walker for mobility. Accommodations not made.A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. On 2-20-24 a maintenance request was submitted to extend the front sidewalk the entire way to the driveway for better access. 2/26/24 is the date maintenance has scheduled the work to be completed. 02/26/2024 Implemented
6400.67(b)The floor has a crack in the doorway between the living room and Individual # 1's Bedroom. There is a gap in the floor laminate by the staff room office desk. Individual # 1 utilizes a walker and has mobility needs which, by his report during the physical site walk through, are negatively affected by the gap in the floor laminate. Floors, walls, ceilings and other surfaces shall be free of hazards.On 2-20-24 a maintenance request was submitted to repair or replace these flooring issues. 2/26/24 is the date maintenance is scheduled to come and decide the best course of action. 03/15/2024 Implemented
6400.68(c)The water testing has to be down 90 days between each test. The test were conducted on 1/24/23, 6/16/23, and 7/21/23.A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.On 2/15/24, The water company PACE was called and they will be setting the testing up before 3-15-23. PACE has been contracted to conduct testing on a quarterly schedule going forward. 03/15/2024 Implemented
6400.151(c)(4)Staff # 3's The full document of Physical Examination dated 11/06/23 was not provided. The document provided starts with Roman Numeral IV. The physical examination does not include Information of medical problems which might interfere with the health of the individuals. The document reads "Are there any special medical problems or chronic diseases which require restriction of activity, medication or which might affect his/her work role? If so, specify________" This space was left blank.The physical examination shall include: Information of medical problems which might interfere with the health of the individuals.On 11/6/23, staff #3 had the physical completed and it is in our management system even though only the first page was presented at the time of inspection. No correction needed. 02/15/2024 Implemented
6400.181(e)(4)Individual # 1's Assessment dated 12/01/23 provides conflicting information as to supervision needs within the home. The document reads "Can safely have unsupervised time in the home/day program···Without Staff for 160 minutes." It then reads, Individual # 1 can be unsupervised in the home with or without staff for 2 hours as long as he has his cell phone on him. After two hours, check in phone calls need to be made every hour." Individual # 1's assessment also reads that "individual # 1 needs staff at arms length when stepping up or down." Individual # 1's Safety cannot be ensured with the Assessment providing conflicting information for supervision as 160 minutes vs 2 hours as currently written. Individual # 1's specified mobility needs of staff at arms length when stepping up or down can not be maintained if staff are not at the home or community to provide that support. The assessment must include the following information: The individual's need for supervision. On 2/22/24, an email was sent to the SC with a corrected annual assessment to have the language updated so that both documents match in language and intent. 02/20/2024 Implemented
6400.163(d)CVS Antifungal powder (prescribed) was not locked during the physical site walk through.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.On 2/14/24, at the time of inspection, this powder was locked in its place and staff were retrained on the spot. 02/14/2024 Implemented
SIN-00205355 Unannounced Monitoring 05/17/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.61(a)Individual #1 is diagnosed with CEREBRAL PALSY, QUADRIPLEGIA, and SPASTICITY WITH MUSCLE CONTRACTURES. During interviews with staff #1, #2, #3, #4, #5, #6, and #7 it was stated that his elbows where scraped up because the door frames where not wide enough to accommodate his arms in this rigid state.A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. Status: Requested Provider's Plan of Correction: (required) Please describe how you plan to correct your noncompliance. You can expand the text box by clicking and dragging the bottom right hand corner. The landlord has agreed for Spectrum to have the property altered to allow for the outside doors to be widened. These were widened with new ramps effective 6/29/22. Videos have been sent to ODP showing that there is no obstruction of any kind since 6/29/22 and the issue was resolved. A validation visit was conducted 7/13/22 where the individual involved was seen exiting the home on his own without incident. A validation video was also sent on 7/16/22 to ODP staff showing a complete fire drill where both individuals were evacuated without incident under the 2.5 minute timeline. 08/10/2022 Implemented
6400.112(b)Staff #5 stated that a asleep fire drill was completed with staff #7 support and based off of schedules there is only one staff on duty during the regular staffing schedule. Fire drills shall be held during normal staffing conditions and not when additional staff persons are present. Fire drills shall be held during normal staffing conditions and not when additional staff persons are present. Status: Requested Provider's Plan of Correction: (required) Please describe how you plan to correct your noncompliance. You can expand the text box by clicking and dragging the bottom right hand corner. Two additional staff have been hired to ensure that there are two staff on duty at all times individual #2, that requires the Hoyer lift, is in bed. After completion of corporate training and training specific to the individuals in this home, there will be two staff scheduled each evening from 10pm until 8am and arrangements made for any other unexpected time the individual will be bed. In the case that a second staff is not available from this particular home schedule, staff that have been trained within the region for these individuals will be pulled in to work in this home to make sure that there is always two staff on shift overnight at this location. If no other staff are available, the manager of the facility that maintains an on-call status 24/7 will cover the shift. If she is unavailable, there is a second manager on staff that was formerly the senior at this home that will be able to cover the shift at this residence or the other residence in the region that houses non-ambulatory individuals. 08/10/2022 Implemented
6400.144Individual #1's ISP dated 3/28/2022 states that PCP wrote an order for the hoyer lift or pivot transfers to be used for all transfers. Staff #5 stated that individual #1 was picked up and transferred during the asleep fire drill. She stated that the hoyer and or pivot transfer was not used.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. 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. Status: Requested Provider's Plan of Correction: (required) Please describe how you plan to correct your noncompliance. You can expand the text box by clicking and dragging the bottom right hand corner. The involved staff, #5, has been retrained on how to use The Hoyer Lift. The involved staff, #5, has reread the ISPs of both individuals in the home and has signed off that they understand the information contained in both. Characters Remaining: 8000 Provider's Plan to Maintain Compliance: (required) Please describe how you plan to remain in compliance with this regulation at all times. You can expand the text box by clicking and dragging the bottom right hand corner. All new staff are trained on how to use the Hoyer Lift during the 24 hour shadowing period as evidenced by the protocol sign off sheet that must be signed before working in either of the non-ambulatory homes after the shadowing period. All staff must read and sign off of any individual's ISP before working independently in this (and all) home(s). All staff that are slated to work in any of the homes serving non-ambulatory individuals will be trained on how to use the Hoyer Lift as part of the 24-hour shadowing process as marked by medical issues that they will sign off on during the shadowing process. New staff to any home that serves non-ambulatory individuals will sign off on the Hoyer Lift packet that can be found within the Extended Reach platform or inside the home itself for both homes in the region that utilize Hoyer Lifts. New hires will be required to demonstrate proper use of the Hoyer Lift before a supervisor signs off on the skill on the shadowing sheet. If a veteran staff member transfers to a home with non-ambulatory individuals, they will sign off on a training sheet with a supervisor after showing competency of the skill. 08/10/2022 Implemented
6400.186Individual #1's ISP dated 3/28/2022 states that PCP wrote an order for the hoyer lift or pivot transfers to be used for all transfers. Staff #5 stated that individual #1 was picked up and transferred during the asleep fire drill. She stated that the hoyer and or pivot transfer was not used.The home shall implement the individual plan, including revisions.Individual #1's ISP dated 3/28/2022 states that PCP wrote an order for the hoyer lift or pivot transfers to be used for all transfers. Staff #5 stated that individual #1 was picked up and transferred during the asleep fire drill. She stated that the hoyer and or pivot transfer was not used. Characters Remaining: 7707 Correction Required: The home shall implement the individual plan, including revisions. Status: Requested Provider's Plan of Correction: (required) Please describe how you plan to correct your noncompliance. You can expand the text box by clicking and dragging the bottom right hand corner. The involved staff, #5, has been retrained on how to use The Hoyer Lift. The involved staff, #5, has reread the ISPs of both individuals in the home and has signed off that they understand the information contained in both. 08/10/2022 Implemented
SIN-00197102 Technical Assistance 12/07/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101At the time of the inspection the front door was unable to be opened by staff #1. At the time of the inspection the back door was unable to be closed by the staff #1.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Both entrances were fixed on 12/10 and video proof sent to Jim Richards for validation and excepted. Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed via staff checking on every shift while working with individuals. If there are any obstructions or maintenance issues that need addresses, staff will inform the Senior of the home who will either call the maintenance team or the Residential Supervisor to follow through. 12/10/2021 Implemented
SIN-00195250 Renewal 11/09/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)The same exit was used for all fire drills reviewed.Alternate exit routes shall be used during fire drills. The regional director has assured that there are appropriate alternate exits at this and each home. For this home, another ramp has been ordered. Prior to October of 2021, there was only one exit in the home that had a ramp that could be used for fire drills, so each fire drill executed by staff went out the side door of the home where the existing ramp was located. The Residential Supervisor and Senior are responsible to check the accuracy of the fire drills each month. The House Manager and staff are responsible to execute monthly fire drills in the residence. 11/22/2021 Implemented
SIN-00194071 Unannounced Monitoring 10/05/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The toilet seat in the back bathroom was removed, the bottom of the shower was corroded, and their were hard water stain in the sink at the time of the inspection.Floors, walls, ceilings and other surfaces shall be in good repair. House Managers are responsible for informing the Residential Supervisor of any maintenance items as they occur. Updated maintenance concerns are to be reported daily by EOPs on the proper maintenance form located on Extended Reach, our current Electronic Management System. Residential Supervisors are to verify that items are entered in our electronic maintenance request system and inform Regional Director within 24 hours. The Regional Director keeps a running list of all outstanding maintenance items to discuss with maintenance and have resolved if they linger for more than a week. Maintenance issue are to be addressed in a timely manner. This item was reported to maintenance and upper management on 10/25/21 due to home being on well water and the home being rented. All outstanding items were addressed with maintenance on 10/16/21 across the region. All staff were retrained on the procedure to file maintenance issue on 10/15/21. 11/28/2021 Implemented
6400.67(b)A golf ball size of lint was located in the lint trap of the dryer at the time of the inspection. Floors, walls, ceilings and other surfaces shall be free of hazards.House Managers and EOPs are responsible to make sure no hazards exist on the floors, walls, ceilings or other surfaces that could create a potential hazard. The lint was removed from the dryer on 10/5/21 shortly after the inspection occurred. All House Managers checked dryers in their homes for this hazard across the region and no other instances of this were noted at any other home. The Residential Supervisor is responsible to check for hazards of all types and maintenance issues on weekly site visits and both correct the hazard and report proper practice and procedures to the House Manager and EOPs working in the home to correct any problem that surfaces. The Regional Director keeps a running list of all outstanding maintenance items to discuss with maintenance and have resolved if they linger for more than a week. Maintenance issue are to be addressed in a timely manner. 10/05/2021 Implemented
SIN-00177558 Renewal 11/10/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104The notification letter to the fire department does not include the exact location of the individual's bedrooms that need assistance to evacuate and both the individuals living in this home cannot independently evacuate during a fire drill.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. Generally Spectrum will, as a result of this inspection, additionally focus on three areas. One, the automation of the files in electronic format. Two, the restructuring of the regulatorily required training. And third, as we expand, the process of making our policies and procedures more specific. In addressing these three general areas, we believe that, in addition to the corrective actions listed below, we will be able to reduce the number of citations in the future. A plan to fix the immediate problem a. WHO (job title) will be responsible for correcting the problem (each step of the process) in the future. The Residential Supervisor has updated and sent a letter to the local fire department indicating who is in which bedroom and who needs assistance evacuating. b. WHAT will be corrected As Spectrum receives new admissions, locations of individuals change, and/or the physical capacity of individuals change, updated letters will be sent to the local fire department indicating who in in which bedroom and who needs assistance evacuating. This will be completed by the Residential Supervisor as changes occur and annually. c. WHEN and HOW (usually attached as procedure) Fire letter for this location was updated and submitted on 11/16/2020 Fire letters will be reviewed for all homes in all regions by 1/8/2020 and updated as necessary to assure they are in compliance. Fire letters in the future will be completed and sent to the local fire department within 48 hours or any change requiring an updated letter. Regional Directors will review and approve all letters before they are sent to the local fire department 2. A plan to prevent future occurrences Spectrum will develop a ¿move in¿ and ¿change of location checklist for Residential Supervisors to assure that new fire letters are completed as required., by 1/20/2020. 3. All Program Specialists, Residential Supervisors and Regional Directors will be trained on how and when to do local fire department letters on 1/7/2020. This training element will be incorporated into their annual training requirements and new hire training requirements by 1/15/2020 4. Send documents that will enable us to validate that the new plan is up and running. Please see updated fire letter for this location labeled Fire Letter 5. Label every attachment and refer to that label on the plan of correction that it applies to. Ex: attachment #1, attachment #2, etc. 01/20/2021 Implemented
6400.112(f)According to the fire department notification letter dated 11/2/2020, there are two exits for this home; the front door and the rear door. Regulation 6400.112f requires alternate exits to be utilized during fire drills. During documentation review, it was notated that from 9/2019 to 10/2020 only the primary exit was used as the evacuation route during fire drills.Alternate exit routes shall be used during fire drills. 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 will be responsible to assuring all fire drills are done alternating exits in the home. The records supervisor will check for this to be completed correctly along with all other data elements as she reviews fire drills as they are entered into our electronic file system b. WHAT will be corrected Every home in every region will alternate exits used when conducting fire drills c. WHEN and HOW (usually attached as procedure) Seniors, DSPs and the Program Specialist have been informed of this error and instructed on how to correct it, by alternating exits being used in a fire drill. All homes will be reviewed for this error and homes that are not conducting the drills correctly will be notified and counseled no later than 12/28/2020. Our records manager has scheduled a training of DSPs, Seniors, and management staff for 1/5/2021 to review this and all aspects of conducting fire drills correctly Conducting fire drills correctly will be incorporated into the required annual and new hire fire safety training. 2. A plan to prevent future occurrences Long-term plans often include changing practice, teaching, and ongoing monitoring. A training will be conducted for all relevant staff from DSPs through the vice president on 1/5/2021. Annual and new hire fire safety training will include how to conduct a correct fire drill. The records supervisor will review and approve each fire drill before it is entered into our electronic file system. 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. Staff at this home have been notified and retrained. The records supervisor will train all staff involved from DSPs through the vice president on 1/5/2021 on how to conduct correct fire drills including alternating exits. Conducting fire drills will be incorporated into the annual and new hire fire safety trainings. 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. Agenda and list of participants in our upcoming training will be sent to Central Region Licensing Director by 1/8/2021 5. Label every attachment and refer to that label on the plan of correction that it applies to. Ex: attachment #1, attachment #2, etc. to be provided by 1/8/2021 01/08/2021 Implemented
6400.113(a)Individuals #1 had fire safety training on 8/24/2020 and Individual #2 had fire safety training on 11/2/2020. There is no documentation from fire drill training conducted in 2019 to verify that fire safety training was completed yearly as required by this regulation. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. 1. A plan to fix the immediate problem a. WHO (job title) will be responsible for correcting the problem (each step of the process) in the future The Regional Director is responsible for assuring that all records for individuals and staff are complete and available. The vice president is responsible for assuring that all records are available both in hard copy in the vice presidents secured files, and in our electronic filing system. b. WHAT will be corrected. Spectrum could not locate the 2019 fire safety training records and therefor could not demonstrate that the 2020 fire safety trainings were done within the 12 month annual requirement. To correct this, files will be redundant and kept in both electronic and hard copy form. c. WHEN and HOW (usually attached as procedure) The redundant system will begin on 1/4/2021. Regional Directors will be trained on how this will be operationalized on 12/23/2020. A review of all hard copy and electronic records will be conducted by 1/4/2021 to determine which staff files contain the 2019 fire safety documentation, and will be duplicated to be included in both electronic and hard copy format. The electronic files will be reviewed to ensure that every document for individuals and staff have a home so they can be easily retrieved, by 1/8/2021. Once we are sure there are no bugs in the process, it will be codified in our procedures by 1/22/2021. 2. A plan to prevent future occurrences Long-term plans often include changing practice, teaching, and ongoing monitoring. Program Specialists, one per region, will be assigned to do quality assurance checks between hard and electronic copies at random, monthly, to assure all files are included. This will commence on 2/1/2021. 3. Note of each plan of correction that you trained the staff responsible for that plan. They are to be trained in their responsibilities. Since the plans are new since licensing was there, the training date needs to be since licensing was there. Regional Directors will be trained on this system on 12/23/2020. Program Specialists will be trained on this system on 1/4/2021. 4. Send documents that will enable us to validate that the new plan is up and running. Ex: if one plan includes a new form to be used for all future quarterly reviews, send a quarterly review completed on that new form. Dont send blank forms. Please send the current year and past years documentation when correcting a violation that requires an annual timeframe. The procedure will be finalized by 1/22/2021 and sent to the Central Region Licensing Director 5. Label every attachment and refer to that label on the plan of correction that it applies to. Ex: attachment #1, attachment #2, etc. 01/22/2021 Implemented
6400.214(b)Copies of the current assessment and ISP were not kept in the residential home. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at 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 will be responsible for assuring copies of assessments and ISPs are available at each home. The Regional Director in their weekly visit to each home will assure this is true. b. WHAT will be corrected. Spectrum will assure that copies of all necessary documents are available at each home at all times. c. WHEN and HOW (usually attached as procedure) A hard copy of the ISPs were available at each home. The original ISPs and assessments were pulled and at the regional office for easy access for the licensers. We will discontinue this practice and make sure that an electronic copy of those documents are available at the regional office for licensers review should they want to do that. All documents were returned to the homes on 11/17/2020. Program Specialists will assure during their weekly visits to each home that all required documents are available at each home and that computer access is working appropriately. Regional Directors will also spot check availability of documents and computer access during their weekly visits. This will begin on 12/28/2020. 2. A plan to prevent future occurrences Staff will no longer pull documents from homes for any reason. They will scan and email documents from homes if necessary. Program Specialists and Regional Directors will check during their weekly visits to each home that these documents are 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. This process will be explained to Program Specialists and Regional Directors on 12/28/2020. 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. Attendance at the training will be sent to the Central Region Licensing Director by 12/30/2020. 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
SIN-00157493 Renewal 08/21/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff #2 did not have a criminal history clearance in her file.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.All staff will have a Pennsylvania criminal history record check done within 5 working days of their hire date. Criminal background will be checked to ensure person is eligible to hire, and then uploaded into our electronic database for future access. All people being hired will have their Human Resources page in the database checked by our HR coordinator to ensure all documents are in place before formal hiring. 09/06/2019 Implemented
6400.22(e)(1)There was no petty cash log for the month of April for Individual #1 If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. Individual 1 has had all his petty cash logs receipts and money accounted for for the month of April. Staff in the home will be responsible for maintaining the logs by month. Residential Supervisor will collect the logs at the end of the month, check to ensure accuracy, and place in the individuals book and upload into extended reach database for record keeping. 09/06/2019 Implemented
6400.22(e)(2)For Individual #1 the Cash log indicated that the cash balance on 5/15 was $59.93, the log indicates that on 5/19 $11.54 was spent and the new balance should be $48.39; however, staff recorded the new balance as $38.29 which is $10.10 less than the actual amount. This error caused the remainder of the cash log to be incorrect for the following months of June, July, and August because the petty cash log was not finalized for each individual month starting with May. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: For a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. All petty cash logs and money for this individual has been accounted for with receipts and petty cash logs have been written in monthly sequence with receipts attached. Staff will be responsible for updated the logs as needed and Residential Supervisor will collect monthly consumer log, check the logs to ensure accuracy, and file in consumer book and uploaded into our database for record keeping. 09/06/2019 Implemented
6400.71There was a portable phone located in the living room that did not contain emergency numbers on the back of the phone.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. All portable phones will have emergency numbers taped to the back of the handset. Weekly house inspections by the Residential Supervisor will include checking the phones to ensure the emergency numbers are still intact. 09/18/2019 Implemented
6400.151(a)Staff #2 was hired on 8/27/18 and did not have her physical completed until 5/20/19. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. All staff will complete a physical prior to hire or provide a physical examination that was performed within 12 months prior to employment and every 2 years thereafter. All examinations will be uploaded into Extended Reach, our electronic database. Warnings will be issued as we approach the deadline for a new medical examination needed to ensure we are able to track and get new examinations prior to the two year expiration. 09/06/2019 Implemented
6400.151(c)(3)Staff #1's Most recent physical dated 10/24/18 did not indicate that this Staff member was free of communicable disease. and Staff #2's most recent physical completed on 5/20/19 did not indicate that she was free of communicable disease. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Revise Spectrums physical form and have a signed statement from the physician. The physician(s) will be provided with the company form that states they are free of communicable diseases or that they are able to work in the home if precautions are taken that will prevent the spread of the disease if the staff person does have a communicable disease. 09/20/2019 Implemented
6400.181(c)Most recent assessment dated 12/31/18 for Individual #1 did not indicate that the assessment was based on instruments, interviews, progress notes, and observationsThe assessment shall be based on assessment instruments, interviews, progress notes and observations. The Extended Reach Form for the Annual Assessment will be updated to include language that identifies what the assessment is based on. Program Specialist will audit individual books monthly to ensure regulatory requirements are met. 09/18/2019 Implemented
SIN-00158654 Unannounced Monitoring 07/11/2019 Compliant - Finalized
SIN-00138962 Initial review 08/02/2018 Compliant - Finalized