Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00248966 Renewal 07/01/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(b)On 7/02/2024 at 10:15 AM, there were mouse traps located in the basement, the garage, and behind the couch in the living area of the home. The mouse trap located in the basement of the home appeared to have what looked like mouse feces inside of the trap.There may not be evidence of infestation of insects or rodents in the home. The home had been serviced in the past for pests. However, there hasn¿t been any activity in the past year. The maintenance department failed to remove the old traps. Pursuant to 6400.64(b), AIMED had the home the maintenance department immediately inspect and remove the pest control traps. 07/17/2024 Implemented
6400.65On 7/02/2024 at 10:20 AM, the bathroom located in the basement of the home did not have an operable window or mechanical ventilation.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. The home has never had a basement bathroom and has never had a ventilation fan. AIMED has been in the is property for approximately five years and this is the first time ODP has cited this as a violation. Pursuant to 6400.65, AIMED has submitted a maintenance request immediately following the state inspection and is waiting for the property manager to notify us when the work will be completed. 08/21/2024 Implemented
6400.72(a)On 7/02/2024 at 10:05 AM, the operable window located in the dining room of the home did not have a screen.Windows, including windows in doors, shall be securely screened when windows or doors are open. The window screen had been replaced prior to state licensing, but somehow was missing on the day of inspection. Pursuant to 6400.72(a), the screen was replaced on 7/8/24. 07/08/2024 Implemented
SIN-00227558 Renewal 07/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual #1's most recent physical examination was completed on 3/21/22. (Repeated Violation-7/14/22, et al).An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The participant¿s mother has adamantly demanded to manage all the appointments for her son. AIMED team made several attempts to get mom to schedule the appointment and time ran out. As a result of 6400.141(a), the individual exam/TB has been scheduled for July 27, 2023. The appointment has been scheduled and emailed to ODP. 07/27/2023 Implemented
6400.141(c)(6)Individual #1's most recent Tuberculin skin testing was completed on 2/6/21.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. The participant¿s mother has adamantly demanded to manage all the appointments for her son. AIMED team made several attempts to get mom to schedule the appointment and time ran out. As a result of 6400.141(a), the individual exam/TB has been scheduled for July 27, 2023. The appointment has been scheduled and emailed to ODP. 07/27/2023 Implemented
6400.166(b)Clonazepam 2mg tablet, take 1 tablet by mouth twice a day, prescribed to Individual #1, was not initialed as administered at 8:00AM on 7/12/23.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.ADDITIONAL Provided by provider on 8/2/2023: [The MAR was corrected by the staff the same morning. The MAR is checked daily by the Residential Supervisor. The Program Administrator does a weekly site inspection to ensure the MAR is completed accurately. (AES,HSLS on 8/2/23)] POC DOES NOT ADDRESS VIOLATION. Maintain: The CEO shall designate the Dr. of Program and Services to ensure the Residential Supervisor reviews the MAR daily for accuracy. The Program Administrator shall be a second layer of checks and review the MAR during the weekly site inspection. The purge, including the MAR is sent to the administrative office by the 5th of the month. The purge and MAR are reviewed by the Program Administrator for accuracy. The participant¿s mother has adamantly demanded to manage all the appointments for her son. AIMED team made several attempts to get mom to schedule the appointment and time ran out. As a result of 6400.141(a), the individual exam/TB has been scheduled for July 27, 2023. The appointment has been scheduled emailed to ODP. 07/27/2023 Implemented
SIN-00206738 Unannounced Monitoring 06/13/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)There is not a mirror in Individual #1's bedroom or en suite bathroom.In bedrooms, each individual shall have the following: A mirror. The Regional Program Director submitted a maintenance request for Non-breakable mirrors on 6/17/2022 and will be arriving on 6/21/2022. It will be installed in the home by 6/30/2022. 06/30/2022 Implemented
6400.166(b)Individual #1's prescribed medication, Chlorpromazine 100 mg Take 1 tablet by mouth at bedtime for mood disorders, was not initialed as administered on 6/4/2022 and 6/5/2022.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The Regional Program Director reviewed the violation with the staff member and was given a written warning and is required to attend an additional medication administration training by 7/8/22, facilitated by our Director of Training and Compliance. 07/08/2022 Implemented
SIN-00141966 Renewal 09/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill records for the fire drills held on 10/26/17, 11/22/17, 12/19/17, 1/31/18, 2/127/18, 3/28/18, 4/29/18, 5/31/18, 5/13/18, 6/24/18, 6/30/18, 7/30/18, 8/31/18 and 9/10/18 did not include if there were problems encountered or whether the fire alarm or smoke detector was operative. [Repeated Violation-9/28/17, et al]A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. As a result of last year¿s violation of 6400.112(c), AIMED revised the agency¿s fire drill form. This revision failed to include a section that indicated if there were any problems encountered during the fire drill as well as whether the fire alarm or smoke detector was operative at time of drill. Immediately upon the conclusion of this year¿s licensing visit (on September 21, 2018), AIMED revised the fire drill form to include the following: 1. Did you encounter problems during fire drill? ¿ Yes ¿ No 2. Was fire alarm operative during fire drill? ¿ Yes ¿ No 3. Designated meeting place AIMED Program Specialist will train all supervisors and direct care staff on how to properly complete the revised form to assure that drills are being conducted properly and the forms are being completed properly agency wide. This training will take place at each site during October¿s monthly team meeting with refresher training at future team meetings. Training and Compliance Manager is responsible for reviewing the fire drill record for accuracy during the weekly site compliance visit. Program Specialists will review fire drill records for accuracy during weekly site visits. Residential Program Manager will review the fire drill record for accuracy during monthly site visits. [Documentation of trainings and audits of fire drill records shall be kept. (DPOC by AES,HSLS on 10/11/18)] 10/02/2018 Implemented
6400.161(e)On 9/20/18, Gabapentin 100mg Capsules and Aripiprazole 15mg Tablets prescribed to Individual #1 which were discontinued on 8/30/18 and remained in the 8:00AM multiple dose bubble pack along with Individual #1's current medications of Certagen Vitamins, Omeprazole 20 mg capsules and Levothyroxine 0.05 mg Tablets. On 9/20/18, Gabapentin 100mg Capsules prescribed to Individual #1 which was discontinued on 8/30/18 remained in the 4:00PM multiple dose bubble pack along with Individual #1's current medication of Buspirone 15mg.Discontinued prescription medications shall be disposed of in a safe manner.The discontinued medication remained in the 8:00AM multiple dose bubble pack along with the individuals current medication. The Training and Compliance Manager will conduct discontinued medication procedure training during site team meetings across the agency effective 11/1/2018. Effectively immediately, all sites have a posting instructing all staff of the proper procedure for handling discontinued medication. As an extra layer of accountability, the Program Specialist is now required to visit the site upon notification of discontinued medication to insure that the new medication bubble pack has been requested and received at the site. The Compliance Manager is required to review the bubble pack during weekly site compliance visits. [Documentation of trainings and audits of medications and discontinued medications procedures shall be kept. (DPOC by AES,HSLS on 10/11/18)] 10/02/2018 Implemented
6400.163(c)Individual #1's psychiatric medication reviews completed 10/5/17, 1/9/18 did not include the reason for prescribing the medications, the need to continue the medications and the necessary dosages. [Repeated Violation-9/28/17, et al] If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The reason for prescribing the medication, need to continue and necessary dosage by the psychiatrist was not completed on the form. The form was revised last year to include the necessary information and all staff was retrained on the proper completion and the required information needed on the form. This particular supervisor had been experiencing workplace conduct issues and failed to follow the procedure for completing the form. The Program Specialist will be responsible for re-training staff and quarterly chart reviews will be conducted to review forms for accuracy. All other forms for this chart were accurate after the supervisor in question resigned. [Immediately, the CEO or designee shall educate all staff persons responsible for ensuring that individuals who are prescribed medications to treat symptoms of a diagnosed psychiatric illness have a review with documentation by a licensed physician at least every 3 months of the requirements of the documentation which need to include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Upon completion, a trained staff person shall audit the review documentation to ensure all required information is included and individuals are administered medications as prescribed. Documentation of audits shall be kept. At least quarterly for 1 year, the CEO or designated management staff person shall audit a 25% sample of individuals' psychiatric medication review documentation to ensure all required information is included and individuals are administered medications as prescribed. (DPOC by AES,HSLS on 10/11/18)] 10/02/2018 Implemented
6400.181(f)The program specialist provided Individual #1's assessment completed 8/29/17 to the SC and plan team members on 10/19/17 for the annual ISP meeting on 10/19/17.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). The program specialist did not provide a copy of the assessment to the team prior to 30 days of the scheduled ISP team meeting. The Program Specialist is responsible for providing the team a copy of the annual assessment at least 30 days prior to the ISP meeting. A new level of accountability will be added as well as additional training to the Program Specialist. Assessments are required to be completed within 60 days prior to the ISP and placed on the shared calendar for the Residential Program Manager to be aware of. Upon completion of the assessment, it will be reviewed by the Residential Program Manager to insure the assessment is given to the team prior to 30 days of the ISP meeting. [Documentation of the audits of assessments and correspondence documentation showing the program specialist provided all individuals' assessments to plan team members, timely shall be kept. (DPOC by AES,HSLS on 10/11/18)] 10/02/2018 Implemented
SIN-00122334 Renewal 09/27/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aid kit did not contain a thermometer. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Training will be redone and site supervisor replaced the thermometer and Compliance Manager will review weekly for compliance. Site date it was replaced. D.O.O reviews the compliance manager¿s weekly site documentation. [Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff working in community homes as to the required items and the restocking procedures for first aid kits to ensure that all required items are present in first aid kits at all times. Documentation of the trainings shall be kept. (AS 11/28/17)] 11/17/2017 Implemented
6400.141(c)(13)The physical examination for Individual #1, completed on 8/17/17 did not include allergies. The section was blank. The physical examination shall include: Allergies or contraindicated medications.The physical form didn¿t include the allergies. The Program Specialist has since corrected the form. The Site Supervisor is responsible for reviewing the form before it¿s submitted to the Program Specialist who is responsible for reviewing the form before it¿s filed to make sure all information is completed. Chart reviews are scheduled quarterly and during the review all forms will be reviewed for accuracy. [Immediately and upon competition, the program specialist and supervisor shall audit all individuals' current physical examination documentation to ensure all required information is completed and will follow up with the completing medical professional to obtain the missing information. Documentation of all audits shall be kept. (AS 11/28/17)] 10/30/2017 Implemented
6400.141(c)(14)The physical examination for Individual #1, completed on 8/17/17, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was blank. [Repeated Violation-9/27/16, et al]The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The physical form didn¿t information pertinent diagnosis. The Program Specialist has since corrected the form. The Site Supervisor is responsible for reviewing the form before it¿s submitted to the Program Specialist who is responsible for reviewing the form before it¿s filed to make sure all information is completed. Chart reviews are scheduled quarterly and during the review all forms will be reviewed for accuracy. [Immediately and upon competition, the program specialist and supervisor shall audit all individuals' current physical examination documentation to ensure all required information is completed and will follow up with the completing medical professional to obtain the missing information. Documentation of all audits shall be kept. (AS 11/28/17)] 10/30/2017 Implemented
6400.181(e)(12)The assessment completed on 8/24/17, for Individual #1, did not include recommendations for specific areas of training, programming and services. This section was blank.The assessment must include the following information: Recommendations for specific areas of training, programming and services. The assessment didn¿t include recommendations for the participant. The Program Specialist reviewed the assessment and made the correction 10/30/17, to include recommendations. The assessment will be reviewed during quarterly chart reviews to insure that all the required information is in the assessment. [Immediately, the program specialist shall review all individuals' current assessment to ensure all required information is included as per 6400.181(e)(1)-(14). Upon completion and at least quarterly for 1 year, the CEO or designated management staff person shall audit all completed individuals' assessments to ensure all required information is included. Documentation of all audits shall be kept. (AS 11/28/17)] 10/30/2017 Implemented
SIN-00181241 Renewal 01/05/2021 Compliant - Finalized