Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00248967 Renewal 07/01/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101On 7/02/2024 at 11:00 AM, the spare bedroom located on the top floor of the home contained a large crawl space with a latch lock on the top left of the door, preventing someone to be able to exit if they are inside of the crawl space and the lock is engaged.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The bedroom had an unknown crawl space in the bedroom. AIMED has been in the property for over 5 years, and wasn¿t aware the space existed. Pursuant to 6400.101, AIMED had maintenance inspected the home on 8/14/24. The crate was removed and a keyless door knob was placed on the crawl space door. 08/14/2024 Implemented
6400.141(a)Individual #1 had a physical examination completed on 4/07/2023 and then again on 6/29/2024. This exceeds the annual requirement.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Unfortunately, AIMED experienced rapid turnover and the participant missed the scheduled appointment. Pursuant to 6400.141(a), the appointment has been placed in electronic health record and on the Google Calendar and shared with the entire team, so that there is backup when needed. 07/19/2024 Implemented
6400.151(a)Direct Service Worker #2, date of hire 6/03/2024, had their initial physical examination completed on 6/05/2024. 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. The new hire did have her physical completed, however, she needed to go back to her physician who forgot to document she didn¿t have a communicable disease. The doctor didn¿t use the initial date and entered a new date that placed the physical outside ODP regulation date parameter. Pursuant to 6400.151(a), the issue was immediately addressed and corrected, however, the physician made the correction with a new date, which created a violation. 06/06/2024 Implemented
6400.171On 7/02/2024 at 10:45 AM, Great Value White Bread with an expiration date of 6/05/2024 was located to the right of the oven. On 7/02/2024 at 10:47 AM, the refrigerator contained Prima Della Pre-Sliced Pepperoni with a use by date of 6/30/2024, Great Value Turkey Bacon with a use by date of 6/29/2024, and Prima Della Pre-Sliced Pepperoni with a use by date of 6/16/2024. On 7/02/2024 at 10:40 AM, the kitchen pantry to the right of the oven contained a bottle of Great Value Soy Sauce an expiration date of 6/17/2024.Food shall be protected from contamination while being stored, prepared, transported and served. The Residential Supervisor received a disciplinary and corrective action due to negligence. Pursuant to 6400.171, all the expired food was disposed of. The food was properly labeled and stored. 07/03/2024 Implemented
6400.165(g)Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness. Individual #1 had psychiatric medication reviews completed on 2/05/2024 and then again on 6/10/2024. This exceeds the at least every 3-months requirement.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Unfortunately, AIMED experienced rapid turnover and the participant missed the scheduled appointment. Pursuant to 6400.141(a), the appointment has been placed in electronic health record and on the Google Calendar and shared with the entire team, so that there is backup when needed. 07/19/2024 Implemented
6400.166(b)Individual #1 is prescribed Clonidine 0.1 MG Tablet with directions to take 1 tablet by mouth at bedtime for ADHD. This medication was not documented as administered on 7/01/2024 at 8:00 PM. Individual #1 is prescribed Divalproex ER 500 MG Tablet with directions to take 1 tablet by mouth twice a day for mood disorders. This medication was not documented as administered on 7/01/2024 at 8:00 PM.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The overnight staff failed to initial the MAR, indicating the medication had been passed. This created a mediation documentation error. Pursuant to 6400.166(b), the Residential Supervisor notified the staff who failed to initial the MAR and made the correction immediately upon coming on shift that day. 07/01/2024 Implemented
6400.182(c)Individual #1's ISP last updated on 6/07/2024 states child locks should be used while they are in a vehicle. Chief Executive Officer #1 stated on 7/01/2024 that Individual #1 no longer needs child locks in the vehicle.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The ISP had outdated information contained in it. The Support Coordinator made the correction. Pursuant to 6400.182(c), The SC was notified on 7/02/2024 to remove the outdated information and update the ISP, which the update has been made on the same day of notification. 07/02/2024 Implemented
6400.213(1)(i)6400.213(1)(ii): Individual #1's record did not address identifying marks.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. (ii) Race/height/weight/hair color/eye color/identifying marks.The Individual record was missing the SS# due to an oversight. Pursuant to 6400.213(1)(i), the individual record was updated 7/3/24 to include all applicable information. 07/03/2024 Implemented
SIN-00227560 Renewal 07/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)Individual #1's physical examination, completed 4/7/23 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. As a result of 6400.141(c)(14), the annual physical was completed on 4/7/23 as scheduled. The form did not have the diagnosis listed; it was left blank. The doctor has completed the blank space. The form has been emailed to ODP. 07/21/2023 Implemented
SIN-00209032 Renewal 07/14/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The self-assessment results, completed 6/28/2022, identifies violations, but a written summary of corrections was not kept.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. The incorrect self assessment was retrieved and used the ODP website, however, the form was outdated. The corrections were documented on a separate sheet of paper. As a result of 6400.15(c), the Dr. of Prog and Srvs immediately downloaded the current form dated 2/2022 on 7/18/22 and saved to the shared drive for future use and the summary will be included on the current form. 07/18/2022 Implemented
6400.64(a)Under the vent on the floor in the dining room of the home was a dense matting of dust and debris. [Repeat Violation, 6/13/2022]Clean and sanitary conditions shall be maintained in the home. The home has been vacant for 18 months due to extreme damage caused by the previous individual. The home was damaged by spraying the fire extinguisher all over the home, creating a build up on the walls, carpet and vents. The vent didn¿t have dust, it was residue from the fire extinguisher (per a professional restoration company). AIMED has been restoring the home back to a livable condition There was no intention to move anyone onto the home until all repairs are completed.. As a result of 6400.64(a), the exhaust vent will be cleaned on 08/18/2022 by a professional restoration company. 08/18/2022 Implemented
6400.64(b)There was an inordinate amount of deceased insects on the shelves and floor in the closet in the basement of the home.There may not be evidence of infestation of insects or rodents in the home. The home has been vacant for 18 months due to extreme damage caused by the previous individual. The living areas of the home were cleaned, however, the unused basement areas were not focused on because AIMED is seeking bids for a professional restoration and cleaning company due to the home being vacant for over a year. AIMED has been restoring the home back to a livable condition and it has been quite extensive. There was no intention to move anyone in until all repairs were completed. As a result of 6400.64(b), the home will be cleaned on 8/18/22 by a professional restoration and cleaning company. 08/18/2022 Implemented
6400.64(f)On the back patio of the home, there was a discarded uncovered cardboard box from a 32 inch television overflowing with miscellaneous discarded items including additional cardboard boxes and plastic bags.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The home has been vacant for 18 months due to extreme damage caused by the previous individual. The previous day a TV was purchased and theTV box was placed outside for trash. The box was stuffed with styrofoam, plastic and cardboard from the contents inside of the box. There may have been one item placed in the box from off the ground in the backyard as the team was leaving but no trash. As a result of 6400.64(f), the box was removed from the premises by program staff on 8/9/22. 08/09/2022 Implemented
6400.67(b)There were eight screws protruding through several boards that were used to replace a 4-inch by 8-inch panel on the front door of the home. [Repeat Violation, 4/14/2022, 6/13/2022] Floors, walls, ceilings and other surfaces shall be free of hazards.The home has been vacant for 18 months due to extreme damage caused by the previous individual. The front door had extensive damage and had some repairs done but the maintenance dept hadn¿t completed all repairs. There were no intentions on moving anyone into the home until all repairs and restoration have been completed. As a result of 6400.64(f), the repairs to the door were completed on 8/30/22 by the maintenance dept. 08/30/2022 Implemented
6400.72(b)The window above the sink in the kitchen of the home is broken with jagged pieces of glasses protruding from the window frame. The window has been covered with plexiglass on the inside and outside. Screens, windows and doors shall be in good repair. The home has been vacant for 18 months due to extreme damage caused by the previous individual. The window was broken with an object with the plexi glass over it. The home had extensive damage and some repairs were done, it has been an ongoing project restoring the home. There were no intentions to move anyone into the home until all repairs and restoration have been completed. As a result of 6400.72(b), the glass for the window has been ordered by the maintenance dept on 8/12/22 and will be replaced 9/15/22, contingent upon the arrival of the glass. 09/15/2022 Implemented
6400.76(a)The front left burner on the gas stove did not have a cover and the spark electrode continued to click in an attempt to ignite when in the off position when the other burners were ignited and flaming. Furniture and equipment shall be nonhazardous, clean and sturdy. The home has been vacant for 18 months due to extreme damage caused by the previous individual. The burner was damaged due to a destroyed burner. The home had extensive damage and some repairs were done but not completely, it has been an ongoing project to restore the home. There were no intentions to move anyone into the home until all repairs and restoration have been completed. As a result of 6400.76(a), the burner plate was ordered by the maintenance dept on 8/30/22, and will be replaced once it arrives. 08/30/2022 Implemented
6400.80(a)The cement slabs of the walkway of the home are uneven posing a tripping and falling hazard. [Repeat Violation, 12/7/2021] Outside walkways shall be free from ice, snow, obstructions and other hazards. The front walkway is not cracked, however, the left side walkway (kitchen exit walkway is). The home has been vacant for 18 months due to extreme damage caused by the previous individual. The management company has been asked to repair the walkway several times. There were no intentions to move anyone into the home until all repairs and restoration have been completed. AIMED will absorb the cost to repair the crack if necessary. As a result of 6400.80(a), the repair to the concrete crack was completed on 8/11/22. (Uploaded picture). 08/11/2022 Implemented
6400.15(b)The agency completed a self-assessment of the home on 06/27/22; however, the agency did not use the Department's most current licensing inspection instrument (reflecting regulatory changes promulgated in February 2020) to measure and record compliance for this chapter.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.AIMED used the DHS-ODP website to download the self-assessment to complete prior to licensing, it is not dated. We were informed after inspection that the form used was incorrect. It is our thought that the ODP website would have up-to-date forms on the website and My ODP. CLS does point you to the website to obtain forms and information. As a result of 6400.16(b), the self-assessment form obtained from DHS-ODP website has been replaced effective immediately with the revised form dated 2/2022 on 7/18/22. The old form has been deleted from our drive. 07/18/2022 Implemented
SIN-00212922 Unannounced Monitoring 09/21/2022 Compliant - Finalized
SIN-00181244 Renewal 01/05/2021 Compliant - Finalized
SIN-00162834 Renewal 09/18/2019 Compliant - Finalized